Whose Patient Is This? A Scoping Review of Patient Ownership

Ownership of Patient Care: Medical Students' Expectations, Experiences, and Evolutions Across the Core Clerkship Curriculum

Phenomenon: Ownership of patient care is a key element of professional growth and professional identity formation, but its development among medical students is incompletely understood. Specifically, how attitudes surrounding ownership of patient care develop, what experiences are most influential in shaping them, and how educators can best support this growth are not well known. Therefore, we studied the longitudinal progression of ownership definitions and experiences in medical students across their core clerkship curriculum. Approach: We conducted a series of four longitudinal focus groups with the same cohort of medical students across their core clerkship curriculum. Using workplace learning theory as a sensitizing concept, we conducted semi-structured interviews to explore how definitions, experiences, and influencers of ownership developed and evolved. Results were analyzed inductively using thematic analysis. Findings: Fifteen students participated in four focus groups spanning their core clerkship curriculum. We constructed four themes from responses: (1) students' definitions of ownership of patient care evolved to include more central roles for themselves and more defined limitations; (2) student conceptions of patient care ownership became more relational and reciprocal over time as they ascribed a more active role to patients; (3) student assessment fostered ownership as an external motivator when it explicitly addressed ownership, but detracted from ownership if it removed students from patient care; and (4) structural and logistical factors impacted students' ability to display patient care ownership. Insights: Student conceptions of ownership evolved over their core clerkship curriculum to include more patient care responsibility and more meaningful relational connections with patients, including recognizing patients' agency in this relationship. This progression was contingent on interactions with real patients and students being afforded opportunities to play a meaningful role in their care. Rotation structures and assessment processes are key influencers of care ownership that merit further study, as well as the voice of patients themselves in these relationships.

Having a Voice: Resident Perceptions of Supervision, Decision-Making and Patient Care Ownership

OBJECTIVE

Heightened resident supervision due to patient safety concerns is increasingly common in pediatrics and may leave residents with fewer opportunities for independent decision-making, a diminished sense of autonomy, and decreased engagement. This may ultimately threaten their development into competent clinicians. Understanding how pediatric residents experience supervision's influence on their involvement in decision-making, engagement in patient care, and learning is crucial to safeguard their transition to independent practice. In relation to supervision, our research investigated: 1) how residents navigated their involvement with clinical decision-making and 2) how opportunities to make clinical decisions influenced their engagement in patient care and learning.

METHODS

From 2019-2020, we recruited 38 pediatric residents from three different programs for a qualitative interview-based study. Through a constructivist stance, we explored clinical decision-making experiences and performed thematic analysis using an iterative and inductive process.

RESULTS

We identified three themes: 1) Residents perceived having autonomy when they had space to make independent decisions, regardless of supervisor's presence; 2) Patient care ownership resulted from having a voice in a variety of contributions to patient care; and 3) Supervisors' behaviors modulated patient care ownership and thereby residents' sense of feeling heard, their engagement in patient care, and their learning.

CONCLUSIONS

Our results suggest that focusing on patient care ownership may better fit with current learning environments than aiming for independence and autonomy. They provide insight on how, in the pediatric learning climate of enhanced supervision, supervisors can preserve resident engagement in patient care and learning by augmenting patient care ownership and ensuring residents have a voice.

Thriving as a Surgical Intern: Three Tips From the Collaboration of Surgical Education Fellows (CoSEF)

We are the multi-institutional organization known as the Collaboration of Surgical Education Fellows (CoSEF). We've collectively reflected on our range of experiences across the country and identified 3 principles which promote a successful intern experience: (1) Own your patients; (2) Treat people like people; and (3) Take care of yourself.

Patient care ownership in medical students: a validation study

BACKGROUND

Psychological Ownership is the cognitive-affective state individuals experience when they come to feel they own something. The construct is context-dependent reliant on what is being owned and by whom. In medical education, this feeling translates to what has been described as "Patient Care Ownership," which includes the feelings of responsibility that physicians have for patient care. In this study, we adapted an instrument on Psychological Ownership that was originally developed for business employees for a medical student population. The aim of this study was to collect validity evidence for its fit with this population.

METHODS

A revised version of the Psychological Ownership survey was created and administered to 182 medical students rotating on their clerkships in 2018-2019, along with two other measures, the Teamwork Assessment Scale (TSA) and Maslach Burnout Inventory (MBI) Survey. A confirmatory factor analysis (CFA) was conducted, which indicated a poor fit between the original and revised version. As a result, an exploratory factor analysis (EFA) was conducted and validity evidence was gathered to assess the new instruments' fit with medical students.

RESULTS

The results show that the initial subscales proposed by Avey et al. (i.e. Territoriality, Accountability, Belongingness, Self-efficacy, and Self-identification) did not account for item responses in the revised instrument when administered to medical students. Instead, four subscales (Team Inclusion, Accountability, Territoriality, and Self-Confidence) better described patient care ownership for medical students, and the internal reliability of these subscales was found to be good. Using Cronbach's alpha, the internal consistency among items for each subscale, includes: Team Inclusion (0.91), Accountability (0.78), Territoriality (0.78), and Self-Confidence (0.82). The subscales of Territoriality, Team Inclusion, and Self-Confidence were negatively correlated with the 1-item Burnout measure (P = 0.01). The Team Inclusion subscale strongly correlated with the Teamwork Assessment Scale (TSA), while the subscales of Accountability correlated weakly, and Self-Confidence and Territoriality correlated moderately.

CONCLUSION

Our study provides preliminary validity evidence for an adapted version of Avey et al.'s Psychological Ownership survey, specifically designed to measure patient care ownership in a medical student population. We expect this revised instrument to be a valuable tool to medical educators evaluating and monitoring students as they learn how to engage in patient care ownership.

Exploring the development of adaptive expertise through the lens of threshold concepts

INTRODUCTION

While expert clinical practice requires a flexible approach to problem solving, evidence shows that medical clerks tend to focus on knowledge acquisition as the key to expertise. It is not until residency training that learners shift their understanding of expertise towards developing adaptive approaches to clinical problems. This raises the possibility that adaptive expertise is a threshold concept and that authentic clinical experiences involving complex problem solving are required to create the liminal state that enables transformation to an adaptive expertise mindset. With this possibility in mind, the current study examined the conceptualisations of expertise held by recently graduated physical therapists using the framework of threshold concepts as a sensitising lens.

METHODS

An exploratory qualitative study in the Constructivist Grounded Theory tradition was conducted, utilising 14 one-on-one semi-structured interviews with recently graduated physical therapists.

RESULTS

Most participants were in a transitional state regarding their conceptualisation of expertise, sometimes focusing on the acquisition of knowledge and routinisation of practice as their hallmark of expertise and at other times acknowledging the need for developing more dynamic and adaptive problem-solving approaches to patient care. These mixed responses were expressed not only in their framing of patient management but also in their reasons for valuing colleagues and in their approach to continuing professional development. Notably, many participants suggested that the interview itself was a key impetus to their reflecting on these issues.

CONCLUSION

Our findings suggest that participants were only beginning to transition into an adaptive expertise mindset upon entering practice, reinforcing the possibility that authentic practice may be an important impetus for recognising the limits of routine expertise. However, spontaneous comments from participants suggest that this transition might be better supported though active guided reflection in addition to meaningful clinical engagement with patients and colleagues.

Association between patient care ownership and personal or environmental factors among medical trainees: a multicenter cross-sectional study

BACKGROUND

Patient care ownership (PCO) is crucial to enhancing accountability, clinical skills, and medical care quality among medical trainees. Despite its relevance, there is limited information on the association of personal or environmental factors with PCO, and thus, authors aimed to explore this association.

METHODS

In 2021, the authors conducted a multicentered cross-sectional study in 25 hospitals across Japan. PCO was assessed by using the Japanese version of the PCO Scale (J-PCOS). To examine the association between personal (level of training, gender, and department) or environmental factors (hospital size, hospital type, medical care system, number of team members, number of patients receiving care, mean working hours per week, number of off-hour calls per month, and perceived level of the workplace as a learning environment) and PCO after adjusting for clustering within hospitals, the authors employed a linear mixed-effects model.

RESULTS

The analysis included 401 trainees. After adjusting for clustering within hospitals, it was confirmed that the senior residents had significantly better J-PCOS total scores (adjusted mean difference: 8.64, 95% confidence interval [CI]: 6.18-11.09) than the junior residents and the perceived level of the workplace as a learning environment had a positive association with J-PCOS total scores (adjusted mean difference per point on a global rating of 0-10 points: 1.39, 95% CI: 0.88-1.90). Trainees who received calls after duty hours had significantly higher J-PCOS total scores than those who did not (adjusted mean difference: 2.51, 95% CI: 0.17-4.85). There was no clear trend in the association between working hours and PCO.

CONCLUSIONS

Seniority and the perceived level of the workplace as a learning environment are associated with PCO. An approach that establishes a supportive learning environment and offers trainees a reasonable amount of autonomy may be beneficial in fostering PCO among trainees. The study findings will serve as a useful reference for designing an effective postgraduate clinical training program for PCO development.

Supported Independence: The Role of Supervision to Help Trainees Manage Uncertainty

PURPOSE

Safe and effective supervised practice requires a negotiated partnership between trainees and their supervisors. Substantial work has explored how supervisors make judgments about trainees' readiness to safely engage in critical professional activities, yet less is known about how trainees leverage the support of supervisors when they perceive themselves to be at the limits of their abilities. The purpose of this study is to explore how trainees use supervisory support to navigate experiences of clinical uncertainty.

METHOD

Using a constructivist grounded theory approach, the authors explored how novice emergency medicine trainees conceptualized the role of their supervisors during experiences of clinical uncertainty. They employed a critical incident technique to elicit stories from participants immediately following clinical shifts between July and September 2020, and asked participants to describe their experiences of uncertainty within the context of supervised practice. Using constant comparison, 2 investigators coded line-by-line and organized these stories into focused codes. The relationships between these codes were discussed by the research team, and this enabled them to theorize about the relationships between the emergent themes.

RESULTS

Participants reported a strong desire for supported independence, where predictable and accessible supervisory structures enabled them to work semiautonomously through challenging clinical situations. They described a process of borrowing their supervisors' comfort during moments of uncertainty and mechanisms to strategically broadcast their evolving understanding of a situation to implicitly invoke (the right level of) support from their supervisors. They also highlighted challenges they faced when they felt insufficiently supported.

CONCLUSIONS

By borrowing comfort from-or deliberately projecting their thinking to-supervisors, trainees aimed to strike the appropriate balance between independence for the purposes of learning and support to ensure safety. Understanding these strategic efforts could help educators to better support trainees in their growth toward self-regulation.

Interchangeability in Military Interprofessional Health Care Teams: Lessons Into Collective Self-healing and the Benefits Thereof

INTRODUCTION

Interchangeability-i.e., the capacity to change places with another-is necessary for military interprofessional health care teams (MIHTs) to provide around-the-clock patient care. However, while interchangeability is clearly a necessity for modern health care delivery, it raises uncomfortable questions for civilian health care teams where it is usually labeled as unsafe. This perception surfaces because interchangeability runs counter to some of health care's cultural beliefs including those around patient ownership and professional scopes of practice. It is, therefore, not surprising that little is known about whether and how some level of interchangeability can be harnessed to improve the productivity of health care teams overall. In this article, we explore the notion of interchangeability in the particular context of MIHTs given that these health care teams are familiar with it. This exploration will offer insights into how interchangeability could maximize civilian health care teams' capacity to adapt.

MATERIALS AND METHODS

We conducted a secondary analysis of interview data as an analytic expansion: "the kind of study in which the researcher makes further use of a primary data set in order to ask new or emerging questions that derive from having conducted the original analysis but were not envisioned within the original scope of the primary study aims". Within our secondary analysis approach, we used thematic analysis as our analytical tool to describe (1) what interchangeability looks like in MIHT teams, (2) how it is fostered in MIHTs, and (3) how it is enacted in MIHTs.

RESULTS

Interchangeability was realized in MIHTs when individual team members adapted to take on roles and/or tasks that were not clearly niched in their specific areas of expertise but instead drew on the broad foundation of their clinical skill set. Cross-training and distributed leadership were ways in which MIHT members described how interchangeability was fostered. Furthermore, five features of working within MIHT teams were identified as key conditions to enact interchangeability: knowing your team members; being able to work with what/who you have; actively seeking others' expertise; situating your role within the broader picture of the mission; and maintaining a learning/teaching mindset.

CONCLUSIONS

Interchangeability can be understood through the theoretical lens of Swarm Intelligence and more specifically, the principle of collective self-healing-which is the ability of collectives to continue to successfully perform despite disruption, challenges, or the loss of a team member. Our findings highlight how MIHTs have adopted interchangeability in a wide array of contexts to realize collective self-healing. Despite the discomfort it provokes, we suggest that interchangeability could be a powerful asset to civilian health care teams.

Parent and Physician Qualitative Perspectives on Reasons for Pediatric Hospital Readmissions

OBJECTIVES

One in 5 parents report a problem in their child's hospital-to-home transition, leading to adverse events, dissatisfaction, and readmissions. Although researchers in several studies have explored parent insights into discharge needs, few have explored perceptions of causes for pediatric readmissions. We sought to investigate factors contributing to pediatric readmissions, from both parent and physician perspectives.

METHODS

We conducted a qualitative study using semistructured interviews with parents, discharging and readmitting physicians, and subspecialist consultants of children readmitted within 30 days of initial discharge from the pediatric ward at an urban nonfreestanding children's hospital. Participants were interviewed during the readmission and asked about care transition experiences during the initial admission and potential causes and preventability of readmission. Data were analyzed iteratively by using a constant-comparative approach. We identified major themes, solicited feedback, and inferred relationships between themes to develop a conceptual model for preventing readmissions.

RESULTS

We conducted 53 interviews from 20 patient readmissions, including 20 parents, 20 readmitting physicians, 11 discharging physicians, and 3 consulting subspecialists. Major themes included the following: (1) unclear roles cause lack of ownership in patient care tasks, (2) lack of collaborative communication leads to discordant understanding of care plans, and (3) incomplete hospital-to-home transitions result in ongoing reliance on the hospital.

CONCLUSIONS

Clear definition of team member roles, improved communication among care team members and between care teams and families, and enhanced care coordination to facilitate the hospital-to-home transition were perceived as potential interventions that may help prevent readmissions.

Scoping reviews in medical education: A scoping review

OBJECTIVES

Over the last two decades, the number of scoping reviews in core medical education journals has increased by 4200%. Despite this growth, research on scoping reviews provides limited information about their nature, including how they are conducted or why medical educators undertake this knowledge synthesis type. This gap makes it difficult to know where the field stands and may hamper attempts to improve the conduct, reporting and utility of scoping reviews. Thus, this review characterises the nature of medical education scoping reviews to identify areas for improvement and highlight future research opportunities.

METHOD

The authors searched PubMed for scoping reviews published between 1/1999 and 4/2020 in 14 medical education journals. The authors extracted and summarised key bibliometric data, the rationales given for conducting a scoping review, the research questions and key reporting elements as described in the PRISMA-ScR. Rationales and research questions were mapped to Arksey and O'Malley's reasons for conducting a scoping review.

RESULTS

One hundred and one scoping reviews were included. On average, 10.1 scoping reviews (SD = 13.1, median = 4) were published annually with the most reviews published in 2019 (n = 42). Authors described multiple reasons for undertaking scoping reviews; the most prevalent being to summarise and disseminate research findings (n = 77). In 11 reviews, the rationales for the scoping review and the research questions aligned. No review addressed all elements of the PRISMA-ScR, with few authors publishing a protocol (n = 2) or including stakeholders (n = 20). Authors identified shortcomings of scoping reviews, including lack of critical appraisal.

CONCLUSIONS

Scoping reviews are increasingly conducted in medical education and published by most core journals. Scoping reviews aim to map the depth and breadth of emerging topics; as such, they have the potential to play a critical role in the practice, policy and research of medical education. However, these results suggest improvements are needed for this role to be fully realised.

Linking Patient Care Ownership and Professional Identity Formation through Simulation

The link between ownership of patient care and professional identity formation (PIF) has not been formally established, yet PIF researchers frequently cite clinical experiences as powerful contributions to PIF. Hypothesis: Using clinical simulation, this study aimed to explore the relationship between patient care ownership and the cognitive processes involved in the creation of a professional identity. Methods: In 2018-2019, 189 third-year students participated in a simulation in which they were placed in the role of a physician treating a patient in respiratory distress. Data were collected from 12 focus groups (n = 84; 44% of the third-year class), each lasting 15-25 minute. Students were asked four questions designed to identify moments when they felt like a physician and experienced feelings of ownership. Each focus group was transcribed and analyzed for the presence of known elements that contribute to feelings of psychological ownership, and then inductively for how students related their feelings of ownership to their professional identity. Results: When students were asked to take ownership of their patient's care, they underwent a three-step process: (1) experiencing disorientation, (2) reconceptualizing roles and responsibilities, and (3) reorientation to professional goals. Patient care ownership was disorienting because it marked a departure from the clinical roles the students had previously experienced. While disoriented, students engaged in a process of reflection during which they asked themselves who they were, who they were becoming, and who they needed to become to effectively serve in the role of a physician. This process prompted students to realize the limitations of their clinical reasoning abilities and that the role of a physician requires new ways of thinking. Conclusions: This study advances a conceptual model of PIF that identifies patient care ownership as a catalyst in developing a professional identity. Assuming responsibility for patients places students into an unfamiliar role, which opens a channel for students to access new perspectives in their development as physicians.

"It is you, me on the team together, and my child": Attending, resident, and patient family perspectives on patient ownership

INTRODUCTION

Patient ownership is an important element of physicians' professional responsibility, but important gaps remain in our understanding of this concept. We sought to develop a theory of patient ownership by studying it in continuity clinics from the perspective of residents, attending physicians, and patients.

METHODS

Using constructivist grounded theory, we conducted 27 semi-structured interviews of attending physicians, residents, and patient families within two pediatric continuity clinics to examine definitions, expectations, and experiences of patient ownership from March-August 2019. We constructed themes using constant comparative analysis and developed a theory describing patient ownership that takes into account a diversity of perspectives.

RESULTS

Patient ownership was described as a bi-directional, relational commitment between patient/family and physician that includes affective and behavioral components. The experience of patient ownership was promoted by continuity of care and constrained by logistical and other systems-based factors. The physician was seen as part of a medical care team that included clinic staff and patient families. Physicians adjusted expectations surrounding patient ownership for residents based on scheduling limitations.

DISCUSSION

Our theory of patient ownership portrays the patient/family as an active participant in the patient-physician relationship, rather than a passive recipient of care. While specific expectations and tasks will vary based on the practice setting, our findings reframe the way in which patient ownership can be viewed and studied in the future by attending to a diversity of perspectives.

Thematic analysis of qualitative data: AMEE Guide No. 131

Thematic analysis is a widely used, yet often misunderstood, method of qualitative data analysis. It is a useful and accessible tool for qualitative researchers, but confusion regarding the method's philosophical underpinnings and imprecision in how it has been described have complicated its use and acceptance among researchers. In this Guide, we outline what thematic analysis is, positioning it in relation to other methods of qualitative analysis, and describe when it is appropriate to use the method under a variety of epistemological frameworks. We also provide a detailed definition of a theme, as this term is often misapplied. Next, we describe the most commonly used six-step framework for conducting thematic analysis, illustrating each step using examples from our own research. Finally, we discuss advantages and disadvantages of this method and alert researchers to pitfalls to avoid when using thematic analysis. We aim to highlight thematic analysis as a powerful and flexible method of qualitative analysis and to empower researchers at all levels of experience to conduct thematic analysis in rigorous and thoughtful way.

Focal Length Fluidity: Research Questions in Medical Education Research and Scholarship

Research and scholarship in health professions education has been shaped by intended audience (i.e., producers vs users) and the purpose of research questions (i.e., curiosity driven or service oriented), but these archetypal dichotomies do not represent the breadth of scholarship in the field. Akin to an array of lenses required by scientists to capture images of a black hole, the authors propose the analogy of lenses with different focal lengths to consider how different kinds of research questions can offer insight into health professions research-a microscope, a magnifying glass, binoculars, and telescopes allow us to ask and answer different kinds of research questions. They argue for the relevance of all of the different kinds of research questions (or focal lengths); each provides important insight into a particular phenomenon and contributes to understanding that phenomenon in a different way. The authors propose that research questions can move fluidly across focal lengths. For example, a theoretical question can be made more pragmatic through asking "how" questions ("How can we observe and measure a phenomenon?"), whereas a pragmatic question can be made more theoretic by asking a series of "why" questions ("Why are these findings relevant to larger issues?"). In summary, only through the combination of lenses with different focal lengths, brought to bear through interdisciplinary work, can we fully comprehend important phenomena in health professions education and scholarship-the same way scientists managed to image a black hole.