Association Between Resident Physicians’ Self-Rated Patient Care Ownership and Medical Professionalism Assessed by Patients: A Single-Center Study

TL;DR

This study found no link between resident physicians' self-rated patient care ownership and how patients assessed their professionalism.

Contribution

It is the first to examine the relationship between self-rated PCO and patient evaluations of professionalism in a Japanese clinical setting.

Findings

J-PCOS scores were not associated with J-IPAMP scores after adjusting for confounders.

Patients may evaluate professionalism based on visible behaviors rather than systemic responsibilities.

Residents and patients may prioritize different aspects of care, leading to a disconnect in evaluations.

Abstract

Introduction

Patient care ownership (PCO) has received substantial attention as a core aspect of medical professionalism. In recent years, a quantitative PCO Scale (PCOS) has been developed and widely utilized. Despite its growing importance, PCOS is measured through resident physician self-assessment, and the association between PCOS scores and resident evaluation by patients, the primary stakeholders in clinical care, remains underexamined.

Methods

This study was conducted at a rural postgraduate clinical training hospital in Japan from July 2022 to March 2023. PCO was assessed using the Japanese version of the PCOS (J-PCOS) as the explanatory variable. Patient-reported medical professionalism was measured using the Japanese version of the Instrument for Patient Assessment of Medical Professionalism (J-IPAMP) as the outcome variable. A linear mixed-effects model was employed to adjust for clustering within residents and individual covariates.

Results

Twelve residents and 99 of their patients were included in the analysis. After adjusting for potential confounders and clustering within physicians, J-PCOS scores were not associated with J-IPAMP scores.

Conclusions

Residents’ self-rated PCO was not associated with patient-reported professionalism. This may be because patients cannot observe key aspects of PCO, such as interprofessional communication and decision-making, and instead evaluate professionalism based on visible behaviors, such as bedside manner. Differences in priorities, with patients focusing on relational aspects of care while physicians emphasize systemic responsibilities and outcomes, may also contribute to this disconnect. Future studies should employ a multicenter design in Japan and conduct analogous surveys internationally.

Tables

Table 1. Characteristics of the participantsJ-PCOS scores range from 7 to 91, with higher scores indicating greater PCO. J-IPAMP scores range from 5 to 55, with higher scores indicating a higher level of medical professionalism as assessed by patients.J-IPAMP, Japanese version of the Instrument for Patient Assessment of Medical Professionalism; J-PCOS, Japanese version of the Patient Care Ownership Scale; PCO, patient care ownership

Characteristic	Value
Physicians
Sex, n (%)
Female	4 (33.3)
Male	8 (66.7)
Others	0 (0.0)
PGYs, n (%)
1	2 (16.7)
2	1 (8.3)
3	3 (25.0)
4	2 (16.7)
5	4 (33.3)
Specialty, n (%)
Internal medicine	10 (83.3)
Orthopedics	2 (16.7)
J-PCOS, mean (SD)	64.7 (8.9)
Patients
Sex, n (%)
Female	46 (46.5)
Male	53 (53.5)
Others	0 (0.0)
Age group, n (%)
20-24 years	1 (1.0)
25-34 years	3 (3.0)
35-44 years	5 (5.1)
45-54 years	13 (13.1)
55-64 years	18 (18.2)
65-74 years	28 (28.3)
≥75 years	31 (31.3)
Education, n (%)
Less than high school	10 (10.1)
High school	45 (45.5)
Junior college	27 (27.3)
College or higher	17 (17.2)
Duration of hospitalization, n (%)
1-10 days	64 (64.6)
11-20 days	19 (19.2)
21-30 days	8 (8.1)
31-40 days	3 (3.0)
41-50 days	1 (1.0)
51-60 days	2 (2.0)
≥61 days	2 (2.0)
J-IPAMP, mean (SD)	41.7 (8.9)

Table 2. Association of J-PCOS with J-IPAMPThe random intercept model was adjusted for resident physicians’ sex, PGYs, and specialty.J-IPAMP, Japanese version of the Instrument for Patient Assessment of Medical Professionalism; J-PCOS, Japanese version of the Patient Care Ownership Scale; PGY, postgraduate year

Unadjusted mean difference	95% CI	Adjusted mean difference	95% CI
-0.03	-0.26 to 0.21	-0.05	-0.27 to 0.18

Full text

Introduction

There has been growing global interest in medical professionalism [1]. It is essential for maintaining public trust in healthcare [2] and has been shown to influence physician-patient relationships, quality of care, and ultimately health outcomes [3]. Therefore, fostering medical professionalism among physicians is crucial for ensuring optimal patient care [1].

Recently, patient care ownership (PCO) has received considerable attention as a key component of medical professionalism [4]. PCO refers to the affective-cognitive state arising from a physician’s knowledge and management of patients, as well as their emotional investment in patient relationships [5-7]. It is expected that strong PCO enhances clinical skills and improves patient care quality [5,8,9], making its cultivation during residency particularly important.

Traditionally, PCO has been described as “the philosophy that one (i.e., the doctor) knows everything about one’s patients and does everything for them” [10]. However, recent research has expanded the concept to encompass multiple dimensions, including physician actions (advocacy, communication and care coordination, therapeutic decision-making, follow-through, acquiring knowledge of the patient, and leadership), physician attitudes (doing more than the minimum requirement, viewing oneself as ultimately responsible, and feeling accountable for patient care and outcomes), physician identity (serving as the primary or main care provider), physician qualities (taking initiative), and quality of patient care (ensuring comprehensive, longitudinal, and patient-centered care) [4].

Previous research on PCO was largely qualitative. In 2019, the quantitative PCO Scale (PCOS) was developed in the US, and its reliability and validity were confirmed in multicenter studies [11]. A Japanese version of the PCOS (J-PCOS) was developed in 2021 and shown to have acceptable reliability and validity among Japanese medical residents [12]. This scale is expected to be useful in a variety of settings, including educational program research aimed at fostering ownership and exploratory studies on the impact of ownership on healthcare outcomes [11,12].

Nevertheless, PCOS is measured through resident self-assessment, and the association between PCOS scores and patient evaluation of residents, arguably the most important stakeholders in clinical care, remains unknown. Our research question was therefore as follows: Is residents’ self-rated PCO associated with medical professionalism as evaluated by patients?

Materials and methods

Study design and participants

From July 2022 to March 2023, we conducted a cross-sectional study at a postgraduate clinical training hospital, a community hospital located in a rural area of Japan. Residents in postgraduate years (PGYs) 1-5 who were enrolled in the hospital’s clinical training program during the study period were eligible. Residents who declined participation were excluded. Patients were eligible if they were inpatients aged 20 years or older under the care of participating residents during the survey period. Patients were excluded if they were unable to complete the questionnaire due to severe physical or mental disorders or if they declined participation.

Questionnaires for medical residents were distributed via the training administrator, while those for patients were distributed by receptionists or survey staff. Patients completed the questionnaire, placed it in an envelope, and submitted it to a collection box at the hospital. Both residents and patients were informed that participation was voluntary and that responses would be accessible only to the researchers. Informed consent was obtained from all participants.

Outcome variable: instrument for patient assessment of medical professionalism

Patient medical professionalism was assessed using the Japanese version of the Instrument for Patient Assessment of Medical Professionalism (J-IPAMP) [13] (Appendix A). The original IPAMP was developed by Ratelle et al. in 2020 [14], building on earlier instruments by Dine et al. and the American Board of Internal Medicine, which demonstrated good internal consistency, reliability, and construct validity [15-17]. Ratelle et al. iteratively refined the instrument, confirming its acceptable reliability and validity [14]. The J-IPAMP, developed in 2021, has also demonstrated sufficient reliability and validity [13]. It is an 11-item tool scored on a 5-point Likert scale (1 = poor, 2 = fair, 3 = good, 4 = very good, and 5 = excellent), giving a total score range of 11-55, with higher scores indicating greater patient-assessed medical professionalism [13].

Explanatory variable: PCOS

Residents’ PCO was assessed using the Japanese version of the PCOS (J-PCOS) [12], a 13-item questionnaire (Appendix B). Each item is scored on a 7-point Likert scale (1 = strongly disagree to 7 = strongly agree), giving a total score range of 13-91, with higher scores indicating higher levels of PCO [12]. The J-PCOS score was used as the explanatory variable.

Covariates

Based on prior research [11,12,14,18], we selected covariates potentially associated with PCO and patient-assessed professionalism. These included residents’ sex, PGY level, and specialty.

Statistical analysis

Data consisted of patients nested within physicians, suggesting the need for multilevel modeling due to the hierarchical structure. Accordingly, we used a linear mixed-effects model (random intercept model) with random effects for physicians and fixed effects for covariates (residents’ sex, PGYs, and specialty). Statistical assumptions for the linear mixed-effects model were checked and met prior to analysis.

The sample size was determined based on feasibility, including all PGY 1-5 residents training at the hospital during July 2022-March 2023 and all inpatients aged ≥20 years under their care during the survey period. We conducted a complete case analysis, including only resident-patient dyads with no missing data. A dyad was considered complete when the dependent variable (patient-rated professionalism), explanatory variable (resident self-rated PCO), and all covariates were observed. Statistical significance was set at a two-tailed p-value < 0.05. Analyses were performed using IBM SPSS Statistics for Mac, Version 29.0 (Released 2022; IBM Corp., Armonk, NY, USA).

Ethical considerations

The study was approved by the Institutional Review Board of the University of Tokyo (2021074NI).

Results

Twelve of the 13 eligible medical residents agreed to participate in the study. Of the 105 patients who consented and completed the questionnaire, six had missing data. Consequently, 99 patients were included in the analysis. Participants’ characteristics are summarized in Table 1.

Table 2 presents the results of the multilevel analysis examining the association between J-PCOS and J-IPAMP scores. After adjusting for potential confounders and clustering within physicians, J-PCOS scores were not significantly associated with J-IPAMP scores (adjusted mean difference per 1-point increase in J-PCOS, -0.05; 95% CI: -0.27 to 0.18).

Discussion

Our study indicated that there was no significant association between scores of the J-PCOS and J-IPAMP. These findings suggest a discrepancy between PCO as assessed by residents themselves and as perceived by their patients.

Several studies have reported a perception gap between healthcare professionals and patients. A Canadian cross-sectional study demonstrated that doctors and patients held differing perspectives on doctors’ communication skills during clinical encounters [19]. Similarly, a German study found that physicians’ perceptions of healthcare service quality substantially differed from those of patients and other employee groups [20]. To our knowledge, however, no prior studies have compared residents’ self-evaluated performance with patient-assessed evaluations. Our findings underscore the importance of assessing medical residents from multiple stakeholder perspectives, particularly patients.

The lack of association between PCO and professionalism assessed by patients may be explained by several factors. First, the two constructs do not necessarily measure the same behavioral domains. Core elements of PCO, such as advocacy, interprofessional communication, and behind-the-scenes decision-making, are often not directly observable by patients. Patients are more likely to evaluate professionalism based on visible interactions, such as bedside manner [21]. Second, patients and physicians may prioritize different aspects of care: patients may emphasize relational components, while physicians focus on systemic responsibilities and outcomes [22]. High-context cultures, which are predominant in Japan and other Asian countries, rely heavily on indirect and nonverbal communication [23]. In such settings, these differences in priorities may remain unspoken, perpetuating divergence. Additionally, in Japan, cultural values such as courtesy and harmony may lead patients to focus more on relational aspects when assessing professionalism [24]. Future research could explore how patient and resident perspectives align or diverge in evaluating professionalism and ownership of patient care.

We note three limitations of our study. First, this was a single-center study, so selection bias cannot be excluded. Conducted in a rural community hospital, the characteristics of residents and patients may differ from those in urban or university hospitals, potentially affecting questionnaire responses [25]. Future studies should examine this research question across multiple institutions with diverse settings. Moreover, the limited sample size may have reduced statistical power, meaning the null result should be interpreted as inconclusive rather than evidence of no association. Second, the study occurred during the COVID-19 pandemic. Residents may have limited direct patient interaction due to infection-control policies, shifting aspects of care to team interactions outside patients’ view. This context could diminish patients’ ratings of relational behaviors and obscure the visibility of ownership behaviors, further weakening any observable association with PCO. Third, although covariates were selected based on previous literature, unknown confounders may have influenced the results. For instance, patient disease severity and treatment outcomes could affect both resident behavior and patient evaluations.

Despite these limitations, two key implications emerge. First, evaluation of residents’ PCO should employ a multi-source, multi-method approach. Medical educators should triangulate self-rated PCO with patient-reported professionalism, 360-degree evaluations from other healthcare professionals [26], and structured direct observation. Second, PCO is influenced by cultural and systemic contexts; what is visible and valued varies across settings [27]. Future research should therefore include multicenter studies within Japan and similar studies internationally to facilitate cross-cultural comparison. Such evidence will enhance our understanding of residents’ PCO and inform strategies to foster professionalism across diverse healthcare environments.

Conclusions

Our study showed that J-PCOS scores were not associated with J-IPAMP scores. This lack of association may reflect patients’ limited ability to observe many aspects of PCO, such as interprofessional communication and decision-making, leading them to evaluate professionalism based primarily on observable interactions, like bedside manner. Additionally, differences in priorities, with patients emphasizing relational aspects of care while physicians focus on systemic responsibilities and outcomes, may contribute to this disconnect. Future research should include multicenter studies within Japan, as well as comparable studies internationally, to better understand these dynamics.