Understanding ownership of patient care: A dual-site qualitative study of faculty and residents from medicine and psychiatry

Abstract

IntroductionWith changes in duty hours and supervision requirements, educators have raised concerns about erosion of patient care ownership by resident physicians. However, the definition of ownership is unclear. This qualitative study investigated definitions of ownership in medicine and psychiatry faculty and residents.MethodsThe authors distributed an anonymous online survey regarding definitions of ownership to faculty and residents at the psychiatry and internal medicine residency programs at the University of Washington and the Harvard Longwood psychiatry residency and conducted a qualitative analysis of free-text responses to identify emergent themes.Results225 faculty (48.6%) and 131 residents (43.8%) across the three programs responded. Responses yielded themes in five domains: Physician Actions, Physician Attitudes, Physician Identity, Physician Qualities, and Quality of Patient Care. All groups identified themes of advocacy, communication and care coordination, decision-making, follow through, knowledge, leadership, attitudes of going ‘above and beyond’ and ‘the buck stops here’, responsibility, serving as primary provider, demonstrating initiative, and providing the best care as central to ownership. Residents and faculty had differing perspectives on ‘shift work’ and transitions of care and on resident decision-making as elements of ownership.DiscussionThis study expanded and enriched the definition of patient care ownership. There were more similarities than differences across groups, a reassuring finding for those concerned about a decreasing understanding of ownership in trainees. Findings regarding shared values, shift work, and the decision-making role can inform educators in setting clear expectations and fostering ownership despite changing educational and care models.

The Patient Care Ownership Scale: Development of an Instrument to Measure Patient Care Ownership Among Internal Medicine Trainees

“…We developed items deductively based on the earlier work by Avey et al 12 Specifically, we adapted this scale to the constructs and themes identified in the studies by McLaren et al and Cowley et al 17,18 We constructed items with the goal of minimizing social desirability bias and the ceiling effect. 16 After developing a prototypic, 20-question ownership scale, we conducted cognitive interviews to assess the face validity of the scale items.…”

“…The first version of the ownership scale included items that measured all the constructs identified by Avey et al, 6 McLaren et al 17 , and Cowley et al 18 We made several modifications to the scale based on the cognitive interviews, which concluded after six interviews (four internal medicine residents and two attending physicians). Items were removed if there was no face validity or if ≥ 2 interviewees felt that the question was at high risk of social desirability bias or the ceiling effect.…”

“…6,15,16 The scale consists of five key constructs that measure the multi-dimensional concept of ownership: self-efficacy, accountability, sense of belongingness, self-identity, and territoriality. 6 Ownership in the medical literature has been limited to qualitative studies 17,18 and single-item questionnaires asking trainees and attending physicians whether decision ownership has worsened with stricter work hours and increased hand-offs. [7][8][9][10][11] Two qualitative descriptive studies that each sought to define ownership of patient care as it pertains to physicians identified similar constructs.…”

“…[7][8][9][10][11] Two qualitative descriptive studies that each sought to define ownership of patient care as it pertains to physicians identified similar constructs. 17,18 Analysis of narrative responses from attending and resident physicians in a 2013 study conducted by McLaren et al identified advocacy, autonomy, commitment, communication, follow-through, knowledge, and teamwork 17 as core elements of ownership. The more recent study, led by Cowley et al in 2017, identified themes of advocacy, communication, care coordination, decision-making, follow-through, knowledge, leadership, attitudes of going Babove and beyondâ nd Bthe buck stops here,^responsibility, serving as primary provider, demonstrating initiative, and providing the best care as central to ownership of patient care.…”

“…Accordingly, we developed a scale intended to reliably measure and quantify ownership of patient care based on previous research. 12,17,18…”