Résumés
Abstract
Background: Ownership of patient care is a concept that embodies a number of professionalism attributes and involves a feeling of strong commitment and responsibility towards patient care. Little is known about how the embodiment of this concept develops in the earliest stages of clinical training. The goal of this qualitative study is to explore the development of ownership of patient care in clerkship.
Methods: Using qualitative descriptive methodology, we conducted twelve one-on-one in-depth semi-structured interviews with final-year medical students at one university. Each participant was asked to describe their understanding and beliefs with regards to ownership of patient care and discuss how they acquired these mental models during clerkship, with emphasis on enabling factors. Data were inductively analyzed using qualitative descriptive methodology and with professional identity formation as the sensitizing theoretical framework.
Results: Ownership of patient care develops in students through a process of professional socialization that includes enabling factors such as role modelling, student self-assessment, learning environment, healthcare and curriculum structures, attitudes of and treatment by others, and growing competence. The resulting ownership of patient care is manifested as understanding patients’ needs and values, engaging patients in their care, and maintaining a strong sense of accountability for patients’ outcome.
Conclusion: An understanding of how ownership of patient care develops in early medical training and the associated enabling factors can inform strategies aimed at optimizing this process, such as designing curricula with more opportunities for longitudinal patient contact and fostering a supportive learning environment with positive role modelling, clear attribution of responsibilities, and purposefully granted autonomy.
Résumé
Contexte/objectif : Le sentiment de responsabilité face aux soins des patients est un concept qui englobe un certain nombre d'attributs liés au professionnalisme et suppose un fort sentiment d’engagement et de devoir quant aux soins aux patients. On sait peu de choses sur la concrétisation de ce concept dans les premières étapes de la formation clinique. Cette étude qualitative vise à explorer le développement du sentiment de responsabilité face aux soins des patients durant l'externat.
Méthodes : À l'aide d'une méthodologie qualitative descriptive, nous avons mené douze entretiens individuels approfondis semi-structurés avec des étudiants en dernière année de médecine d’une université. Nous avons demandé aux participants de décrire leur compréhension et leurs croyances concernant le sentiment de responsabilité face aux soins des patients et d’expliquer la façon dont ces modèles mentaux leur ont été transmis pendant l'externat, avec une emphase sur les facteurs facilitateurs. Les données ont été analysées de manière inductive à l'aide d'une méthodologie descriptive qualitative prenant la formation de l'identité professionnelle comme cadre théorique sensibilisateur.
Résultats : Le sentiment de responsabilité face aux soins des patients ' se développe chez les étudiants par le biais d'un processus de socialisation professionnelle qui comprend des facteurs facilitateurs comme les modèles de rôles, l'auto-évaluation chez l'étudiant, l'environnement d'apprentissage, les structures des soins de santé et du cursus, les attitudes et les interactions avec les autres, et le développement de la compétence. Le sentiment de responsabilité face aux soins des patients qui en résulte se manifeste par une compréhension des besoins et des valeurs des patients, par l’engagement du patient dans leurs soins et par le maintien d'un fort sentiment d’imputabilité par rapport à leurs résultats de santé (« outcomes »).
Conclusion : Il est utile de comprendre le processus par lequel se développe le sentiment de responsabilité face aux soins des patients au début de la formation médicale et les facteurs qui facilitent cette appropriation pour élaborer des stratégies visant à l’optimiser. À titre d’exemple, on peut envisager la conception de cursus qui offrent plus d’occasions de contacts longitudinaux avec les patients et un environnement d’apprentissage favorable avec la présence d’un modèle de rôle positif, l’attribution de responsabilités clairement définies et l’octroi volontaire d’une autonomie grandissante aux externes.
Parties annexes
Bibliography
- Van Eaton EG, Horvath KD, Pellegrini CA. Professionalism and the shift mentality: how to reconcile patient ownership with limited work hours. Arch Surg. 2005;140(3):230-5. https://doi.org/10.1001/archsurg.140.3.230
- McLaren K, Lord J, Murray SB, et al. Ownership of patient care: a behavioural definition and stepwise approach to diagnosing problems in trainees. Perspect Med Educ. 2013;2(2):72-86. https://doi.org/10.1007/s40037-013-0058-z
- Masson V, Snell L, Dolmans D, Sun NZ. Exploring the evolving concept of ‘patient ownership’ in the era of resident duty hour regulations. International Conference on Residency Education; September 30, 2016; Niagara Falls, Canada2016.
- Kiger ME, Meyer HS, Hammond C, et al. Whose patient is this? A scoping review of patient ownership. Acad Med. 2019;94(11S):S95-S104. https://doi.org/10.1097/ACM.0000000000002920
- Sun NZ, Gan R, Snell L, Dolmans D. Use of a night float system to comply with resident duty hours restrictions: perceptions of workplace changes and their effects on professionalism. Acad Med. 2016;91(3):401-8. https://doi.org/10.1097/ACM.0000000000000949
- Greenzang KA, Kesselheim JC. Responsibility for patient care in graduate medical education: yours, mine, or ours? JAMA Pediatr. 2015;169(11):987-8. https://doi.org/10.1001/jamapediatrics.2015.1825
- Cruess RL, Cruess SR, Boudreau JD, Snell L, Steinert Y. Reframing medical education to support professional identity formation. Acad Med. 2014;89(11):1446-51. https://doi.org/10.1097/ACM.0000000000000427
- Keegan R. The evolving self: problem and process in human development. Cambridge: Harvard UP. 1982.
- Tien L, Wyatt TR, Tews M, Kleinheksel A. Simulation as a tool to promote professional identity formation and patient ownership in medical students. Simulation & Gaming. 2019;50(6):711-24. https://doi.org/10.1177/1046878119869038
- Wyatt TR. Investigating the meaning of patient ownership: an exploratory study of a commonly used phrase within an internal medicine department. J Med Humanit.2020. https://doi.org/10.1007/s10912-020-09632-8
- Latessa R, Schmitt A, Beaty N, Buie S, Ray L. Preceptor teaching tips in longitudinal clerkships. Clin Teach. 2016;13(3):213-8. https://doi.org/10.1111/tct.12416
- Wyatt TR, Bowen J, Mann K, Regehr G, Cianciolo AT. Coming in from the cold-physician professional development as deepening participation in the healthcare community. Teach learn med. 2016;28(4):358. https://doi.org/10.1080/10401334.2016.1208095
- Wood E, Wyatt T, Egan S. Clinical setting differences in third-year medical students’ perceptions of “ownership.” JRMC. 2019;2(1). https://doi.org/10.24926/jrmc.vXiX.XXX
- Sandelowski M. Focus on research methods-whatever happened to qualitative description? Res Nurs Health. 2000;23(4):334-40. https://doi.org/10.1002/1098-240X(200008)23:43.0.CO;2-G
- Kim H, Sefcik JS, Bradway C. Characteristics of qualitative descriptive studies: a systematic review. Res Nurs Health. 2017;40(1):23-42. https://doi.org/10.1002/nur.21768
- Guest G, Bunce A, Johnson L. How many interviews are enough? An experiment with data saturation and variability. Field methods. 2006;18(1):59-82. https://doi.org/10.1177/1525822X05279903
- Boddy CR. Sample size for qualitative research. Qual. Mark. Res. 2016;19(4):426-32. https://doi.org/10.1108/qmr-06-2016-0053
- Dicicco-Bloom B, Crabtree BF. The qualitative research interview. Med Educ. 2006;40(4):314-21. https://doi.org/10.1111/j.1365-2929.2006.02418.x
- Greenzang KA, Revette AC, Kesselheim JC. Patients of our own: defining “ownership” of clinical care in graduate medical education. Teaching learn med. 2019:1-9. https://doi.org/10.1080/10401334.2018.1556103
- Soeprono T, Markman J, Grodesky M, Cowley D. Practical interventions to enhance resident ownership of patient care. Acad Psychiatry. 2018;42(2):222-7. https://doi.org/10.1007/s40596-017-0731-3
- Cruess RL, Cruess SR, Boudreau JD, Snell L, Steinert Y. A schematic representation of the professional identity formation and socialization of medical students and residents: a guide for medical educators. Acad Med. 2015;90(6):718-25. https://doi.org/10.1097/ACM.0000000000000700
- Saba GW, Villela TJ, Chen E, Hammer H, Bodenheimer T. The myth of the lone physician: toward a collaborative alternative. Ann Fam Med. 2012;10(2):169-73. https://doi.org/10.1370/afm.1353
- Djulbegovic M, Beckstead JW, Fraenkel L. The patient care ownership scale: development of an instrument to measure patient care ownership among internal medicine trainees. J Gen Intern Med. 2019:1-8. https://doi.org/10.1007/s11606-019-05066-8
- Pololi L, Frankel R, Clay M, Jobe A. One year′ s experience with a program to facilitate personal and professional development in medical students using reflection groups. Educ Health. 2001;14(1):36-49. https://doi.org/10.1080/13576280010015074
- Stephenson AE, Adshead LE, Higgs RH. The teaching of professional attitudes within UK medical schools: reported difficulties and good practice. Med ed. 2006;40(11):1072-80. https://doi.org/10.1111/j.1365-2929.2006.02607.x
- Benbassat J. Undesirable features of the medical learning environment: a narrative review of the literature. Adv Health Sci Educ. 2013;18(3):527-36. https://doi.org/10.1007/s10459-012-9389-5
- Jarvis-Selinger S, MacNeil KA, Costello GRL, Lee K, Holmes CL. Understanding professional identity formation in early clerkship: a novel framework. Acad Med. 2019;94(10):1574-80. https://doi.org/10.1097/ACM.0000000000002835
- Wyatt TR, Egan SC, Wood E. Assessing patient ownership in clerkships: an exploratory study of student and clerkship directors’ perceptions. J Contemp Med Edu. 2018;7(2):38-41. DOI:10.1177/1046878119869038
- Ogur B, Hirsh D. Learning through longitudinal patient care—Narratives from the Harvard Medical School–Cambridge integrated clerkship. Acad Med. 2009;84(7):844-50. https://doi.org/10.1097/ACM.0b013e3181a85793
- Norris TE, Schaad DC, DeWitt D, Ogur B, Hunt DD, Consortium of Longitudinal Integrated C. Longitudinal integrated clerkships for medical students: an innovation adopted by medical schools in Australia, Canada, South Africa, and the United States. Acad Med. 2009;84(7):902-7. https://doi.org/10.1097/ACM.0b013e3181a85776
- Walters L, Greenhill J, Richards J, et al. Outcomes of longitudinal integrated clinical placements for students, clinicians and society. Med Educ. 2012;46(11):1028-41. https://doi.org/10.1111/j.1365-2923.2012.04331.x
- Jarvis-Selinger S, Pratt DD, Regehr G. Competency is not enough: integrating identity formation into the medical education discourse. Acad Med. 2012;87(9):1185-90. https://doi.org/10.1097/ACM.0b013e3182604968
- Biondi EA, Varade WS, Garfunkel LC, et al. Discordance between resident and faculty perceptions of resident autonomy: can self-determination theory help interpret differences and guide strategies for bridging the divide? Acad Med. 2015;90(4):462-71. https://doi.org/10.1097/ACM.0000000000000522