Gender differences on medical students’ attitudes toward patient-centred care: a cross-sectional survey conducted in Heilongjiang, China

Introduction

Traditional biomedicine practices are based on Western science, focusing on the specific disease rather than the patient as a whole and tending to grant doctors the decision-making power (Engel, 1980). Patient-centred care, which was proposed by Balint et al. and is an overall approach to medical practice compared with the biomedical medical practice, treats patients as unique human beings and establishes a more egalitarian relationship between doctor and patient (Balint, 1969; Ishikawa, Hashimoto & Kiuchi, 2013). Byrne et al. and Levenstein et al. further expanded upon these ideas, which have attracted the attention of medical practices over the past few decades (Levenstein et al., 1986). Patient-centred care has been recognized as an indispensable factor that is vital to improving the quality of healthcare delivery, patient care strategies, and medical education (Aljuaid et al., 2016).

Patient-centred care refers to the establishment of relationships among doctors, patients, and their families in order to care for patients’ needs and preferences and to provide the necessary information and support so that patients can actively participate in clinical decision-making and in their own care (America, 2001; Health & Delivery, 2001). With this approach, doctors use their communication skills to understand the patient’s ideas, expectations, emotions, preferences, and concerns about the illness in order to seek an integrated understanding of the patient’s world (Stewart, 2001; Epstein et al., 2005a; Epstein et al., 2005b; Stewart et al., 2000). Patient-centred care can also be described with two dimensions. The first dimension (i.e., the sharing dimension) refers to the sharing of power, responsibility, and information. The second dimension (i.e., the caring dimension) considers whether the patient’s feelings, expectations, and preferences are taken into account in medical decision-making (Lee et al., 2008a). Patient-centred care has been associated with positive patient outcomes in many fields by increasing satisfaction, promoting effective communication, reducing medical complaints, decreasing consultation time, improving perceptions on service delivery quality (Pereira et al., 2013; Stone, 2008; Hudon et al., 2011).

With an increase in the realization of patient-centred care’s advantages and importance, this approach has attracted attention worldwide and been measured in many countries including the United States, Brazil, and Pakistan (Haidet et al., 2002; Ribeiro, Krupat & Amaral, 2007; Ahmad et al., 2015; Mudiyanse et al., 2015). In recent years, medical educators have gradually established clinical practice courses with the purpose of teaching communication skills, professional values, attitudes, and humanistic behaviors to medical students (Schmidt, 1998). In healthcare and medical education, it is important to assess practitioners’ attitudes about care (Pereira et al., 2013). The Patient-Practitioner Orientation Scale (PPOS) is an instrument that was developed in 1999 in America to assess physicians’, medical students’, and patients’ attitudes regarding whether providers and patients should have equal power and control (Krupat et al., 1999; Street et al., 2003; Krupat et al., 2000). The Patient-Practitioner Orientation Scale (PPOS) contains a four-element patient-centred care model and has been translated into different languages and validated in several countries (Krupat et al., 1999; Kim, 2013; Tsimtsiou, Kirana & Hatzichristou, 2014; Dockens, Bellon-Harn & Manchaiah, 2016).

In southwest China, Ting et al. first attempted to use the PPOS to investigate patients’ perceptions of patient-centred communication in doctor-patient consultations (Ting et al., 2016). Later, Wang et al. improved the Chinese translation and incorporated characteristics of Chinese culture and the Chinese medical and healthcare fields to develop the Chinese-revised Patient-Practitioner Orientation Scale (CR-PPOS), which was based on the original PPOS scale (Wang et al., 2017). First, the patient-centred scale was sinicized with the permission of the original author to translate it in a Chinese context. Next, the bilingual PPOS versions were separately sent to five advanced health practitioners in China for further modifications. After that, the Chinese PPOS (C-PPOS) was then retranslated into English and sent back to the original author for confirmation regarding its accuracy. Finally, based on reliability, validity, and discriminative power tests, the C-PPOS was revised to the CR-PPOS. The psychometrics of the CR-PPOS has been validated with a reliability test (test-retest reliability) and validity tests (exploratory factor analysis, confirmatory factor analysis, and internal consistency). In the relevant study, the results were within the acceptable range. Wang et al. conducted a survey with the CR-PPOS in Shanghai, China to investigate preferences towards patient-centred communication among physicians and patients. This is the only known application of CR-PPOS in China (Wang et al., 2017). Though it is an innovative tool, the CR-PPOS does not measure medical students’ patient-centred attitudes in China. For example, it only explores physicians’ and patients’ views on patient-centred communication and lacks medical students’ views.

Medical students’ patient-centred attitudes have been measured in numerous countries. For instance, American scholar Krupat et al. measured first-year US medical students’ patient-centred attitudes and found that female students scored higher on patient-centred attitude scales than did male students (Krupat et al., 1999). Additional American scholars, Haidet and colleagues, conducted studies on patient-centred attitudes during medical education programs and established that there are gender differences in such attitudes; female medical students have a higher prevalence of these attitudes (Haidet et al., 2002). Furthermore, Kheng Hock Lee, in his study on Asian (Indian) students’ patient-centred attitudes, also demonstrated the same gender differences (Lee et al., 2008b). Therefore, existing studies have reported that there are gender differences in patient-centred attitudes. The present study will advance measurements of Chinese medical students’ patient-centred attitudes, and it will explore whether gender and other background factors impact such attitudes (as has been established in countries outside of China). In doing so, the present study will increase an understanding of patient-centred attitudes in China, and it will provide references for future medical education practices based on China’s current doctor-patient relationships and its medical/healthcare policy background.

Methods

Results

PPOS scores for different major categories and gender

The average total CR-PPOS score for the entire cohort was 3.63 ± 0.54, ranging from 1.00 to 5.55. The average ‘Caring’ score for the entire cohort was 4.53 ± 0.82, and the average ‘Sharing’ score was 2.88 ± 0.67. Figure 1 depicts the distributions of overall CR-PPOS scores by gender. The cross-sectional difference in the ‘Caring’ subscale scores, the ‘Sharing’ subscale scores, and the total CR-PPOS scores differed between females and males. Female students had significantly higher overall PPOS, ‘Caring’, and ‘Sharing’ scores (3.69 ± 0.60, 4.61 ± 0.74, 2.92 ± 0.63, respectively) than did male students (3.54 ± 0.50, 4.42 ± 0.92, 2.81 ± 0.72, respectively). Gender was significantly associated with total CR-PPOS score, ‘Caring’ subscale score, and ‘Sharing’ subscale score (P = 0.002, P = 0.009, P = 0.051, respectively).

Discussion

This is the first study to report on Chinese medical students’ attitudes toward patient-centred care. Comparing the Chinese medical students’ scores with non-Chinese medical students’ scores (measured with the same tool) promotes a more comprehensive understanding of Chinese medical students’ patient-centred attitudes. This study’s results are consistent with the results obtained in most other countries, indicating that female students tend to be more patient-centred than male students (Haidet et al., 2002; Ribeiro, Krupat & Amaral, 2007; Lee et al., 2008b).

In general, Chinese medical students tended toward patient-centred attitudes, as indicated by a mean CR-PPOS score of 3.63 (scores higher than 3.5 indicate patient-centred attitudes), which is higher than Malian (3.38) and Pakistani (3.40) medical students but lower than American (4.57) and Brazilian (4.66) medical students (Hurley et al., 2018; Ribeiro, Krupat & Amaral, 2007; Haidet et al., 2002; Ahmad et al., 2015). The Chinese medical students’ ‘Sharing’ subscales (2.88) were generally lower than Malian (3.04), Pakistani (3.18), and Brazilian (4.10) medical student scores. However, the Chinese medical students’ ‘Caring’ subscales (4.53) were generally lower than Brazilian students (5.20) but higher than Pakistani (3.63) and Malian (3.68) students. Therefore, the Chinese scores were lower than the scores reported by studies conducted in America and Brazil, but the Chinese scores are nearly equivalent to scores obtained in Pakistan and Mali.

These results might be explained by differences in socio-economic conditions or by religious and cultural differences across countries. In China, the results indicate that, although medical students generally have mid-level patient-centred attitudes, they have higher preferences for ‘Caring’ than for sharing information with patients and engaging in decision-making with patients. The difference in “Caring” versus “Sharing” subscales might be explained by different cultural values, because in Asian cultures, patients prefer doctors who are more likely to make “family-based” or “doctor-based” decisions in the process of diagnosis and treatment. This differs from the culture in Western countries, where patients prefer that the doctors share veracious ‘breaking bad news’, such as managing end-of-life care. It is a similar to Africa’s cultures that have similarly seen higher caring scores as compared to sharing (Lee et al., 2008b; Searight & Gafford, 2005; Tai & Tsai, 2003; Hurley et al., 2018). In China, Ting et al. (2016) found that patients were more likely to rely on doctors to control consultations, decision-making, and information distribution; also, Ting et al. established that patients do not think that they have the knowledge or ability to handle medical issues (Ting et al., 2016; Epstein et al., 2005a; Epstein et al., 2005b). The higher ‘Caring’ subscales might be due to medical students hoping that doctor-patient relationships can be based on mutual understanding and that patients can be treated in a friendly way in accordance with their psychosocial background information (Ting et al., 2016).

This study showed that there is a difference between female and male students in that female students tend to have more patient-centred attitudes than male students (Ribeiro, Krupat & Amaral, 2007). The female students surveyed in this study displayed higher mean scores than male students for the overall CR-PPOS scores and for the ‘Sharing’ and ‘Caring’ subscale scores. Women are seen as more empathetic and as having better communitarian orientations than men (Wahlqvist et al., 2010). Hojat et al. (2009), in a study on the empathy of medical students, demonstrated that there are differences by gender regarding the development of empathy throughout medical school. Moreover, in communicating with patients, women (more so than men) have greater communication abilities that involve more positive conversations, higher use of emotional conversations, and active consultations with patients, which might mean that they are more acceptable to patients (Roter, Hall & Aoki, 2002). Furthermore, these characteristics of female doctors might explain why there are fewer lawsuits against female doctors around the world (Sandhu et al., 2009). In general, our results corroborate the findings of these existing studies.

Previous PPOS measurement results have indicated that patient-centred attitudes can be influenced by both investigators’ personal characteristics and social environmental factors. In the present study, students at the First-affiliated hospital displayed higher CR-PPOS, ‘Caring’, and ‘Sharing’ mean scores for patient-centred care. It is plausible that these results can be explained by patients’ varying residences and by the specific economic conditions at the different affiliated hospitals. Compared with other affiliated hospitals, the First-affiliated hospital patients were largely from local areas, and they therefore harmoniously communicated with doctors due to having similar cultural backgrounds. There is also evidence that patients’ attitudes and behaviors exhibited during the clinical encounters can influence doctors’ patient-centred preferences (Lee et al., 2008b), which might help explain why the patient-centred care scores at the First-affiliated hospital were higher than the scores obtained at the other hospitals.

The seven-year clinical category students had higher ‘Caring’ subscale scores than did the five-year clinical category students; however, interestingly, they scored lower on the ‘Sharing’ subscale than did the five-year category students. This might be because the seven-year category medical students were participating in clinical doctor-patient communication courses during the investigation; however, the five-year clinical category students had previously taken such courses before the investigation started. The timing of when a student participates in the practical courses has an impact on the ‘Sharing’ and ‘Caring’ dimensions. While taking a doctor-patient communication course in clinical practice, the seven-year clinical category students are more likely to have empathy and to be able to use the patients’ perspectives to understand patients and to provide care. Also, these students regard patients as a group that needs to be cared for rather than as a group with equal rights to doctors; therefore, these students then have higher ‘Caring’ subscale scores but lower ‘Sharing’ subscale scores compared with the five-year clinical category students.

This study also found that students with siblings have higher Sharing scores. One possible explanation for this findings is that the students with siblings are more likely to share, to communicate, and to pay attention to others’ feelings in their daily lives. These explanations help shed light on why these students achieved higher Sharing scores.

Conclusion

In general, our findings indicated that Chinese medical students’ attitudes are more patient-centred as measured by the CR-PPOS and ‘Caring’ subscale scores but less patient-centred as measured by the ‘Sharing’ subscale scores. Gender has a significant impact on medical students’ patient-centred attitudes, as has been reported in other countries. Higher patient-centred attitudes were also associated with seven-year clinical category students, students who studied at the First-affiliated hospital, students from villages, and students without siblings.

Our research indicates that, if medical schools want to bridge the gap between male and female patient-centred attitudes and to improve patient-centred attitudes, more attention should be paid to the doctor-patient communication courses in clinical practice. The patient-centred differences by gender, major categories, and other factors should be incorporated into medical education. We suggest that the Chinese medical schools learn from Sweden’s mixed-group education method, in which male students actively role play doctor-patient communication scenarios so that they develop patience and become approachable (even though there are still distinct differences between men and women) (Wahlqvist et al., 2010). Moreover, it is important that medical schools think critically about at which point in the categories they should offer the relevant doctor-patient communication courses. In addition, this study also identifies that medical students’ personal characteristics and social environmental factors impact their patient-centred care attitudes. Improving medical students’ patient-centred skills via relevant medical education can result in establishing more high-quality medical services in China. However, education reform alone cannot fully achieve patient-centred care; instead, society as a whole and the entire healthcare system also need to affirm the value and significant of patient-centred care before it can be fully realized.

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