The concept of ownership
, or more specifically, psychological ownership
, is well described within the organizational psychology literature [1
]. When people develop a sense of ownership towards a target, they tend to seek to ‘protect and improve the [target] of the ownership’, which can be tangible (e.g. an object) or intangible (e.g. a process) [1
]. In medicine, ownership of patient care, often referred to as patient ownership
, is widely recognized as a key element of medical professionalism and as a critical skill to develop during residency training [2
]. It has traditionally been described as ‘the philosophy that one knows everything about one’s patients and does everything for them’ [3
], and as ‘being assigned the care of a patient 24 h a day, 7 days a week; being responsible for the patient’s management and eventual disposition; and being the one person in charge of decision-making’ [4
]. Since the advent of resident duty hour regulations, multiple authors have raised concerns about their impact on the development of patient ownership, fearing that shift-based scheduling might threaten acquisition of this important skill [3
]. The applicability of existing conceptual definitions of patient ownership [2
] in the context of newer scheduling systems that are compliant with duty hour regulations is unclear. Furthermore, how residents’ development of patient ownership may be influenced by duty hour regulations, such as through the use of night float scheduling, remains unknown. In this study, we sought to explore how internal medicine residents and faculty describe resident patient ownership in the context of an in-patient teaching unit with duty hour regulations, and to understand how its development in residents might have been affected by the introduction of shift-based scheduling.
In this study, staff physicians and residents identified three key features of patient ownership within the context of an internal medicine in-patient service with duty hour regulation: continuous personal concern for patients, professional capacity for autonomous decision-making, and having detailed knowledge of patients’ issues. Previous studies have also highlighted autonomy, commitment, and knowledge as essential elements of patient ownership within the specific context of psychiatry and internal medicine residency programs [2
]. This echoes our findings, supporting the importance of these consistent key elements to the concept of patient ownership across not only different subspecialties, but also different scheduling systems.
From a theoretical perspective, our participants’ description of patient ownership strongly parallels the concept of psychological ownership. Pierce et al. describe three mechanisms by which people come to feel psychological ownership towards a target: by ‘investing self into the target’, by ‘controlling the target’, and by ‘coming to intimately know the target’ [12
]. If patient care is considered the target of ownership, parallels can be drawn as follows: continuous personal concern for patients (investing self into patient care), professional capacity for autonomous decision-making (controlling patient care), and detailed knowledge of patients’ issues (coming to intimately know the details of patient care).
Some authors have expressed concerns over the implied notions of power and dominance in the word ‘ownership’, which can potentially undermine collaborative care and patient empowerment [13
]. The appropriateness of the word ‘ownership’ is further challenged by the study by Lingard et al., which outlines the collaborative complexity that can arise from involvement of different medical teams in patient care and the lack of ‘stable locus of control or authority’ in such context [14
]. However, despite the potential paternalistic and individualistic connotations of the theme ‘professional capacity for decision-making’, we believe that, taken as a whole, the three key features of patient ownership we identified support a patient ownership construct that is in keeping with the predominant discourse in the literature, which is patient-centred with notions of commitment, responsibility, accountability, advocacy, and continuity [3
In our study, we did not find significant divergence between resident and faculty perceptions of patient ownership or of the factors enabling its development in residents, which contrasts others’ observations [2
]. This difference may be explained by the fact that, while others have explored how residents and faculty define patient ownership as constructed by each group’s own experience, we asked our faculty participants to specifically reflect on resident patient ownership, which may not be the same as their conception of faculty patient ownership.
Analyzing the impact of night float scheduling on resident patient ownership, we identified a number of both positive and negative noteworthy effects. Comparing night float with the previous 24-hour scheduling system, study participants felt that being more rested and having a more consistent interaction with patients over consecutive days without the interruptions caused by post-call days made it easier for residents to develop patient ownership. This finding of more consistent patient interaction echoes those of Mathew et al., who also observed that night float scheduling positively affected senior residents’ patient ownership on internal medicine clinical teaching units as a result of improved continuity of care during daytime hours [16
]. This contrasts with other authors’ portrayal of the negative impact of duty hour regulations on continuity of patient care and patient ownership in surgical residents [17
], which raises interesting questions about the influence of specialty-specific context and culture.
The increased number of handovers was felt to have the potential to limit trainees’ knowledge of patient issues and consequently their sense of patient ownership. Additionally, residents and staff physicians both agreed that the limited presence of supervising clinicians at night creates a more permissive work environment due to reduced role modelling and guidance for decision-making and may impede the development of patient ownership in residents with weaker work ethics. The importance of resident autonomy for the development of patient ownership has been highlighted by several other studies [8
]. Our study identifies the additional nuanced view that, when left without adequate supervision at night, trainees sometimes feel uncomfortable making autonomous decisions, which can deleteriously impact ownership taking. This phenomenon has previously been described by Olmos-Vega et al., who highlighted that residents retreat to being passive observers when they perceive a lack of autonomy within an unsafe learning environment, such as when the supervisor is unavailable [23
]. In our study, this translated into the risk of compromising residents’ development of patient ownership.
Those with experience with the prior 24-hour call scheduling system highlighted the positive impact of the marked improvement in consistency of resident-patient contact, both during daytime and night-time. We believe that the structure of our night float system, which employs a stable team of residents independent from the daytime teams (thus protecting the latter’s integrity) over a number of consecutive night shifts (thus providing consistency in patient contact), played an important role in fostering patient ownership.
Deconstructing the concept of patient ownership helps us to better understand its key features, which can help inform assessment criteria and guide learning environment optimization to promote its development. Clearly articulated assessment criteria can inform selection of entrustable professional activities and associated milestones as we transition to competency-based medical education. The key descriptors of patient ownership that we found help to complement the developing literature [2
] in providing a better understanding of this concept and how it relates to the broader concept of psychological ownership.
We identified a few elements of night float scheduling that may impair development of patient ownership in residents and argue that these can be mitigated by institutions and training programs. For instance, residency training programs might consider facilitating faculty contact with residents working night shifts, including encouraging open discussions between residents and faculty regarding expectations related to when residents should engage in autonomous decision-making at night (with review of decisions delayed until the next morning) and when they should seek immediate guidance. Curricula should aim to integrate opportunities to support residents’ autonomous decision-making. For example, using simulations to practice challenging clinical scenarios might empower trainees to feel more capable of making decisions when left unsupervised. Our findings suggest that consistency of resident-patient contact is a key element of ownership. Night float systems should therefore be purposefully designed to provide stability of both daytime and night-time teams and thus permit consistent resident-patient interaction for the entire duration of residents’ clinical teaching unit (and night float) rotations. Finally, given the important impact of information transfer on patient ownership, we suggest that residency programs should work towards adopting the principles of continuity-enhanced handovers as proposed by Arora et al. and encouraging a culture where both the leaving and receiving parties are held accountable for providing high-quality handovers [24
Our study has a number of limitations. This was a single-centre study focusing on data gathered from one residency training program within the specific context of internal medicine clinical teaching units. The specific night float scheduling system used at our institution might also differ in part from others used elsewhere [25
]. However, we hope the detailed description of our study context (Appendix 1 of the Electronic Supplementary Material) will help inform the transferability of our findings.