Building a professionalism framework for healthcare providers in China: A nominal group technique study

Abstract

Background: Medical professionalism is valued globally. However, Western frameworks of medical professionalism may not resonate with the cultural values of non-Western countries.

Aims: This study aims to formulate a professionalism framework for healthcare providers at Peking Union Medical College (PUMC) in China.

Methods: This study was conducted using nominal group technique (NGT) in a convenient sample of 97 participants at PUMC in November and December, 2011. Participants were sorted into 13 occupational groups, each discussing and ranking categories of medical professionalism. The authors compared the results of each group's ranked categories and analyzed meeting transcripts.

Results: A pre-existing framework provided eight categories: clinical competence, communication, ethics, humanism, excellence, accountability, altruism, and integrity. Participants created four categories: teamwork, self-management, health promotion, and economic considerations. Clinical competence and communication ranked highly among most groups. Only hospital volunteers and resident physicians included self-management in their top-ranked items. Only public health experts prioritized health promotion. Standardized patients were unique in mentioning “economic considerations.” Medical students and attending physicians both referenced Chinese traditional values.

Conclusions: Our study was able to document effects of East Asian cultural influences and conflicts between Western ideologies and Asian traditions that led to divergent interpretations of medical professionalism.

Introduction

Medical professionalism has gained increasing prominence in both clinical medicine and medical education over the past two decades (Hodges et al. 2011). In the 1990s, the American Board of Internal Medicine (ABIM) embarked on “Project Professionalism” and proposed six elements of professionalism (American Board of Internal Medicine Committee on Evaluation of Clinical Competence 1995), which included altruism, accountability, excellence, duty, honor and integrity, and respect for others. There is no dispute that medical professionalism is crucial as professional and regulatory organizations require the incorporation of medical professionalism into professional codes and training programs (Medical Professionalism Project 2002; ACGME-International 2010; Liaison Committee on Medical Education 2010). However, how to establish elements of medical professionalism and how to teach and assess them remains controversial (Wilkinson et al. 2009; Hafferty & Castellani 2010; Tsai et al. 2012) and limited to Western literature.

Because medical professionalism is a social construct, the ways in which it is conceptualized may vary by region and cultural environment (Al-Eraky & Chandratilake 2012). Some Asian countries have adopted themes and contents of medical professionalism originally developed in the West (Chin et al. 2011). However, Western frameworks of medical professionalism may not be suited to the cultural values of non-Western countries (Ho et al. 2011), an issue which thus far only a handful of studies have addressed. Research in Hong Kong indicates that perceptions of medical professionalism are affected by both Western cultural influences and traditional Chinese views (Leung et al. 2012). In addition, Ho et al. (2011, 2012) reported that while Western frameworks dichotomized physicians’ professional and personal lives, Taiwanese stakeholders were influenced by Confucian cultural traditions toward harmonizing these roles. These divergent perspectives called for further studies beyond the Western frameworks.

Table

Practice points

Building a professional framework for healthcare providers in China could reap benefits both in China and overseas. Nominal group technique (NGT) ensures that all views have equal weight and all group members have an equal opportunity to express their opinions. Participants from diverse backgrounds added four categories to pre-existing framework: teamwork, self-management, health promotion, and economic considerations. The effects of Chinese cultural influences lead to divergent interpretations of medical professionalism.

Existing research on medical professionalism also relies heavily on the perspectives of physicians or medical students in determining the attributes that define professionalism (Campbell et al. 2007; Kovach et al. 2009; Borgstrom et al. 2010). Some studies have expanded their samples to include medical school faculty (Ginsburg et al. 2008), but few have sought to encompass the full spectrum of professions affected by the medical field and their perspectives on how doctors can best fulfill the needs of those they serve.

Building a professionalism framework for healthcare providers in China could provide valuable insights that could reap benefits both in China and overseas. The People's Republic of China has approximately 150 medical schools (Taneda 2011) serving a population of 1.3 billion (National Bureau of Statistics of China 2011). Peking Union Medical College (PUMC) in Beijing is consistently among the highest-ranked of these medical schools and is considered a flagship center of both research and clinical care. At PUMC's affiliated hospital, “faculty holds esteemed positions within the Chinese Medical Association (total of 83 societies), Chinese Medical Doctor Association as president, chairman, vice chairman or board commissioners; Beijing Medical Association as well as chief editors or editors of various specialty journals,” rendering PUMC a reliable indicator of medical professionalism in China (Peking Union Medical College Hospital 2013).

Moreover, China is among the top 10 countries of origin for international medical graduates working in the United States (American Medical Association 2010), not to mention the country of origin for millions of overseas Chinese whose cultural backgrounds may influence their expectations of the medical field. Mainland China's unique political history, particularly the Cultural Revolution, has had a significant impact on the development of its healthcare system and the ways that medical issues there are perceived and interpreted (Kleinman & Kleinman 1994). This study expands on previous research from Hong Kong and Taiwan to encompass more of the spectrum of cultural and historical influences on healthcare in the Chinese-speaking world.

The goal of this qualitative study is to address the gaps in the literature by formulating a non-Western framework for medical professionalism at the PUMC. Our study also seeks to incorporate the perspectives of nurses, public health experts, hospital volunteers, and other relevant members of healthcare systems in order to capture a more expansive picture of medical professionalism for Chinese healthcare providers.

Methods

We conducted this study using nominal group technique (NGT) in a stratified convenient sample of 97 participants at the PUMC in November and December, 2011. NGT ensures that all views have equal weight and all group members have an equal opportunity to express their opinions, negating some issues commonly occurring in group meetings such as dominant personalities or deference to seniority (Ho et al. 2011). We recruited participants either in person or over the phone through a key informant in their field and then sorted them into one of 13 occupational groups: attending physicians, chief residents, resident physicians, head nurses, nurses, nursing students, medical students, graduate students with a first medical degree (abbreviated as graduate students), medical humanities educators, public health experts, medical school administrators, standardized patients and hospital volunteers. The key informant in each group was initially contacted by the first author and asked to recruit colleagues who would be available at the time of the NGT meeting and who would be representative of a broad spectrum of opinions on medical professionalism. Demographic data are shown in Table 1. This study was exempted from the approval by the PUMC's institutional review board.

Table 1  Demographic data of 97 NGT participants at PUMC, November and December 2011

Group	Number of participants	Average age	Average years in position
Attending physicians	8	38.8 (±2.4)	11.0 (±5.6)
Chief residents	6	34.7 (±5.0)	5.1 (±3.9)
Resident physicians	9	27.4 (±2.6)	1.5 (±1.0)
Head nurses	6	38.3 (±2.4)	16.8 (±3.9)
Nurses	8	29.6 (±4.3)	8.1 (±4.6)
Nursing students	8	21.4 (±1.0)	12.8 (±1.8)
Medical students	6	24.3 (±0.5)	5.5 (±2.6)
Graduate students	8	23.4 (±0.7)	0.9 (±0.2)
Medical humanities educators	8	31.3 (±7.0)	4.0 (±3.4)
Public health experts	6	32.7 (±4.2	5.0 (±2.9)
Medical school administrators	8	48.0 (±6.9)	17.5 (±12.4)
Standardized patients	8	60.6 (±2.7)	9.2 (±1.9)
Hospital volunteers	8	36.6 (±11.5)	14.5 (±11.2)

We facilitated the meetings convened by individual occupational groups. They lasted between 40 minutes and one hour. We offered participants refreshments as compensation and gave them a brief description of the NGT process. There are five steps in the NGT procedure: silent listing of items, round-robin stating and recording of items, discussing and compiling of related items, voting using a Likert scale for each item, and summating of votes. First, we asked each participant to write down on individual sticky notes what he or she considered the essential abilities of a professional doctor, reflecting their expectations of medical professionalism. In a round-robin format, participants named each of their items one at a time, without naming any previously mentioned items, until all items had been exhausted. Participants then posted their notes on a blackboard one item at a time under the category they deemed most appropriate. The wording of the prompt and the categories were taken from a previous NGT study on medical professionalism conducted at National Taiwan University College of Medicine (NTUCM) (Ho et al. 2011). Items that did not fit into any existing categories were placed in the “Other” category.

Participants discussed the list of items and combined related items into a single item. In cases of dispute, the person who raised the item could decide whether or not to combine it with another item. New categories were then created to classify the items in the “Other” category. Participants each selected the five categories they considered most important and ranked them on a Likert scale, where 1 = least important and 5 = most important. Finally, voting results were summed across participants in each group and the categories ranked to determine results for that group. Votes from participants who chose multiple categories with the same Likert number were not counted.

We recorded and transcribed NGT meetings verbatim. The transcript filled 85 pages and contained 68,379 Chinese characters. We analyzed the items according to the pre-existing framework and engaged in an open coding to account for new themes and divergences among the groups’ frameworks.

Results

Items were sorted into a total of 12 possible categories. Categories identified and ranked by all groups are presented in Table 2. Categories with zero votes were not ranked. Eight categories were provided by the NTUCM framework: clinical competence, communication, ethics, humanism, excellence, accountability, altruism, and integrity (Ho et al. 2011). PUMC participants used the term “morality” instead of “integrity” and created the four remaining categories to sort items originally placed in “Other”: teamwork, self-management, health promotion, and economic considerations. Among the last four categories, participants considered that “teamwork” referred to both actively supporting and avoiding undermining the work of other hospital staff, “self-management” referred to the ability to control one's emotions and maintain calm in crisis situations, “health promotion” included the ability to encourage patients to prevent the development and transmission of disease as well as treating it, and “economic considerations” meant doctors should consider the patients’ ability to afford medications when determining a suitable treatment.

Table 2  Voting results of each nominal group, ranked by percentage received out of total possible votes

Rank	Attending physicians		Chief residents		Resident physicians
	Items	%	Items	%	Items	%
1	Clinical competence	31	Clinical competence	29	Clinical competence	31
2	Communication	20	Communication	24	Communication	27
3	Morality	18	Humanism	12	Self-management	13
4	Humanism	10	Morality	10	Humanism	9
5	Excellence	9	Accountability	8	Teamwork	8
6	Accountability	6	Ethics	7	Morality	5
7	Self-management	3	Teamwork	4	Accountability	4
			Altruism
8	Teamwork	2	Excellence	1	Ethics	1
					Excellence
9	Altruism	1
Rank	Head nurses		Nurses		Nursing students
	Items	%	Items	%	Items	%
1	Clinical competence	26	Clinical competence	25	Clinical competence	31
2	Communication	17	Teamwork	15	Accountability	13
	Accountability				Teamwork
3			Communication	13
4	Humanism	16	Humanism	12	Humanism	12
5	Excellence	10	Accountability	9	Morality	11
6	Ethics	7	Morality	8	Communication	10
7	Morality	4	Excellence	7	Excellence	8
			Self-management
8	Teamwork	2	Ethics	4	Self-management	2
	Altruism
Rank	Medical students		Graduate students		Medical humanities educators
	Items	%	Items	%	Items	%
1	Clinical competence	30	Clinical competence	30	Clinical competence	28
2	Humanism	18	Communication	19	Humanism	17
3	Communication	14	Humanism	13	Communication	16
4	Morality	13	Ethics	10	Ethics	9
			Excellence
5	Accountability	9	Morality	8	Accountability	7
					Teamwork
6	Excellence	8	Accountability	6	Legal consciousness	5
					Self-management
7	Teamwork	4	Altruism	3	Altruism	3
8	Self-management	3	Teamwork	2	Excellence	2
9			Self-management	1
Rank	Public health experts		Administrators		Standardized patients		Hospital volunteers
	Items	%	Items	%	Items	%	Items	%
1	Clinical competence	32	Clinical competence	30	Clinical competence	30	Clinical competence	30
2	Excellence	14	Communication	26	Morality	25	Communication	25
3	Health Promotion	13	Teamwork	11	Humanism	18	Self-management	15
4	Altruism	12	Altruism	8	Communication	14	Altruism	10
	Communication		Excellence
5	Morality	9	Accountability	5	Accountability	5	Excellence	6
			Morality		Excellence		Morality
			Humanism
6	Ethics	4	Ethics	3	Altruism	4	Humanism	5
7	Self-management	2	Self-management	1			Accountability	3
8							Ethics	1

In analyzing the rankings, it was noteworthy that both clinical competence and communication ranked highly among most groups. A hospital volunteer explained clinical competence by stating that “a doctor must have a solid foundation of knowledge, regardless of what he does. Everything in his career after this will depend on it.” Only nursing students did not include communication in their top five items. One of the standardized patients explained the importance of communication by stating, “[The doctor's] language must be precise… The doctors address the whole disease but tell you some things that are ambiguous, so that returning home after your appointment you do not understand [your disease condition]. Am I still sick or am I no longer sick?… I think the language should be precise.”

Humanism also ranked highly in all groups except public health experts, administrators, and hospital volunteers. One of the medical students described humanism as “[being] able to truly understand the demands of the patient [and] to make an effort to really care about them.” Conversely, it was notable that only graduate students and medical humanities educators listed ethics among their top five items. A graduate student explained, “Morality depends on your own moral character; ethics should refer to the norms that medicine should follow…You have to know, can you do this under the medical framework? Can you do this under the ethical framework? [Doctors] must have this ability.”

Among healthcare professionals directly involved with patient care (all physician and nursing groups), only attending physicians and head nurses included excellence in their top five items. A member of the attending physician group justified the inclusion by stating: “Doctors should have a self-learning ability, because medicine is a special field that requires lifelong learning. Five years or eight years of learning is not enough; later we still need to be able to learn continuously from our day-to-day practice.” Notably, excellence was also prioritized by many groups not directly involved in patient care: graduate students, public health experts, administrators, patients, and hospital volunteers.

Hospital volunteers and resident physicians included self-management in their top five items. One resident physician said: “Self-management includes controlling one's emotions and having a positive attitude. When faced with critical patients, [doctors] have to keep calm and avoid a situation of panic.” In analyzing the transcripts, we found that hospital volunteers believed that doctors unable to manage their own health needs or emotional stress were less capable of attending to their patients’ health needs. Furthermore, hospital volunteers felt that patients observing doctors’ failure to manage their own health were less likely to trust in their treatment ability.

Public health experts were the only group to prioritize health promotion. One of the public health experts stated, “Health promotion has two components. One is to help the patient improve his consciousness. The second is that doctors themselves should be aware of disease prevention tactics.” Transcript analysis showed they thought a good doctor should make an effort to prevent disease, in contrast to medicine's traditional emphasis on treatment. Public health experts also considered teaching health promotion to be more effective than administering medicine.

Although it was not ranked among their top items, transcripts revealed that standardized patients were unique in mentioning “economic considerations". They felt doctors should be conscientious of the price of medications they prescribed to patients and should avoid prescribing a more expensive medication if a cheaper one was equally effective. In the transcripts, some standardized patients mentioned their concern that doctors prescribed more expensive medications in order to get benefits from pharmaceutical companies. Economic considerations were not proposed by any other group, although they were obliquely referenced by hospital volunteers when they expressed that doctors should avoid the temptations of “red envelope culture.” This refers to patients giving doctors extra money in order to receive more attention, a common practice in Mainland China (Cui & Yuan 2012).

Transcript analysis also revealed that both medical students and attending physicians referenced Chinese traditional cultural values. Medical students mentioned that in the course of their studies many students alluded to “仁” (ren ai), a Confucian attribute sometimes translated as “humane love” (Liu 2007). Attending physicians made several references to “公” (gong xin), or “public spiritedness,” another Confucian value. Both of these cultural values were listed under the morality category.

Discussion

Although several studies have analyzed medical professionalism from the perspectives of medical educators, physicians, and medical students over the past two decades (Swick 2000; Wagner et al. 2007; Miles & Leinster 2010), most of these studies lack input from allied health professionals, patients, and public health experts. Moreover, only a few have characterized medical professionalism in Asian countries (Ho et al. 2011; Cui & Yuan 2012; Leung et al. 2012). This study added to the body of knowledge about medical professionalism in China using nominal group technique. Our study sample included not only doctors, medical students, and educators but also patients, nurses, medical school administrators, and other related experts such as public health and medical humanities educators. We sought to incorporate a myriad of perspectives on important attributes of good doctors from both healthcare providers and the general population.

The general concurrence among many group participants on the importance of both clinical competence and communication may be partially attributed to the negative regard for the medical profession in China. The complexity of medical programs and the rapid expansion in the number of medical graduates (Xu et al. 2010) has caused many Chinese citizens to question doctors’ clinical competence. Given that many doctors in China are perceived as struggling to keep up with constantly evolving medical skills, participants in this study felt that medical professionalism in China should focus on encouraging doctors to acquire sufficient competency in the clinical skills needed to serve the patients. Participants also felt that communication was an important item due to the wide gap in knowledge between doctors and patients, and to recent news events about dissatisfied Chinese patients assaulting their doctors (Cheng 2011).

Although ethics was named as one of Stern's basic tenets of medical professionalism (Stern 2006) and has been recognized by the PUMC health system as an important part of medical students’ education (Yu et al. 2007), only graduate students and medical humanities educators prioritized ethics in their lists. This discrepancy may be due to the nascent phase of incorporating ethics into Chinese medical education. Ethics is a predominantly Western concept that has been adapted to Eastern medical education with some difficulty. It is possible that healthcare professionals in China may consider ethics secondary to more collectivist Confucian values such as guanxi (Dunning & Kim 2007), or the fostering of social relationships through the mutual exchange of favors. The fact that ethics was prioritized only by graduate students and medical humanities educators indicates that although morality was emphasized in most groups, at this stage ethics may be more of a concern for research-oriented healthcare professionals than for those engaged in day-to-day patient care.

The prioritization of excellence among attending physicians and head nurses may be due to their supervisory roles at PUMC. PUMC is a prestigious medical research university established by the Rockefeller Foundation and modeled after Johns Hopkins University in the United States (Rockefeller Foundation 2012). Attending physicians and head nurses there may be more involved with medical research than the other healthcare groups in our study. Lower-ranking doctors and nurses, for example, may opt to transfer out to other facilities if they are less interested in research. The high expectations for PUMC in the general population may also explain the prioritization of excellence among many healthcare professional groups not directly involved in patient care.

Self-management may have been prioritized by resident physicians and hospital volunteers due to their respective positions in the medical system hierarchy. Resident physicians are recent graduates from medical schools who are just beginning their careers and may have difficulties adjusting to the overwhelming workload. They seek a balance between caring for patients and maintaining their personal lives (Ho et al. 2011), a balance that more senior physicians may have been already achieved. The transcript text of the resident physician group also showed that they referenced time management for family and self; healthy lifestyle and mind; and self-protection/safety from patients’ assaults. Hospital volunteers may have also prioritized self-management because although not directly involved in patient care, they serve as day-to-day observers of the effects of stress on the physicians around them, effects that might pass unnoticed by other healthcare professionals.

Health promotion was prioritized only by the public health experts. This may again be related to perceived deficiencies in clinical competence among Chinese physicians – other healthcare professionals in China may feel that physicians are so preoccupied with the challenge of maintaining clinical skills for treating existing diseases that they may not be able to address the prevention of future ones.

We also found evidence of profound cultural influences at the PUMC. Ren ai has deep historical roots in China (Liu 2007). In traditional Confucianism, it is widely accepted that under ren ai everyone must be treated equally, even social deviants. Ren ai is one of the core values considered integral to becoming a Confucian scholar or official. The references to ren ai in the transcripts show that cultural factors may have influenced participants to interpret medical professionalism differently from their Western counterparts.

The Chinese concept of gong xin (public spiritedness) broached by the attending physicians has two interpretations. One emphasizes the consideration of public benefits, and the other emphasizes justice and fairness for society. Wagner's study (Wagner et al. 2007) conducted in the United States mentioned that students and patients in that study did not address the issue of social justice. This is another instance where a variety of perspectives on medical professionalism leads to more nuanced comprehension of the term.

This study has several limitations. The study relied on a convenience sample so results may not be applicable to all populations. We also conducted only one NGT meeting per group; it is possible that further iterations of these sessions might have produced new items, though it is questionable whether this would be worth the additional cost and effort. Some groups may have been stimulated to reference items like “self-protection” due to concurrent news coverage of patients attacking doctors at Beijing hospitals (Cheng 2011). This study was also limited to one institution, so results may not be applicable to other medical institutions in China. In addition, although this study did include hospital volunteers and standardized patients to represent non-healthcare professionals, it is possible that these groups were so closely connected with the healthcare field that their views might not be as distinct.

To the extent of our knowledge, this study is the first study to use a highly heterogeneous sample in creating a framework of professionalism for healthcare providers in Mainland China. Our study was able to document the effects of traditional cultures and societal needs that led to divergent conceptualizations of medical professionalism frameworks between Asian and Western countries. It is hoped that further research building upon the foundation of this study will provide a more comprehensive framework to enhance medical professionalism both within China and around the world.

Glossary of terms

Nominal Group Technique: Nominal group technique (NGT) is a structured variation of a small-group discussion to reach consensus. NGT gathers information by asking individuals to respond to questions posed by a moderator, and then asking participants to prioritize the ideas or suggestions of all group members. The process prevents the domination of the discussion by a single person, encourages all group members to participate, and results in a set of prioritized solutions or recommendations that represent the group's preferences.

Reference: Tague R The Quality Toolbox, 2004. Second Edition, ASQ Quality Press, pp. 364–365.

Declaration of interest: The authors report no declarations of interest.

This study was funded by the National Science Council of Taiwan; the Ministry of Education, Republic of China; and the Ministry of Education, People's Republic of China.