In this study, results indicate that the 18-item Chinese PPOS exist two different perspectives with medical students as research participants, which were the traditional 2-factor model (Care and Sharing) and the exploratory 4-factor model (medical technology comprehensiveness; whether the patient is competent; doctor's interpersonal style; and whether the patient's feelings matter).
First, for the traditional 2-factor model, we re-evaluated the reliability and validity of the tool using the internal consistency index and confirmatory factor analysis. The overall Cronbach's α value of the questionnaire was 0.763, the care subscale score was 0.574, and the sharing subscale score was 0.685. Confirmatory factor analysis results support an adequate model fit (χ2/df = 2.13, p༜0.001, RMSEA = 0.07, GFI = 0.87, AGFI = 0.83, NFI = 0.69, IFI = 0.81, and CFI = 0.80). Compared with the Chinese version of the PPOS study in 2017, the above results show significant improvement in both reliability and validity.14 In the 2017 study, the overall Cronbach's α value of the questionnaire was 0.668, the care subscale score was 0.493, and the sharing subscale score was 0.575. Confirmatory factor analysis results suggested an acceptable model fit (χ2/df = 5., 4,p༜0.0, 1༌RMSEA = 0.11, GFI = 0.76, AGFI = 0.70, NFI = 0.52, IFI = 0.58, and CFI = 0.57), which is comparable to the results of Portuguese version of PPOS[17]. Therefore, the Chinese version of the PPOS of 18 items is also applicable to the Chinese population.
Second, through exploratory factor analysis and confirmatory factor analysis, this study found that the 18-item PPOS scale could extract 4 factors with principal component eigenvalues greater than 1. The 4-factor model also has good reliability and validity performance. The Cronbach's α value of Factor 1 was 0.470, Factor 2 was 0.547, Factor 3 was 0.770, and Factor 4 was 0.554. The results of the confirmatory factor analysis showed that χ2/df = 1.89, p༜0.001, RMSEA = 0.06, GFI = 0.90, AGFI = 0.87, NFI = 0.73, IFI = 0.85, and CFI = 0.85. This result is statistically superior to the 2-factor model, but the practical value of the 4-factor model depends on its ability to better explain the doctor–patient relationship.
By analysing the meaning of items, this study leads to the conclusion that the 4-factor model evaluates the attitudes of interviewees from the following perspectives: ① Factor 1 evaluated whether medicine was considered omnipotent; ② Factor 2 evaluated whether the patients were recognized as competent; ③ Factor 3 evaluated how to view doctors' interpersonal style; and ④ Factor 4 evaluated whether recognition of patients' feelings would affect patients' medical behaviour and outcome.
Factor 1 includes the following items:
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1. The doctor is the one who should decide what is talked about during a visit.
2. Although health care is less personal these days, this is a small price to pay for medical advances.
3. The most important part of the standard medical visit is the physical exam.
13. A treatment plan cannot succeed if it conflicts with a patient’s lifestyle or values.
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According to our analysis, Factor 1 is related to whether the participants agree that "medicine is an all-powerful science". In theory, the more that participants agreed that medicine was "all-powerful," the more physician-centred they tended to be (Item 1), the more likely they were to consider that the physical examination was the most important (Item 3), and the more likely they were to surrender their inner feelings (Items 2 and 13). Since this study used Chinese medical students as the research participants, we speculated that the aforementioned outcomes might be related to the fact that medicine is often endowed with the colour of omnipotence in traditional Chinese culture, and the ability of doctors is described as having the capacity to accurately predict and judge patients' conditions. For example, the story of the miraculous doctor, Bian Que meeting Duke Cai Huan, by Han Fei describes the doctor discovering the duke's potential disease through observation, and predicting its occurrence and development. Another story involves hanging silk for pulse diagnosis–Sun Simiao is another magical doctor who could cure the queen by sensing the pulse vibrations of silk threads. On the one hand, such stories increase the public's trust and respect for doctors, but on the other hand, they may also raise the people's psychological expectations of doctors' "perfect medical skills". Therefore, the more the patient believes in the existence of such a doctor who, through his or her medical knowledge, is sufficient to guide all of the patient's treatment, a doctor/disease-centred attitude is more likely. In contrast, the more the imperfection and uncertainty of medicine itself is acknowledged, the less likely it is that there will be a physician/disease-centred attitude.
Factor 2 includes the following entries:
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4. It is often best for patients if they do not have a full explanation of their medical condition.
8. Many patients continue asking questions even though they are not learning anything new.
12. When patients disagree with their doctor, this is a sign that the doctor does not have the patient’s respect and trust.
18. When patients look up medical information on their own, this usually confuses more than it helps.
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According to our analysis, Factor 2 reflects whether patients can make desirable choices when faced with medical uncertainties. In the medical decision-making process, because the doctor uses diagnostic technology, aetiology and prognosis, treatment and prevention strategies are fully understood and therefore may question the ability of patients to make clinical decisions (items 4 and 8, items 12 and 18) listed on the entry, thinking that the patient's positive participation is meaningless. However, the fact that only the patient knows his or her disease experience, social environment, habits and behaviours, risk attitudes, values and preferences may contain important information that can affect the therapeutic effect and should be given greater attention. Therefore, whether patients are recognized as having the ability to choose in medical decision-making reflects attitudes towards the "doctor/disease centred" or "patient-centred" medical service models. This attitude varies among different populations, according to previous research data.(Akkafi M, 2019; Drivenes K, 2019; Fothan AM, 2019; Howren MB, 2020; Hur Y, 2017; Hurley EA, 2018; Iloh GUP, 2019; Ishikawa H, 2018; Mudiyanse RM, 2015; Pers M, 2019; Rosewilliam S, 2019; Wang D, 2020; Zhumadilova A, 2018) In more economically developed regions, both doctors and patients are more likely to accept the patient-centred attitude, while on the other hand, people in less developed areas are more likely to accept the doctor/disease-centred attitude. A possible cause of this difference is that the patients in areas with high levels of regional economic and social development received higher education and were more aware of their needs; thus, in medical treatment, they expressed their expectations and desires to receive more attention and were more inclined to adopt a patient-centred attitude towards medical services.
Factor 3 includes the following entries:
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5. Patients should rely on their doctors’ knowledge and not try to diagnose their conditions on their own.
6. When doctors ask many questions about a patient’s background, they are prying too much into personal matters.
7. If doctors are truly good at diagnosis and treatment, the way they relate to patients is not that important.
11. If a doctor’s primary tools are being open and warm, the doctor will not have much success.
14. Most patients want to get in and out of the doctor’s office as quickly as possible.
16. It is not that important to know a patient’s culture and background to treat the person’s illness.
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According to our analysis, Factor 3 is concerned with the expectations of the assessed interpersonal style of doctors. Since the middle of the last century, attention has been given to the influence of doctors' interpersonal style on doctor–patient relationships.(D, 1998; DO, 1999; JE, 1984; JT, 1981; M, 2018) In previous studies, doctors' interpersonal styles were divided into paternalistic and partnership styles. The paternalistic interpersonal style is very common in the medical service systems across the world; in this interpersonal style, in a sense, the doctor plays a similar role to a parent, and in this style, the doctor is well-intentioned and accepts more responsibility, which may lead to good health outcomes while simultaneously creating and sustaining an unhealthy dependency. A partnership interpersonal style is one in which people work together towards a common goal. Their relationship is based on mutual respect for each other's skills and abilities and the advantages of being able to combine those resources to achieve beneficial outcomes. Successful partnerships are equal, with partners making decisions and sharing responsibilities.(A, 1999) We believe that each item in Factor 3 reflects the evaluation of doctors' interpersonal styles. Previous studies have shown that East Asian cultures, such as Japan and South Korea, are more physician- and disease-centred than Europe and North America at the same economic level.(Howren MB, 2020; Hur Y, 2017; Ishikawa H, 2018; Rosewilliam S, 2019) This may be related to the fact that traditional medicine in East Asian cultural areas is deeply influenced by Confucianism. The moral code of doctors in Inner Canon of the Yellow Emperor (the most authoritative text of early medical theory and drug therapy) emphasizes that "doctors should have the same responsibilities as parents", which means that doctors should treat patients as parents treat children, and doctors should adopt a more patriarchal interpersonal style.
Factor 4 includes the following entries:
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9. Patients should be treated as if they were partners with the doctor, equal in power and status.
10. Patients generally want reassurance rather than information about their health.
15. The patient must always be aware that the doctor is in charge.
17. Humour is a major element of the doctor’s treatment of the patient.
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In our analysis, Factor 4 focuses on whether the participants accepts that the patients' emotions and feelings affects their medical decisions. That is, whether patients make so-called "irrational" choices influenced by their feelings even when they know that there may be something rationally better or worse. Many previous studies have focused on irrational decision-making. In behavioural studies based on financial distribution, the vast majority of participants are influenced by emotions, such as sympathy, disappointment and humiliation, to make irrational decisions.(Leone L, 2015) As a result, human beings are often influenced by their emotions to make so-called "irrational" decisions. Thus, we hypothesized that the more aware the participants were of the influences of emotions and feelings on human behaviour, the more likely they were to be patient-centred in their medical activities. According to our analysis, each item of Factor 4 evaluates whether the participant agrees with the patient's feeling of being respected (Item 9), whether they are comforted emotionally (Item 10), whether they feel valued by the doctor (Item 15), and whether the doctor is capable of relieving emotional tension (Item 17).
In conclusion, individuals who frequently accept medical limitations are more apt to respect patients' abilities, tend to adopt a partner style in doctor–patient communication, understand that people are more likely to be affected by emotions, are more willing to share power in medical activities, and respect patients' right to know and decision-making (sharing) in medical activities. They are also more inclined to respect their feelings (care).
The contribution of this paper is reflected in the following aspects: First of all, there is only one study on C-PPOS，and the test result is not ideal，the number of items lost a lot. In this paper, the reliability and validity of this tool are retested in the context of China, in an attempt to provide new support for the effective use of PPOS in China; Secondly, this paper discusses the patient centered care from the perspective of medical students, rather than the traditional perspective of doctors and patients. Selecting medical students with certain theoretical basis and clinical practice experience as research objects is a beneficial extension of PPOS related research, and also helps to improve the patient centered care from the perspective of medical education；Thirdly, by further exploring the factor structure of PPOS, the original two factors are extended to four factors in attitude level, which is conducive to a deeper understanding and identification of patient-centeredness.
Limitations and Prospects: This paper uses Chinese data to test the reliability and validity of PPOS tool and discusses patient-centeredness from the perspective of medical students. Some positive findings have been made, but due to data limitations, sample representativeness and applicability of conclusions may be relatively limited. In the future, the sample can be further expanded to conduct heterogeneity analysis, and in-depth discussion from more perspectives can be attempted to enhance the universal applicability of the conclusion.