Figure 1
Flow diagram describing two phases of the development and validation processes of the China Medical Professional Inventory (CMPI). Black arrows indicate the steps to develop the CMPI and collect validity evidence.
*The 28 added items are Chinese policy items not already found among the 110 items from systematic review and extraction.
Table 1
Items Included in Three Versions of the China Medical Professionalism Inventory (CMPI).
| FACTOR | ITEM NO.$ | ITEM | CMPI VERSION 2 (58 ITEMS) | CMPI VERSION 4 (40 ITEMS) | CMPI (FINAL) (20 ITEMS) |
|---|---|---|---|---|---|
| Respect, Compassion, and Communication | 1 | Attends to psychological and emotional factors and socio-psychological factors related to the patient’s health. | √ | ||
| 2 | Talks about preventative care (e.g., quitting smoking, weight control, sleeping, alcohol, exercise, etc.). | √ | |||
| 3 | Presents professional opinion to the patient in a way the patient can understand. | √ | √ | √ | |
| 4 | Takes the time and effort necessary to explain information to patients. | √ | |||
| 5 | Helps the patient with their fears and worries. | √ | |||
| 6 | Explains to the patient what they need to know about their problems, how and why they occurred, and what to expect next. | √ | √ | √ | |
| 7 | Takes the patient’s embarrassment, shyness, and reluctance into account and provides timely emotional support when necessary. | √ | √ | ||
| 8 | Demonstrates respect for patient autonomy by ensuring patients understand their situation and make informed clinical decisions. [added by expert review*] | √ | √ | √ | |
| 9 | Does not use degrading or mocking words when discussing a patient with coworkers. | √ | |||
| 10 | Does not discriminate against or refuse to treat a patient due to gender, race, religion, nationality, family background, sexual orientation, or economic status. [Chinese policy^] | √ | √ | ||
| 11 | Greets patients warmly; calling them by the names they prefer; is friendly, never crabby or rude. | √ | √ | ||
| 12 | Deals appropriately with a patient who is emotionally out of control. | √ | |||
| 13 | Follows the regulations and procedures for declaration of a patient’s death and takes care of the family’s emotions to give proper comfort. [Chinese policy^] | √ | √ | ||
| 14 | Discusses options with patients, asks their opinions, offers choices, and lets them decide what to do before making decisions. | √ | √ | √ | |
| 15 | Does not treat the patient’s informed consent for surgery, tests, or treatment as a means to escape from responsibility. [Chinese policy^] | √ | |||
| 16 | Follows the patient’s preference to accept or refuse any clinical treatment. | √ | √ | √ | |
| 17 | Places their patient’s convenience before their own when arranging the tests and treatment. | √ | |||
| 18 | Follows the patient’s decisions before loss of cognitive capacity and protects their rights and interests by means of a will or alternative consent by a close relative. [Chinese policy^] | √ | |||
| 19 | Maintains a positive rapport with the whole healthcare team and provides emotional support for colleagues. | √ | √ | √ | |
| 20 | Works collaboratively across disciplines to complete medical responsibilities. | √ | √ | ||
| 21 | Demonstrates respect for clinical assistants, such as nurses and other staff. | √ | √ | ||
| 22 | Demonstrates trust in the professional knowledge and skills of coworkers. | √ | √ | ||
| 23 | Resolves interdisciplinary conflicts in a collegial and respectful manner. | √ | √ | √ | |
| Integrity | 24 | Avoids discussing and revealing confidential patient information in public. | √ | √ | √ |
| 25 | Maintains patient/physician relationships that do not exploit personal financial gain, privacy, or sexual advantages. | √ | √ | √ | |
| 26 | Actively reports any personal medical or research errors. | √ | |||
| 27 | Acts to minimize the possibility of treatment failure and medical error. | √ | |||
| 28 | Takes responsibility for their own clinical decisions and medical practices (i.e., they do not seek to evade responsibility). | √ | √ | ||
| 29 | Takes responsibility even in the face of difficulties. | √ | |||
| 30 | Does not allow any possible personal benefit to impact on professional behavioral and decision making. [Chinese policy^] | √ | |||
| 31 | Avoids conducting non-scientific or unethical research supported by commercial sponsorship. [Chinese policy^] | √ | √ | √ | |
| 32 | Does not sell any medical products or prescribe drugs for personal benefit. [Chinese policy^] | √ | √ | ||
| 33 | Does not participate in commercially sponsored banquets, tourism, training, or other activities that may lead to medical bias. [Chinese policy^] | √ | √ | ||
| 34 | Does not attract patients through misleading advertising. [Chinese policy^] | √ | √ | ||
| 35 | Participates in peer evaluations of the quality of care provided by colleagues objectively. | √ | √ | ||
| 36 | Reports colleagues’ misconduct or medical error to a hospital or a professional organization, and does not shield peers. [Chinese policy^] | √ | |||
| 37 | Explains treatment risks to patients fully and does not give patients false hope. | √ | √ | √ | |
| 38 | Provides appropriate and clear information to colleagues for follow-up patient care. | √ | √ | √ | |
| Excellence | 39 | Follows scientific standards and bases decisions on scientific evidence and experience. | √ | √ | |
| 40 | Applies new clinical practice guidelines into patient care actively and independently. | √ | √ | √ | |
| 41 | Acknowledges the meaning and relative value of scientific evidence in decision-making. | √ | √ | √ | |
| 42 | Uses practical experience as a basis for critical self-reflection. | √ | √ | ||
| 43 | Consults other medical colleagues to manage a situation that is beyond one’s ability. | √ | √ | √ | |
| 44 | Seeks additional learning opportunities to acquire new knowledge and skills to remain current in their profession. | √ | |||
| 45 | Engages in continuous professional development (CPD). | √ | √ | ||
| 46 | Commits to keep up with current academic literature and participate in peer discussions in their field. [Chinese policy^] | √ | |||
| 47 | Promotes the welfare and career of junior faculty. | √ | √ | ||
| 48 | Shares experience, skills, and knowledge with junior colleagues. [added by expert review*] | √ | √ | √ | |
| Responsibility | 49 | Pays attention to the risk factors that may threaten the safety of the patient by actively providing early warning and improvement suggestions to the relevant authority. [Chinese policy^] | √ | √ | √ |
| 50 | Does not provide unnecessary or excessive testing or medical treatment. [Chinese policy^] | √ | √ | √ | |
| 51 | Does not change care practice due to the social status and economic situation of the patient. | √ | |||
| 52 | Advocates for public health and transfers knowledge of public health to patients. [Chinese policy^] | √ | √ | ||
| 53 | Ensures that the patient understands the content and meaning of the informed consent correctly and fully. | √ | √ | √ | |
| 54 | Does not participate in or support behavior or academic activities that go against humanism. [Chinese policy^] | √ | |||
| 55 | Distinguishes between accepted treatment and experimental activities and abides by ethical standards. | √ | √ | √ | |
| 56 | Does not harm the patient or put the patient at unnecessary risk by using medical knowledge and skills that the doctors know to not be in the best interest of the patient. [Chinese policy^] | √ | √ | ||
| 57 | Collaborates with peers to avoid unnecessary tests and optimizes the use of medical resources. | √ | √ | ||
| 58 | Chooses appropriate medical treatment for a patient with financial constraints and helps them in finding other means of assistance. [Chinese policy^] | √ | √ |
[i] $ Item numbers correspond to the 58-item CMPI Version 2, used for the first of three psychometric studies.
^Added from Chinese policies about medical professionalism during Phase I.
*Added by the first expert survey in Phase II.
Table 2
Characteristics of physicians from psychometric studies of three versions of the China Medical Professionalism Inventory (CMPI), 2017–2018.
| CHARACTERISTIC | GROUP | 1ST PSYCHOMETRIC STUDY, n (% OF 360 PHYSICIANS)c | 2ND PSYCHOMETRIC STUDY, n (% OF 3653 PHYSICIANS)d | 3RD PSYCHOMETRIC STUDY, n (% OF 955 PHYSICIANS)e |
|---|---|---|---|---|
| Sex | Male | 183 (50.8) | 1777 (48.6) | 472 (49.4) |
| Female | 176 (48.9) | 1870 (51.2) | 480 (50.2) | |
| Age | ≤30 | 84 (23.4) | 927 (25.4) | 176 (18.4) |
| 31–40 | 181 (50.4) | 1420 (38.9) | 497 (52.0) | |
| 41–50 | 69 (19.2) | 789 (21.6) | 200 (21.0) | |
| 51–60 | 24 (6.7) | 433 (11.9) | 66(7.0) | |
| ≥61 | 1 (0.3) | 16 (0.5) | 5 (0.5) | |
| Educational levela | Doctorate degree | 179 (47.2) | 750 (20.5) | 214 (22.4) |
| Master’s degree | 175 (48.6) | 1690 (46.3) | 490 (51.3) | |
| Bachelor’s degree | 11 (3.1) | 1152 (31.5) | 225 (23.6) | |
| Other degree | 1 (0.3) | 33 (0.9) | 11 (1.2) | |
| Specialization | Internal medicine | 139 (38.6) | 1543 (42.2) | 392 (41.4) |
| Surgery | 145 (40.3) | 1207 (33.0) | 367 (38.4) | |
| Obstetrics and Gynecology | 24 (6.7) | 203 (5.6) | 61 (6.4) | |
| Pediatrics | 11 (3.1) | 113 (3.1) | 42 (4.4) | |
| Intensive care and otherb | 39 (10.8) | 378 (10.1) | 74 (7.8) |
[i] a In the Chinese medical education system, medical school begins at the undergraduate level. The Chinese Bachelor of Medicine, Bachelor of Surgery (MBBS) degree is regarded as the equivalent of the Doctor of Medicine (MD) degree in the United States. The master’s degree is in addition to MBBS, and a PhD is in addition to MBBS or a master’s degree. The “other degree” refers to qualifications below MBBS, such as associate degrees or technical secondary school diplomas.
b The category “other” includes Dermatology, Otorhinolaryngology, Intensive Care, etc.
c The 1st psychometric study used CMPI Version 2, which produced CMPI Version 3.
d The 2nd psychometric study used CMPI Version 3, which produced CMPI Version 4.
e The 3rd psychometric study provided validity evidence for the final, 20-item CMPI.
Table 3
Measures of fit for two rounds of confirmatory factor analysis (CFA).
| MODEL | χ2, df, P-VALUE, NORMED χ2a | CFIb | TLIc | RMSEA (95% CI)d | SRMRe |
|---|---|---|---|---|---|
| Phase II:Second psychometric study CFA | χ2 = 3305.3, df = 735, P < .0001, Normed χ2 = 4.50 | 0.93 | 0.91 | 0.059 (0.053–0.066) | 0.036 |
| Phase II: Third psychometric study CFA | χ2 = 660.5, df = 166, P < .0001, Normed χ2 = 3.98 | 0.97 | 0.97 | 0.060 (0.054–0.066) | 0.009 |
[i] Abbreviations: χ2, chi-square test; df, degrees of freedom; CFI, comparative fit index; TLI, Tucker-Lewis index; RMSEA root mean square error of approximation; CI, confidence interval; SRMR, standardized root mean square residual.
a For model fit, when calculating χ2 for CFA, a P-value >0.05 is considered “significant” suggesting the proposed model represents the data; this standard, however, is affected by sample size. With samples sizes >200 (e.g., as in our study: we sampled 3504 and 803 in our two CFAs), the P-value will nearly always be >0.05 which undermines the utility of using χ2 for CFA. The recommended statistical approach is to use “normed” χ2 wherein P < 0.05 is acceptable.
b CFI calculations, a measure of model fit, estimate the proportion of sample data the proposed model explains. CFI measurements adjust for sample size issues that exist when calculating model fit by the chi-square test. CFI values range from 0 to 1; values above 0.90 are generally considered acceptable. CFI should be used in the context of other results and not as a single strict cut-off.
c TLI is one of several calculations to determine “model fit.” Model fit is an overall determination of the degree to which the data confirm the proposed model (in our study, the model is shown in Figure 2). TLI values of >0.80 are usually considered acceptable.
d RMSEA is one of several calculations to determine “model fit.” RMSEA calculations take into account degrees of freedom in the covariance matrices. RMSEA results represent standardized differences between proposed model and predicted models. RMSEA values <0.08 are considered an acceptable fit of the data to the proposed model.
e SRMR is one of several calculations to determine “model fit.” The SRMR takes into account the standardized differences between proposed model and predicted models. The SRMR predictions of goodness of fit may be less affected by sample size. SRMR values <0.08 are considered an acceptable fit of the data to the proposed model.
Figure 2
Confirmatory factor analysis (CFA) of the final, 20-item China Medical Professionalism Inventory (CMPI). Path coefficients appear as numeric values on the arrows connecting CMPI to its subscales. Each coefficient indicates the relationship between CMPI and its factors. Item factor loading appears as numeric values on the arrows connecting factors to corresponding individual items, which are all above 0.5. We adjusted the model based on the modification indices that indicated the correlation between error terms for two items on the “Respect and Communication” (RCC) factor (RCC item 1 and RCC item 2).
Abbreviations: RCC indicates respect, compassion, and communication; Int, integrity; Exc, excellence; and Res, responsibility.