East Meets West: Evidence for Validity for the China Medical Professionalism Inventory

East Meets West: Evidence for Validity for the China Medical Professionalism Inventory | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article East Meets West: Evidence for Validity for the China Medical Professionalism Inventory Honghe Li, David Hirsh, Jing Jin, Edward Krupat, Nan Jiang, Ning Ding, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3810250/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The characteristics of medical professionalism (MP) vary across cultural contexts. Theories of professionalism and MP tools currently rely on Western cultural perspectives. The authors developed the China Medical Professionalism Inventory (CMPI) using standard processes through four steps: Phase I) systematic review and synthesis of the literature to develop an item pool; Phase II) survey of Chinese clinical and educational experts to develop evidence based on test content; Phase III) two rounds of pilot studies of practicing physicians to measure internal structure and internal consistency; and Phase IV) refinement of the instrument using an expert survey and pilot study. Systematic review of the English- and Chinese-language literature identified 1537 professionalism-specific items from 63 sources as foundation of the item pool. The authors conducted two rounds of expert review, including surveying nationally prominent Chinese healthcare leaders (n = 34, response rate 85%, and n = 76, response rate 63%). The authors conducted three pilot studies of practicing Chinese physicians (n = 360, response rate 92%; n = 3653, response rate 89%; and n = 955, response rate 95%). The results generated a 40-item CMPI and a shortened 20-item CMPI, with four domains “Respect, Compassion, and Communication; Integrity; Excellence; and Responsibility.” Applying the standards of Messick, the American Psychological Association, and Kane, the authors present the CMPI's validity evidence related to content, response process, internal structure, relationship to other variables, and consequences. This study aims to extend the conceptualization and reach of MP measurement. Medical professionalism Measurement Behaviors Validity Evidence China Scale Figures Figure 1 Figure 2 Introduction Medical professionalism (MP) is a complex, multi-dimensional construct (Hodges et al., 2019 ; Irby & Hamstra, 2016 ) that may affect health outcomes, patient well-being, and satisfaction (Wang et al., 2023 ; Khawar et al., 2022 ). Elements of MP connect to cultural context: culture and societal expectations of physicians influence the general public’s, patients’, physicians’, and other health professionals’ perceptions of MP (Ho, 2013 ; Nie et al., 2015 ; Nilchaikovit et al., 1993 ; Goddard & Brockbank, 2023 ). Multiple reviews highlight that current MP tools embody Western frameworks and were developed in Western contexts (Goddard & Brockbank, 2023 ; Li et al., 2017 ; Tay et al., 2020 ; Kwan et al., 2018 ). Educators and researchers outside Western cultures are now calling for research to characterize and promote MP (Li et al., 2017 ; Wang et al., 2016 ). Chinese leaders seek that MP should connect to historical tradition, current culture, and modern conceptualizations of MP inside and outside China (Nie et al., 2015 ; Wang et al., 2016 ; Hu et al., 2014 ). Indeed, advancement of MP in China could have benefits in the region and beyond. Confucianism grounds Chinese culture and the cultures of other societies in the region including Hongkong, Taiwan, Japan, Singapore, Philippines, and North and South Korea (Rozman, 2014 ; Wei-ming, 1993). In these regions, Confucianism has an influence on health, health care, and health systems (Badanta, 2022). There are also potential cross-cultural benefits of advancing MP in this region. Historically, MP tools have been described in the West, translated, and adapted for MP assessment in Eastern contexts. Is it also possible to imagine that instruments developed in Eastern contexts, with validation evidence, could inform Western conceptualizations of MP? Further, professionalism instruments developed in health professions such as nursing (Hisar, 2010; Lin, 2016) and counseling psychology (Dnnmer, 2011), are adapted for use among physicians. One can imagine that tools developed among physicians might also offer some insights for use in other health professions. The literature reports more than 80 instruments related to MP (Li et al., 2017 ; Wilkinson et al., 2009 ; Wang et al., 2017 ; Chen et al., 2019 ; Yu et al., 2019 ; Larramendy-Magnin et al., 2019 ; Goss et al., 2017 ; Multak, 2017 ; Berendonk et al., 2018 ; Kalet et al., 2017 ). Systematic reviews evaluating psychometric properties of MP tools suggest that although these instruments are plentiful and diverse, only a limited number of studies document acceptable evidence of reliability and validity (Hodges et al., 2019 ; Li et al., 2017 ; Tay et al., 2020 ; Kwan et al., 2018 ; Wang et al., 2016 ). Ideally, MP tool development should follow standard processes for psychological testing (Messick, 1989 ; AERA et al., 2014; Cook & Beckman, 2006 ; Downing, 2003 ; Cook et al., 2006; Kane & Brennan, 2006) and report evidence for validity incorporating the context of the tool’s use (Hodges et al., 2019 ; Ho, 2013 ; Ginsburg et al., 2000 ). Researchers are also calling for MP tools focused on behaviors (i.e., items are “behaviorally-referenced”) (Lesser et al., 2010 ; Ginsburg & Stern, 2004 ; Boudreau et al., 2004; Birden et al., 2014 ; Van Mook, 2011 ). Two theoretical lenses ground our approach; we incorporate virtue-based professionalism with the aim to advance behavior-based professionalism (Irby & Hamstra, 2016 ). Although researchers have made progress defining MP in non-Western contexts (Ho et al., 2011 ; Pan et al., 2013 ; Ho et al., 2014 ; Wang et al., 2016 ; Hu et al., 2014 ; Hisar, 2010), our review of the English language and Chinese literature identified no MP tools that met above needs and criteria. This study, therefore, has three aims: 1) to create an instrument derived from MP principles established in the literature, augmented with principles connected to the Chinese context; 2) to develop an MP inventory referring to physicians’ behaviors; and 3) to provide evidence for the validity of this inventory in this Eastern context. Our ultimate goal is to extend the conceptualization and reach of MP measurement. Methods Study design and ethics Following Cook & Beckman ( 2006 ), Downing ( 2003 ), Messick ( 1989 ) and the current Standards for Educational and Psychological Testing (2014), we undertook a 4-phase process to collect validity evidence for the China Medical Professionalism Inventory (CMPI): Phase I) systematic review and synthesis of the literature to develop an item pool; Phase II) an expert survey to evaluate the inventory’s content-based evidence; Phase III) two rounds of pilot studies to determine psychometric properties; and Phase IV) an expert survey and pilot study to refine and potentially shorten the instrument. Figure 1 summarizes the methods, participants, and items involved. The protocol was approved by the Bioethics Advisory Commission, the Institutional Review Board of China Medical University (Identification number: 2017075). (Fig. 1 should be put here) Phase I: Systematic review and synthesis of professionalism instruments We reviewed the literature reporting instruments that measure MP. At that time, our search of the Chinese-language literature revealed no Chinese MP tools with validation evidence. We systematically searched the English language literature using PubMed, Web of Science, and PsycINFO databases to identify studies and instruments assessing MP between January 1, 1990 and December 31, 2015 (Li et al., 2017 ). Applying Terwee’s search construct (Terwee et al., 2009 ), our strategy combined key terms: professionalism AND physicians AND instruments or assessing AND psychometric properties . To create the initial item pool, three researchers (H.L., J.J., N.J.) extracted items from existing instruments assessing MP that had been identified by the systematic review (Li et al., 2017 ). We eliminated duplicate items using the professionalism framework of Lesser et al ( 2010 ), which categorized items into four domains: compassionate, respectful, and collaborative orientation; integrity and accountability; pursuit of excellence; and fair and ethical stewardship of health care resources. Items that did not fit into these four domains, we categorized together as “other.” We translated all maintained items into Chinese. To develop evidence for cross-cultural validity, we followed Brislin’s modified model (Lee et al., 2009 ). Bicultural, bilingual members of the research team who are Chinese (H.L. and N.D.) and Chinese-Canadian (N.J.), created the item pool through several rounds of blinded forward and back translation. For the last step, two pairs of researchers (H.L. with D.M. and H.L. with D.A.H.) separately ensured the final English and Chinese translations met standards for content, semantic, technical, criterion, and conceptual equivalence (Lee et al., 2009 ). To support this instrument’s representativeness and alignment with the Chinese healthcare context, we supplemented the item pool with items from published Chinese government policies related to MP (e.g., “Physicians should avoid conducting non-scientific or unethical research supported by commercial sponsorship.”) (CMDA, 2016; CMDA, 2014; NHFPC, 2012). We converted all items expressing attitudes or values into behavioral terms (e.g., “have commitment” was changed to “demonstrate responsibility for”), to create CMPI Version 1 (Fig. 1 ). Phase II: National experts survey To gather evidence based on content and to enhance item quality, we followed a standard practice for providing validity evidence (Cook et al., 2015 ; Lawshe, 1975 ; Boateng et al., 2018 ) by inviting experts to review the items individually. We invited 40 nationally prominent Chinese healthcare leaders using the following criteria: 1) Expertise in medical education, health system science, medical ethics, or MP; 2) Diversity of geographical location to include all seven administrative regions of China; and 3) Associate Professors or higher academic rank. Our expert review had additional importance in connecting to context (AERA et al., 2014; Cook et al., 2015 ) given that nearly the entire item pool was derived from studies outside of China. We asked experts to evaluate each item according to whether it fit the Chinese context (1 = Yes and 2 = No) and its relevance and importance to MP in China (1 = very low and 5 = very high). Items were phrased to indicate behaviors with stems that began, “The physician [action verb]…”. Because it is a standard approach for determining content-based evidence (AERA et al., 2014), experts also had opportunities to consider revisions or propose additional items. Following accepted standards for defining consensus (Diamond et al., 2014 ) and expert review of item content (Polit & Beck, 2006 ), we kept those items when > 90% of the experts determined the item fit the Chinese context. We then calculated mean scores for relevance and importance and retained only items with scores for both relevance and importance > 4. This process resulted in CMPI Version 2 (Fig. 1 ). Phase III: Pilot surveys Participants and questionnaire For the first pilot survey, we distributed the CMPI Version 2 to 390 physicians from two tertiary teaching hospitals: China Medical University First Affiliated Hospital and Sheng-Jing Hospital. These two hospitals are located in Shenyang, Liaoning Province and serve the general adult and pediatric population of this region of > 43 million people (LSB, 2020). We selected a stratified random sample of participants with equal proportions of physicians from major specialty disciplines (medicine, surgery, obstetrics and gynecology, pediatrics, radiology, and acute care). This self-administered survey asked participants to indicate the frequency they have demonstrated each item in practice, using a 5-point Likert-style scale (1 = not at all to 5 = very much). The sum of all items provided the total score, with higher scores indicating higher frequency of self-reported MP behaviors. The results of the psychometric analysis after the first pilot survey produced the CMPI Version 3. Using the identical set of items from the first pilot study, the second pilot again used a stratified cluster sampling method, administering Version 3 to 4,070 physicians from nine diverse hospitals (i.e., their location, size, mission, ranking) in eight cities in Liaoning. This second pilot survey was also self-administered. This step aimed to determine the CMPI’s relationship to other variables, in particular to investigate convergent evidence. (AERA et al., 2014; Downing, 2003 ) 30,32 Using a previously published Chinese version of the Penn State College of Medicine Professionalism Questionnaire (PSPQ),(Song et al., 2019 ) 51 a recognized MP instrument originally developed in the West, we expected a moderate correlation with the CMPI. Also, because prior studies have reported that physicians’ burnout level negatively correlates with MP,(Wang et al., 2023 ; Dyrbye et al., 2020 ) 3,52 we administered the short version of the Maslach Burnout Inventory (MBI),(West et al., 2009 ) 53 expecting an association (negatively) with this scale as well. We collected demographic information and the specialty of the physicians in the two pilot surveys. Statistical analysis This phase included statistical analyses (we explain statistical terms in Appendix 1). For the first pilot study in Phase III, we calculated corrected item-total correlations (CITC) for the CMPI’s four domains to identify the degree to which items correlate with each domain. A CITC greater than 0.5 is acceptable. We determined the Cronbach’s Alpha if Item Deleted (CAID) to delete items with a CAID higher than the total scale Cronbach’s alpha. To evaluate the performance of individual items and to further describe the underlying structure of CMPI, we performed exploratory factor analysis (EFA) (AERA et al., 2014; Cook & Beckman, 2006 ; Downing, 2003 ). We conducted principal component factor extraction with a varimax rotation with the factor pattern matrix to extract the factors. We evaluated assumptions regarding matrix identity and sampling adequacy using the Bartlett Test of Sphericity and the Kaiser–Meyer–Olkin (KMO) test. To be included in the inventory, each factor needed to have an eigenvalue > 1 and at least three items, and each item needed to have a factor loading ≧ 0.45. We used Cronbach’s alpha to determine internal consistency for the total scale and each factor in EFA (Cook & Beckman, 2006 ). We considered alpha values larger than 0.7 to be acceptable. For the second pilot study in Phase III, we examined evidence based on internal structure of the scale using confirmatory factor analysis (CFA) to assess model fit (Cook & Beckman, 2006 ). We fit the covariance matrix of the data with the 4-domain model from the empirical findings of the EFA in the first pilot study and deleted items with a factor loading of < 0.45. To determine model fit, we used the following five indices: normed χ 2 statistic ( 0.90), Tucker-Lewis index (TLI) (> 0.80), and standardized root mean square error of approximation (RMSEA) (< 0.08), and Standardized root mean square residual (SRMR) (< 0.08) (Hooper et al., 2008 ; Li-tze & Bentler, 1999). We analyzed for convergent evidence to determine CMPI’s relation to other variables using Pearson correlation coefficients (AERA et al., 2014; Cook & Beckman, 2006 ; Downing, 2003 ). We used the results of statistical analysis in the two pilot studies to create the Long Version CMPI. Phase IV: Instrument refinement We undertook a process to refine the survey and consider its length following the guidance of Galesic and Bosnjak ( 2009 ). To maintain reliability while potentially shortening the survey, we used a “content evaluation panel” described by Lawshe ( 1975 ). We sent the Long Version CMPI to 120 experts from 19 clinical disciplines in 17 medical universities across China. We considered “experts” as educators who are eligible to consult with China’s National Medical Examination Center (NMEC)—the national organization that oversees the medical licensing examination in China. The NMEC chooses these consultants for their high expertise in clinical medicine, medical education, and assessment. We asked the experts to select the 5 most important MP items for doctors to demonstrate for each domain determined by EFA and CFA. We decided in advance to maintain only the top 50% of items as determined by the number of experts who agreed to keep the item. This process modified Lawshe’s guidance (1975); we chose this 50% standard because we anticipated that the number of items chosen would exceed Lawshe’s range and therefore potentially leave redundant items in the survey. As a final step, we distributed the shortened CMPI to 1,002 physicians selected by stratified random sampling, with equal proportions from 8 tertiary hospitals in Liaoning Province. We collected demographic information and the specialty of the physicians. We used CFA to assess for evidence based on internal structure and Cronbach’s alpha to assess for internal consistency of the Short Version CMPI (Cook & Beckman, 2006 ). Group differences were tested by independent sample t-test and one-way ANOVA. To account for multiple comparisons given the four demographic features, we used a Bonferroni-corrected significance threshold of .0125 (.05/4). All statistical analyses were carried out by IBM SPSS (IBM Corp. Released 2011, Version 20.0. Armonk, NY: IBM Corp. Chicago, IL, USA) and Amos Version 21.0 (Chicago: IBM SPSS. Released 2012) for CFA. Results Phase I: Item pool generation We extracted 1537 individual items from the 63 scales that met our search criteria. As planned, to facilitate removal of duplicate items, we organized the items into 4 domains described by Lesser (2010). These included 535 items in “compassionate, respectful, and collaborative orientation”; 431 in “integrity and accountability”; 123 in “pursuit of excellence”; and 345 in “fair and ethical stewardship of health care resources.” We also removed duplicate items for the 103 “other” items that did not fit into the four categories. Elimination of duplicate items resulted in a pool of 110 items. The Chinese official policies produced 28 additional items to supplement the pool. The final CMPI Version 1 included 138 items. Phase II: National expert survey We received completed questionnaires from 34 (85%) of the national examination experts. Experts represented 27 medical schools, each ranked among the “first class” universities in China on the government’s official recommendation list. The experts determined 82 items (11 from Chinese policies and 71 from our original literature review) to be less related or less important. These items were eliminated, resulting in a pool of 56 items including 17 items sourced from policy documents. The experts recommended two additional items: “respects patient autonomy and their informed decisions” and “shares experience, skills, and knowledge with junior colleagues,” resulting in CMPI Version 2 with 58 items (Appendix 2A). Phase III: Two pilot surveys Three hundred and sixty physicians (response rate, 92.3%) returned the first pilot survey and 3653 physicians (response rate, 89.8%) returned the second pilot survey. Table 1 (columns 3 and 4) depicts the socio-demographic characteristics of physicians in the two pilot surveys. Table 1 Characteristics of physicians from two pilot surveys and the Short Version China Medical Professionalism Inventory (CMPI), 2017–2018 Characteristic Group 1st pilot survey, n (% of 360 physicians) 2nd pilot survey, n (% of 3653 physicians) Short Version CMPI survey, n (% of 955 physicians) 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 level a 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 (MBBS) 11 (3.1) 1152 (31.5) 225 (23.6) Lower 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 other b 39 (10.8) 378 (10.1) 74 (7.8) 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 PhD is in addition to MBBS or master’s degree. b The category “other” includes Dermatology, Otorhinolaryngology, Intensive Care, etc. (Table 1 should be put here) For the first pilot survey, we removed 19 surveys (5%) with missing data and analyzed 341 responses for EFA. We deleted 14 items that did not meet the criteria of the CITC and CAID analyses (8, 2, 2, and 2 items in the four domains, respectively) including six items from Chinese policies (#15, #18, #30, #36, #46, #54) (Appendix 2B). Forty-four items remained for the EFA. Both the Bartlett Test of Sphericity ( χ 2 = 16,281, P < .001) and the KMO test (0.98) indicated that the correlation matrix was factorable. The final result of the EFA determined 4 factors with eigenvalues greater than 1.0. Three items did not meet the predetermined standard for factor loading; we retained 41 items with factor loading ≧ 0.45 (Table 2 ). These items made up the CMPI Version 3 used in the second pilot study. For each domain, the research team labeled the 4 factors according to the basis of the relatedness of their items: “Respect, Compassion, and Communication”; “Integrity”; “Excellence”; and “Responsibility.” The four domains account for a total of 66.65% of the scale variance, an acceptable standard. With one exception, none of the items were “factorially complex” (i.e., loaded > .50 in more than one domain). However, we observe that item 26 loaded 0.45 in “Integrity” and 0.46 in “Excellence.” Cronbach’s alpha coefficients for each factor were greater than 0.9 (Table 2 ). Table 2 Factor loadings for the 41 items of the China Medical Professionalism Inventory (CMPI) Version 3 resulting from the exploratory factor analysis, with Cronbach’s alpha for each factor, 2017 (n = 341 physicians) * CMPI element (item number $ ) Item loadings by domain † Cronbach’s ɑ by domain RCC Int Exc Res Please check how often you have demonstrated the following behaviors in practice : Greets patients warmly; calling them by the names they prefer; be friendly, never crabby or rude. (item 11) 0.72 0.21 0.25 0.12 0.95 Demonstrates respect for patient autonomy and their informed decisions. (item 8) 0.71 0.18 0.26 0.17 Takes the patient’s embarrassment, shyness, and reluctance into account and provides timely emotional support when necessary. (item 7) 0.70 0.17 0.33 0.16 Explains to the patient what they need to know about their problems, how and why they occurred, and what to expect next. (item 6) 0.68 0.22 0.30 0.16 Presents professional opinion to the patient in a way the patient can understand. (item 3) 0.68 0.13 0.17 0.27 Does not discriminate against or refuse to treat a patient due to gender, race, religion, nationality, family background, sexual orientation, or economic status. (item 10) 0.68 0.36 0.22 0.08 Discusses options with patients, asks their opinions, offers choices, and lets them decide what to do before making decisions. (item 14) 0.68 0.27 0.15 0.32 Works collaboratively across disciplines to complete medical responsibilities. (item 20) 0.68 0.33 0.21 0.26 Follows the regulations and procedures for declaration of a patient’s death and takes care of the family's emotions to give proper comfort. (item 13) 0.65 0.32 0.06 0.41 Maintains a positive rapport with the whole healthcare team and provides emotional support for colleagues. (item 19) 0.65 0.38 0.23 0.24 Demonstrates respect for clinical assistants, such as nurses and other staff. (item 21) 0.62 0.41 0.25 0.24 Demonstrates trust in the professional knowledge and skills of coworkers. (item 22) 0.61 0.40 0.21 0.27 Resolves interdisciplinary conflicts in a collegial and respectful manner. (item 23) 0.60 0.38 0.25 0.32 Follows the patient’s preference to accept or refuse any clinical treatment. (item 16) 0.59 0.37 0.20 0.28 Avoids conducting non-scientific or unethical research supported by commercial sponsorship. (item 31) 0.33 0.74 0.26 0.19 0.95 Does not sell any medical products or prescribe drugs for personal benefit. (item 32) 0.32 0.73 0.28 0.18 Does not attract patients through misleading advertising. (item 34) 0.30 0.69 0.22 0.33 Takes responsibility for their own clinical decisions and medical practices (i.e., not seek to evade responsibility). (item 28) 0.33 0.67 0.30 0.23 Participates in peer evaluations of the quality of care provided by colleagues objectively. (item 35) 0.28 0.67 0.27 0.31 Maintains patient/physician relationships that do not exploit personal financial gain, privacy, or sexual advantages. (item 25) 0.29 0.67 0.24 0.27 Provides appropriate and clear information to colleagues for follow-up patient care. (item 38) 0.30 0.65 0.26 0.36 Does not give patients false hope and fully explains treatment risks to them. (item 37) 0.31 0.65 0.26 0.35 Does not participate in commercially sponsored banquets, tourism, training, or other activities that may lead to medical bias. (item 33) 0.30 0.61 0.28 0.20 Avoids discussing and revealing confidential patient information in public. (item 24) 0.35 0.60 0.16 0.37 Promotes the welfare and career of junior faculty. (item 47) 0.24 0.09 0.75 0.07 0.92 Shares experience, skills, and knowledge with junior colleagues. (item 48) 0.24 0.30 0.69 0.23 Engages in continuous professional development. (CPD). (item 45) 0.27 0.26 0.66 0.20 Acknowledges the meaning and relative value of scientific evidence in decision-making. (item 41) 0.23 0.32 0.65 0.30 Uses practical experience as a basis for critical self-reflection. (item 42) 0.29 0.34 0.61 0.32 Applies new clinical practice guidelines into patient care actively. (item 40) 0.25 0.36 0.61 0.32 Follows scientific standards and bases decisions on scientific evidence and experience. (item 39) 0.30 0.33 0.55 0.35 Consults other medical colleagues to manage a situation that is beyond one’s ability. (item 43) 0.29 0.43 0.47 0.33 Actively reports any personal medical or research errors. (item 26) ¥ 0.25 0.45 0.46 0.35 Distinguishes between accepted treatment and experimental activities and abides by ethical standards. (item 55) 0.32 0.42 0.17 0.67 0.94 Focuses on the risk factors that may threaten the safety of the patient and actively provide early warning and improvement suggestions to the relevant authority. (item 49) 0.34 0.30 0.25 0.65 Chooses appropriate medical treatment for a patient with financial constraints and helps them in finding other means of assistance. (item 58) 0.31 0.27 0.37 0.60 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. (item 56) 0.27 0.43 0.30 0.59 Ensures that the patient understands the content and meaning of the informed consent correctly and fully. (item 53) 0.33 0.35 0.36 0.59 Collaborates with peers to avoid unnecessary tests and optimizes the use of medical resources. (item 57) 0.28 0.34 0.38 0.58 Advocates for public health and transfers knowledge of public health to patients. (item 52) 0.31 0.32 0.43 0.54 Does not provide unnecessary or excessive testing or medical treatment. (item 50) 0.30 0.36 0.40 0.54 † Abbreviations of domains: RCC indicates respect, compassion, and communication; Int, integity; Exc, excellence; and Res, responsibility. In this table, bold Cronbach’s alpha values correspond to bold item loadings in each domain. * Number of physicians (n) represents respondents with missing data removed, the number of surveys used for exploratory factor analysis (EFA). $ Item numbers correspond to the 58-item CMPI Version 2, the first of three pilot studies (listed in Appendix 2). ¥ The CFA provided a satisfactory fit to the 4-domain model (Table 3 ) by deleting the one item (item 26), with a factor loading that was nearly identically strong in two domains on EFA (Table 2 should be put here) For the Phase III second pilot survey, we removed 149 surveys (4%) because of missing data and analyzed 3504 responses for CFA. The CFA provided a satisfactory fit to the 4-domain model (Table 3 ) by deleting the one item (item 26), with a factor loading that was nearly identically strong in two domains on EFA. This process resulted in the Long Version CMPI with 40 items (see Appendix 3 and 4 respectively for the Long Version CMPI in English and Chinese). Cronbach’s alpha coefficients for each factor ranged from 0.92–0.96. The results of the survey produced a Long Version CMPI mean score of 182.5 (SD = 20.46), a median of 188, and the range of actual scores from 54 to 200. Table 3 Measures of fit for two rounds confirmatory factor analysis (CFA) Model χ 2 , df , P -value, Normed χ 2 a CFI b TLI c RMSEA (95% CI) d SRMR e Phase III: Second pilot study CFA χ 2 = 3305.3, df = 735, P < .0001, Normed χ 2 = 4.50 0.93 0.91 0.059 (0.053–0.066) 0.036 Phase IV: Pilot study CFA χ 2 = 660.5, df = 166, P < .0001, Normed χ 2 = 3.98 0.97 0.97 0.060 (0.054–0.066) 0.009 Abbreviations: χ 2 , 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 χ 2 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 χ 2 for CFA. The recommended statistical approach is to use “normed” χ 2 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-squared 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 Fig. 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. (Table 3 should be put here) As expected, our results indicated that the CMPI correlated positively with the Chinese version of the PSPQ (Pearson r = 0.77, P < .01) and correlated negatively with the short version MBI (Pearson r = -0.22, P < .01). Appendix 1 offers explanations of statistical analyses. Phase IV: Creating the Short Version CMPI Seventy-six national clinical experts (response rate, 63%) completed the survey to rank the importance of each item. We retained the top 50% of items in each domain to generate the shortened CMPI containing 20 items (see Appendix 5 and 6 respectively for the Short Version CMPI in English and Chinese). In the Phase IV pilot study, 955 clinicians (response rate, 95.3%) completed the Short Version CMPI. Table 1 (column 5) presents the socio-demographic characteristics of these physician respondents. We removed 152 surveys (15.9%) because of missing data and analyzed 803 responses for CFA. After we adjusted for correlated item pairs based on the modification index, the subsequent CFA indicated that all 20 items loaded significantly ( P < .01) on their respective factors (Fig. 2 ). The CFA provided a satisfactory fit to the 4-domain model (Table 3 ). The internal consistency of the total scale and four domains are all in a satisfactory level (Cronbach’s alpha > .7) (Table 4 ). The fit of the model to the data indicates that a 4-domain structure was suitably descriptive of the data. Table 4 Interfactor correlations and Cronbach’s alpha coefficients of a confirmatory factor analysis of the Short Version China Medical Professionalism Inventory (CMPI) by factors, 2018 (n = 803 physicians)* CMPI domains k M (SD) Interfactor Correlations: Pearson r (Cronbach’s alpha) a RCC Int Exc Res Respect, Compassion, and Communication 7 4.41 (0.47) (0.88) — — — Integrity 5 4.50 (0.49) 0.61 b (0.90) — — Excellence 4 4.43 (0.49) 0.53 b 0.72 b (0.86) — Responsibility 4 4.45 (0.49) 0.57 b 0.75 b 0.82 b (0.87) Abbreviations: RCC indicates respect, compassion, and communication; Int, integity; Exc, excellence; Res, responsibility; M, mean; SD, standard deviation. * Number of physicians (n) represents respondents with missing data removed, the number of surveys used for confirmatory factor analysis (CFA). a Cronbach’s alpha values are those in parentheses on the diagonal. b P < .01. (Fig. 2 should be put here) (Table 4 should be put here) The results of this pilot survey produced a Short Version CMPI mean score of 88.3 (SD = 20.47), a median of 89, and a range of actual scores from 60 to 100. Table 4 demonstrates the mean score of items for each domain and interfactor correlations. Appendix 7 reports the mean scores for each individual item. On the Short Version CMPI, female physicians scored higher than males ( P < .001, Cohen’s d = 0.21). Respondents less than 30 years old had lower professionalism scores than physicians over 30 years old ( P < .001, Cohen’s d = 0.28). Respondents identifying as surgeons had lower scores than physicians working in internal medicine ( P < .001, Cohen’s d = 0.23). Discussion We developed a long (40 item) and short (20 item) version of the Chinese Medical Professionalism Inventory (CMPI) to assess MP of Chinese physicians and collected validity evidence from two rounds of expert surveys and three pilot studies. Our analysis suggests that the process of developing the CMPI included supportive evidence based on content and internal structure in the Chinese context. Our EFA and CFA processes determined that CMPI has four domains (“Respect, Compassion, and Communication,” “Integrity,” “Excellence,” and “Responsibility”). To our knowledge, the CMPI is the first behaviorally-referenced MP scale incorporating Chinese health system policies and engaging Chinese experts in scale development. Below, we summarize our processes of collecting evidence for validity, comment about future use and connect our findings to recent healthcare reforms in China. We aimed to describe the sources of validity evidence for this inventory systematically. We present our findings according to the framework presented by Cook and Beckman ( 2006 ) and Downing ( 2003 ) following Messick ( 1989 ) and the American Psychological Association (APA) Standards for Educational and Psychological Testing (2014). Following Messick and the Standards, we organize our results using five criteria for characterizing an instrument’s validity evidence: content, response process, internal structure, relationship to other variables, and consequences (Messick, 1989 ; AERA et al., 2014). We developed evidence based on content by surveying two distinct groups of national experts from across China to rate and provide feedback on each item’s importance and relevance. Considering evidence based on response process, we engaged experts in Phase IV of this study who are practicing clinicians and likely had similar experiences with study participants and with the intended recipients of this inventory; thus, their views may represent the “thought processes of subjects” suggested by Cook and Beckman ( 2006 ). We administered pilot studies to physicians to provide evidence based on internal structure of the 4-domain model. Each of the 4 domains and the total scale score showed high internal consistency based on Cronbach’s alpha. For analysis of relationships to other variables, we determined convergent evidence. The CMPI showed a strong positive correlation with the PSPQ that assesses MP attitudes and a negative correlation, albeit weak, with the MBI that assesses physician burnout. Cook and Beckman ( 2006 ) suggest that evidence of consequential validity may “explore whether desired results have been achieved and unintended effects avoided” (p. 166.e12). Our desire is that the items in this inventory can contribute to MP measurement in China by generating formative feedback and discourse for professional development. Currently, the CMPI should be used formatively for self-evaluation in conjunction with other MP-related activities: for example, as part of a Professionalism Mini-Evaluation Exercise (P-MEX) (Cruess et al., 2006 ), “360-degree” activities (Kwan et al., 2018 ), OSCEs, or peer-peer discussions. Although we used self-reports of behavior for the purpose of scale development, we believe that subsequent versions of the CMPI may have the future potential to make a contribution as an observational tool to assess the professional behaviors of others. We caution about applying the current CMPI as an observational tool or with individuals or groups that have not been studied in this research (e.g. students, other health professionals) and without developing validation evidence in other Chinese, other Eastern, or other non-Eastern contexts. Because of possible consequences and implications of using MP scales, we further caution about using CMPI for summative judgments (e.g., determining academic advancement or patients’ or colleagues’ assessments of competency) without further research determining validity evidence with such new uses and new contexts. We conclude our summary of validity evidence by highlighting Kane’s ( 2006 ) work that informed our approach and drives our conclusions. Specifically, we consider the long and short versions of the CMPI to support the beginning of a process of MP assessment in China, and potentially beyond, which may lead to developing observational tools (Kwan et al., 2018 ), and ideally, tools to support MP that improves patient outcomes (Tay et al., 2018). Subsequent iterations of the CMPI will require new validation evidence in the context of its use, judgement about scoring, generalization, extrapolation, and implication, and incorporation of “qualitative and subjective data” from “multiple assessment data points”(p. 561).(Cook et al., 2015 ) 33 Ultimately, we agree with Artino et al., ( 2014 ) summarizing Kane, who remind that assessing validity evidence involves “the accumulation of evidence across time, settings and samples to build a scientifically sound validity argument. Thus, establishing validity is an ongoing process of gathering evidence” (p. 465). CMPI and the Chinese healthcare context To create a contextually-derived instrument (Ho, 2013 ; Ho et al., 2011 ; Pan et al., 2013 ; Nie et al., 2015 ; Nilchaikovit et al., 1993 ), our process resulted in items that connect to the recent 10-year healthcare reform in China (Yip et al., 2019 ; SC, 2017; Mao et al., 2022 ; Tao et al., 2020 ; Chen et al., 2020 ) and to China’s changing doctor-patient relationship (Tang & Guan, 2018 ; Ting et al., 2016 ; Xiao et al., 2022; Nie et al., 2018 ).The recent Chinese national healthcare reform includes new payment policies and fee schedules—specifically, cutting the relationship between physicians’ income and drug dispensing and laboratory examinations (Yip et al., 2019 ; Mao et al., 2022 ). In Phase I and Phase II of our process, we reviewed official Chinese documents and conducted expert review; this process resulted in the CMPI incorporating items involving personal and financial integrity emphasized in China’s current healthcare system reform (Yip et al., 2019 ; Mao et al., 2022 ). As well, the CMPI includes a high proportion of items related to communication, shared decision-making, and respecting patient autonomy, domains that connect to changing conceptualizations of the doctor-patient relationship in China and the East (Tang & Guan, 2018 ; Ting et al., 2016 ) This approach to MP would reflect a change from earlier Eastern medical practice which was more hierarchical and paternalistic, whereby patients viewed doctors as authority figures who direct the treatment strategy (Nilchaikovit et al., 1993 ; Hu et al., 2014 ). Strengths Our study has methodological strengths. We followed processes described by Messick ( 1989 ) and the APA Standards (2014) and incorporated Kane’s guidance (2006). After our search found no Chinese-derived items in MP instruments with validity evidence in the Chinese literature, we extracted items by following a recommended process (Terwee et al., 2009 ) of structured literature review of the English-language literature; our search collected 1537 items from 63 sources, including tools developed for or applied in other health professions. We used Lesser’s MP behavioral framework (2010) to ensure we covered the domains of MP and avoided redundancy. Our translation strictly followed standard processes to provide evidence for cross cultural validity (Lee et al., 2009 ). We used two expert surveys using standard processes (AERA et al., 2014; Boateng et al., 2018 ; Polit & Beck, 2006 ).The first expert review included 34 diverse and nationally renowned experts and incorporated MP elements related to the China’s current healthcare policies. The second expert review included 76 diverse experts from 19 clinical disciplines in 17 medical schools. We undertook three pilot studies that included over 5000 practicing physicians (response rates 92.3%, 89.8%, and 95.3%), from multiple and diverse institutions in different cities. We worded items to be behaviorally-referenced so future development of the tool could determine validation evidence for observational use (Kwan et al., 2018 ). MP is contextual and dynamic and includes cultural values and expectations of the profession and the public (Ho, 2013 ; Ho et al., 2011 ; Pan et al., 2013 ; Nie et al., 2015 ; Nilchaikovit et al., 1993 ; Goddard & Brockbank, 2023 ). Historically in China, MP has been assessed indirectly using related constructs such as empathy, lifelong learning, and teamwork. In 2016, Wang et al. reported results of their scoping review of MP research published in the Chinese language. The authors concluded that there is “little empirical evidence informing the state of medical professionalism in China” (p. 8) (Wang et al., 2016 ). Since 2016, our review finds 4 papers that developed empirically-derived tools to assess MP in China: three in the English language literature (Wang et al., 2017 ; Chen et al., 2019 ; Yu et al., 2019 ) and one in the Chinese language literature (Sun et al., 2021). The three English language studies (Wang et al., 2017 ; Chen et al., 2019 ; Yu et al., 2019 ), like earlier works (Kwan et al., 2018 ), adapted tools developed in Western cultures or adapted tools developed outside of the medical context. The Chinese language study evaluates “professional cognition” of medical students. None of the four instruments focused on behaviors, and each study missed steps in the recommended methodological processes that guided our work (Messick, 1989 ; AERA et al., 2014; Cook & Beckman, 2006 ; Downing, 2003 ; 34). To facilitate comparison of the CMPI with MP instruments from our searches, we present instruments with direct observation of behaviors, instruments applied in the Chinese context, and instruments determined to have top validity evidence (Li et al., 2017 ) in Appendix 8. The CMPI offers a new instrument, with supportive validity evidence, attentive to the Chinese context, studied in practicing physicians. Limitations This study has limitations. The pilot surveys were conducted in Liaoning Province, and regional factors could influence elements of MP. We compared our sample demographics with the 2017 China Health Statistics Yearbook (2017), and the sample appears representative of China’s overall physician population demographics, but unmeasured factors could still influence results. We only surveyed physicians from tertiary hospitals and missed perspectives of healthcare providers in rural practices. In Phase II, we relied on a cohort of multidisciplinary experts; although diverse geographically and diversely experienced, these experts were primarily urban and tertiary-trained professionals. Regarding evidence based on internal structure, our three rounds of surveys relied on participants’ self-report of behavioral frequency which has limitations (Eva & Regehr, 2008 ) and offers potential for social desirability bias. We attempted to reduce this possibility by wording questions for physicians as frequencies (i.e., how often), by wording questions for expert reviewers indirectly (Fisher, 1993 ) (“what should a physician demonstrate”), and by ensuring that all pilot participants and experts were informed that surveys were anonymous and that they were not being individually judged, rated, or assessed. In Phase IV, we created a shortened version of the CMPI; although the CMPI’s Cronbach’s alpha suggests room to reduce the number of items, our use of Lawshe’s approach (1975) could result in leaving too many or too few items in the 20-item Short Version. If future research develops CMPI as an observational tool, to assess the professional behaviors of other physicians (not oneself), the process of reducing the items could use information on the relative test-retest and interrater reliability of the items. We offer both 40 and 20 item versions in appendices to allow for future study and refinement. Conclusion To better characterize, support, and foster MP in China, leaders within and outside of medicine will require trustworthy instruments. Such tools should be culturally-aligned with ongoing rigorous considerations of validity evidence within the context of their use. We created the CMPI as a behaviorally-referenced tool to meet these requirements. Recognizing the practice of applying Western MP tools in the East, we hope the contextually-derived CMPI may support MP in China, and potentially further our understanding of professionalism more broadly as “East meets West.” Abbreviations RCC indicates respect compassion,and communication Int integity Exc excellence and Res responsibility. Declarations Competing Interests and Funding Project of the Education Department of Liaoning Province (LJKMR20221216). The authors have no financial or competing interests directly or indirectly related to this study. Previous presentations An early presentation as “research-in-progress” was presented internally within China Medical University, Li Honghe’s institution, in their institute for Health Professions Education and Research in 2021. Acknowledgments The authors thank Dr. Yanan Ma for his statistical consultation and for assistance in establishing the representativeness of the survey. The authors also express their gratitude to Ms. Wang Bin and Dr. Zhang Xu for supporting participant enrolment. The authors acknowledge and thank Adele Weaver, MA, a PhD candidate in the Department of Psychology at The University of Rhode Island, and Dr. Judith Hall, University Distinguished Professor Emeritus Northeastern University College of Science, for their thoughtful review of our explanations of statistical terms. The authors thank Glenn Regehr, PhD for his generous and deeply instructive critical review of the final manuscript. Author contributions Honghe Li and Deliang Wen conceived of the study and study design. Deliang Wen supported data collection. Honghe Li led the data collection, data management, and data analysis. David Hirsh participated in data analysis and co-wrote and co-edited the manuscript with Honghe Li, with equal contributions from each. Jing Jin participated in data collection and data management. Edward Krupat contributed to the data analysis, writing, editing, and critical appraisal of the manuscript. Nan Jiang contributed to editing and critical appraisal of the manuscript. Ning Ding contributed to the data analysis and critical appraisal of the manuscript. Ming Jung Ho and Dianne Manning contributed to critical appraisal and editing the final manuscript. All authors read and confirmed the final version of the manuscript. Ethics statement The ethical review board of the Academic Committee of China Medical University approved this study. 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Assessing Professionalism in Medicine - A Scoping Review of Assessment Tools from 1990 to 2018. Journal of medical education and curricular development , 7 , 2382120520955159. https://doi.org/10.1177/2382120520955159 . K. R. Terwee, C. B., Jansma, E. P., Riphagen, I. I., & de Vet, H. C. (2009). Development of a methodological PubMed search filter for finding studies on measurement properties of measurement instruments. Quality of life research: an international journal of quality of life aspects of treatment care and rehabilitation , 18 (8), 1115–1123. https://doi.org/10.1007/s11136-009-9528-5 . The State Council of the People's Republic of China (2017, January 9). People's Republic of China13th five-year plan for healthcare reform. http://www.gov.cn/zhengce/content/2017-01/09/content_5158053.htm . Ting, X., Yong, B., Yin, L., & Mi, T. (2016). Patient perception and the barriers to practicing patient-centered communication: A survey and in-depth interview of Chinese patients and physicians. Patient education and counseling , 99 (3), 364–369. https://doi.org/10.1016/j.pec.2015.07.019 . Van Mook, W. N. K. A. (2011). Teaching and assessment of professional behaviour: rhetoric and reality . [Doctoral Thesis, Maastricht University]. Datawyse / Universitaire Pers Maastricht. https://doi.org/10.26481/dis.20110513wm . Wang, D., Hu, Y., Liu, K., Liu, Z., Chen, X., Cao, L., Zhang, W., Li, K., & Hu, J. (2023). Issues in patients' experiences of enhanced recovery after surgery (ERAS): a systematic review of qualitative evidence. BMJ open , 13 (2), e068910. https://doi.org/10.1136/bmjopen-2022-068910 . Wang, J., He, B., Miao, X., Huang, X., Lu, Y., & Chen, J. (2017). The reliability and validity of a new professionalism assessment scale for young health care workers. Medicine , 96 (25), e7058. https://doi.org/10.1097/MD.0000000000007058 . Wang, X., Shih, J., Kuo, F. J., & Ho, M. J. (2016). A scoping review of medical professionalism research published in the Chinese language. BMC medical education , 16 (1), 300. https://doi.org/10.1186/s12909-016-0818-7 . Wei-ming, T. (1996). Confucian Traditions in East Asian Modernity. Bulletin of the American Academy of Arts and Sciences , 50 (2), 12–39. https://doi.org/10.2307/3824246 . West, C. P., Dyrbye, L. N., Sloan, J. A., & Shanafelt, T. D. (2009). Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals. Journal of general internal medicine , 24 (12), 1318–1321. https://doi.org/10.1007/s11606-009-1129-z . Wilkinson, T. J., Wade, W. B., & Knock, L. D. (2009). A blueprint to assess professionalism: results of a systematic review. Academic medicine: journal of the Association of American Medical Colleges , 84 (5), 551–558. https://doi.org/10.1097/ACM.0b013e31819fbaa2 . Xiao, Y., Chen, T. T., Wang, P., & Tang, R. (2023). The importance of medical professionalism in breaking doctor-patient mistrust. Medical education , 57 (5), 488. https://doi.org/10.1111/medu.14971 . Xiao, Y., Chen, T. T., Wang, P., & Tang, R. (2023). The importance of medical professionalism in breaking doctor-patient mistrust. Medical education , 57 (5), 488. https://doi.org/10.1111/medu.14971 . Yip, W., Fu, H., Chen, A. T., Zhai, T., Jian, W., Xu, R., Pan, J., Hu, M., Zhou, Z., Chen, Q., Mao, W., Sun, Q., & Chen, W. (2019). 10 years of health-care reform in China: progress and gaps in Universal Health Coverage. Lancet (London England) , 394 (10204), 1192–1204. https://doi.org/10.1016/S0140-6736(19)32136-1 . Yu, F. F., Du, C. Y., Liu, Z. F., Chen, L. J., Huang, Y. X., & Zhang, L. L. (2019). Development and Validation of a Simplified Chinese Version of the Assessment Tool for Students' Perceptions of Medical Professionalism. Current medical science , 39 (4), 670–678. https://doi.org/10.1007/s11596-019-2090-7 . Additional Declarations No competing interests reported. Supplementary Files Appendix1ExplanationsofStatisticalTerms.docx Appendix2Aand2BItemsIncludedandExcludedinCMPI.docx Appendix3LongVersionCMPIinEnglish40Items.docx Appendix4LongVersionCMPIinChinese40Items.docx Appendix5ShortVersionCMPIinEnglish20Items.docx Appendix6ShortVersionCMPIinChinese20Items.docx Appendix7ShortVersionCMPIMeanScoreofItems.docx Appendix8CharacteristicsofExistingInstruments.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3810250","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":264563396,"identity":"52619e52-b93d-4ef3-8930-a9c23820ccc5","order_by":0,"name":"Honghe Li","email":"","orcid":"","institution":"China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Honghe","middleName":"","lastName":"Li","suffix":""},{"id":264563397,"identity":"34cb0438-2f81-40d1-8cce-f5b0662655aa","order_by":1,"name":"David Hirsh","email":"","orcid":"","institution":"Harvard Medical School/Cambridge Health Alliance, Boston and Cambridge","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Hirsh","suffix":""},{"id":264563398,"identity":"dcdd9c54-4c33-446f-936d-28e079c403bd","order_by":2,"name":"Jing Jin","email":"","orcid":"","institution":"China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jing","middleName":"","lastName":"Jin","suffix":""},{"id":264563399,"identity":"aacaa6ba-446f-4056-bc86-92a42f1ac17c","order_by":3,"name":"Edward Krupat","email":"","orcid":"","institution":"Beth Israel Deaconess Medical Center, Harvard Medical School","correspondingAuthor":false,"prefix":"","firstName":"Edward","middleName":"","lastName":"Krupat","suffix":""},{"id":264563400,"identity":"8f64ffb0-42cd-4a68-98c6-8912219d2ec8","order_by":4,"name":"Nan Jiang","email":"","orcid":"","institution":"China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Nan","middleName":"","lastName":"Jiang","suffix":""},{"id":264563401,"identity":"adc60f4b-3641-4edd-bf77-04c23264d7d1","order_by":5,"name":"Ning Ding","email":"","orcid":"","institution":"China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ning","middleName":"","lastName":"Ding","suffix":""},{"id":264563402,"identity":"7bfd7445-9e7c-4738-b003-3d96000893b1","order_by":6,"name":"Ming-Jung Ho","email":"","orcid":"","institution":"Georgetown University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Ming-Jung","middleName":"","lastName":"Ho","suffix":""},{"id":264563403,"identity":"bb78cf31-1aaa-4a43-9736-20f20582626f","order_by":7,"name":"Dianne Manning","email":"","orcid":"","institution":"University of Pretoria","correspondingAuthor":false,"prefix":"","firstName":"Dianne","middleName":"","lastName":"Manning","suffix":""},{"id":264563404,"identity":"a70ae118-c5af-4201-aefd-279f63c4bae8","order_by":8,"name":"Deliang Wen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAr0lEQVRIiWNgGAWjYDCC4yCiAsKWIE7LYRBxhmQtjG2kaOE7zGP4uHCeXbTBAeaDt3kY7PIIapE8zGNsPHNbcu6GA2zJ1jwMycUEtRgc5t0mzbvtAFALj5k0D8OBxAYitGz/zTsHpIX/G9FatjHzNoBtYSNOi+Rh/s/SPMeSc2ceZjO2nGOQTFgL3/G2xM88NXa5fcebH954U2FHWAsCMIPdSbz6UTAKRsEoGAV4AAAG2DoD+p3JKQAAAABJRU5ErkJggg==","orcid":"","institution":"China Medical University","correspondingAuthor":true,"prefix":"","firstName":"Deliang","middleName":"","lastName":"Wen","suffix":""}],"badges":[],"createdAt":"2023-12-27 03:14:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3810250/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3810250/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49022146,"identity":"6f228449-563c-4e3a-8fb2-34d14a49fdba","added_by":"auto","created_at":"2024-01-01 10:00:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":347487,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram describing four phases of the development and validation of the Chinese Medical Professional Inventory (CMPI)\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3810250/v1/23a6a5b6f914f97b64d0762e.png"},{"id":49022149,"identity":"04dcae47-4df4-4d38-a831-e8a9d2e187f9","added_by":"auto","created_at":"2024-01-01 10:00:56","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":475534,"visible":true,"origin":"","legend":"\u003cp\u003eConfirmatory factor analysis (CFA) of the 20-item Short Version China Medical Professionalism Inventory (CMPI). Path coefficients appears as numeric values on the arrows connecting CMPI to its subscales. Each coefficient indicates the relationship between CMPI and its domains. Item factor loading appears as numeric values on the arrows connecting domains 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) domain (RCC item 1 and RCC item 2).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAbbreviations:\u003c/em\u003e RCC indicates respect, compassion, and communication; Int, integity; Exc, excellence; and Res, responsibility.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3810250/v1/57c5d4ee2a30fdf819c54564.jpeg"},{"id":51917198,"identity":"4a9bae2a-da87-4852-b77f-369e9705f66b","added_by":"auto","created_at":"2024-03-03 15:45:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":790248,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3810250/v1/20c258e8-7f3a-4c39-b1f0-c84839215676.pdf"},{"id":49022147,"identity":"6fc7410f-f2e6-4ac7-a283-4936906d142e","added_by":"auto","created_at":"2024-01-01 10:00:56","extension":"docx","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":19117,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1ExplanationsofStatisticalTerms.docx","url":"https://assets-eu.researchsquare.com/files/rs-3810250/v1/b58608d6455f93c943e2d335.docx"},{"id":49022148,"identity":"82466b72-d3d6-432d-986d-56770df79e19","added_by":"auto","created_at":"2024-01-01 10:00:56","extension":"docx","order_by":9,"title":"","display":"","copyAsset":false,"role":"supplement","size":29577,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix2Aand2BItemsIncludedandExcludedinCMPI.docx","url":"https://assets-eu.researchsquare.com/files/rs-3810250/v1/196870b0e97c0333b087635e.docx"},{"id":49022479,"identity":"8a25f96f-206f-41e2-8db1-80fc47b93ddc","added_by":"auto","created_at":"2024-01-01 10:16:56","extension":"docx","order_by":10,"title":"","display":"","copyAsset":false,"role":"supplement","size":24296,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix3LongVersionCMPIinEnglish40Items.docx","url":"https://assets-eu.researchsquare.com/files/rs-3810250/v1/81d130b729caf6a60f5fccee.docx"},{"id":49022150,"identity":"3eb585e4-8a02-4090-8a96-0cc8e19607da","added_by":"auto","created_at":"2024-01-01 10:00:56","extension":"docx","order_by":11,"title":"","display":"","copyAsset":false,"role":"supplement","size":24639,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix4LongVersionCMPIinChinese40Items.docx","url":"https://assets-eu.researchsquare.com/files/rs-3810250/v1/b23437a143277a130e55749d.docx"},{"id":49022344,"identity":"5f9a5c14-00ed-45d7-a301-6402fdd4ea92","added_by":"auto","created_at":"2024-01-01 10:08:56","extension":"docx","order_by":12,"title":"","display":"","copyAsset":false,"role":"supplement","size":16484,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix5ShortVersionCMPIinEnglish20Items.docx","url":"https://assets-eu.researchsquare.com/files/rs-3810250/v1/220013b200f85b0a686a1287.docx"},{"id":49022155,"identity":"9fca5493-92c6-489b-a4e3-ce4282a8bb40","added_by":"auto","created_at":"2024-01-01 10:00:56","extension":"docx","order_by":13,"title":"","display":"","copyAsset":false,"role":"supplement","size":16563,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix6ShortVersionCMPIinChinese20Items.docx","url":"https://assets-eu.researchsquare.com/files/rs-3810250/v1/cce905d690e79fde6f707390.docx"},{"id":49022153,"identity":"fd60ab03-851f-469d-ac66-f8d1da40ae4a","added_by":"auto","created_at":"2024-01-01 10:00:56","extension":"docx","order_by":14,"title":"","display":"","copyAsset":false,"role":"supplement","size":20076,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix7ShortVersionCMPIMeanScoreofItems.docx","url":"https://assets-eu.researchsquare.com/files/rs-3810250/v1/d1b3d7c83ddfc8ee89ec7ee8.docx"},{"id":49022342,"identity":"1f8687a0-7b55-4b19-af44-2e4a3b310cf3","added_by":"auto","created_at":"2024-01-01 10:08:56","extension":"docx","order_by":15,"title":"","display":"","copyAsset":false,"role":"supplement","size":28525,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix8CharacteristicsofExistingInstruments.docx","url":"https://assets-eu.researchsquare.com/files/rs-3810250/v1/e8b17f25e557bade6580fd95.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"East Meets West: Evidence for Validity for the China Medical Professionalism Inventory","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMedical professionalism (MP) is a complex, multi-dimensional construct (Hodges et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Irby \u0026amp; Hamstra, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) that may affect health outcomes, patient well-being, and satisfaction (Wang et al., \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Khawar et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Elements of MP connect to cultural context: culture and societal expectations of physicians influence the general public\u0026rsquo;s, patients\u0026rsquo;, physicians\u0026rsquo;, and other health professionals\u0026rsquo; perceptions of MP (Ho, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Nie et al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Nilchaikovit et al., \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e1993\u003c/span\u003e; Goddard \u0026amp; Brockbank, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMultiple reviews highlight that current MP tools embody Western frameworks and were developed in Western contexts (Goddard \u0026amp; Brockbank, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Li et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Tay et al., \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Kwan et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Educators and researchers outside Western cultures are now calling for research to characterize and promote MP (Li et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Wang et al., \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Chinese leaders seek that MP should connect to historical tradition, current culture, and modern conceptualizations of MP inside and outside China (Nie et al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Wang et al., \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Hu et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Indeed, advancement of MP in China could have benefits in the region and beyond. Confucianism grounds Chinese culture and the cultures of other societies in the region including Hongkong, Taiwan, Japan, Singapore, Philippines, and North and South Korea (Rozman, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Wei-ming, 1993). In these regions, Confucianism has an influence on health, health care, and health systems (Badanta, 2022).\u003c/p\u003e \u003cp\u003eThere are also potential cross-cultural benefits of advancing MP in this region. Historically, MP tools have been described in the West, translated, and adapted for MP assessment in Eastern contexts. Is it also possible to imagine that instruments developed in Eastern contexts, with validation evidence, could inform Western conceptualizations of MP? Further, professionalism instruments developed in health professions such as nursing (Hisar, 2010; Lin, 2016) and counseling psychology (Dnnmer, 2011), are adapted for use among physicians. One can imagine that tools developed among physicians might also offer some insights for use in other health professions.\u003c/p\u003e \u003cp\u003eThe literature reports more than 80 instruments related to MP (Li et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Wilkinson et al., \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Wang et al., \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Chen et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Yu et al., \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Larramendy-Magnin et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Goss et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Multak, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Berendonk et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Kalet et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Systematic reviews evaluating psychometric properties of MP tools suggest that although these instruments are plentiful and diverse, only a limited number of studies document acceptable evidence of reliability and validity (Hodges et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Li et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Tay et al., \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Kwan et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Wang et al., \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Ideally, MP tool development should follow standard processes for psychological testing (Messick, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e1989\u003c/span\u003e; AERA et al., 2014; Cook \u0026amp; Beckman, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Downing, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2003\u003c/span\u003e; Cook et al., 2006; Kane \u0026amp; Brennan, 2006) and report evidence for validity incorporating the context of the tool\u0026rsquo;s use (Hodges et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Ho, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Ginsburg et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). Researchers are also calling for MP tools focused on behaviors (i.e., items are \u0026ldquo;behaviorally-referenced\u0026rdquo;) (Lesser et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Ginsburg \u0026amp; Stern, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2004\u003c/span\u003e; Boudreau et al., 2004; Birden et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Van Mook, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Two theoretical lenses ground our approach; we incorporate virtue-based professionalism with the aim to advance behavior-based professionalism (Irby \u0026amp; Hamstra, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough researchers have made progress defining MP in non-Western contexts (Ho et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Pan et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Ho et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Wang et al., \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Hu et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Hisar, 2010), our review of the English language and Chinese literature identified no MP tools that met above needs and criteria. This study, therefore, has three aims: 1) to create an instrument derived from MP principles established in the literature, augmented with principles connected to the Chinese context; 2) to develop an MP inventory referring to physicians\u0026rsquo; behaviors; and 3) to provide evidence for the validity of this inventory in this Eastern context. Our ultimate goal is to extend the conceptualization and reach of MP measurement.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e \u003cb\u003eStudy design and ethics\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFollowing Cook \u0026amp; Beckman (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2006\u003c/span\u003e), Downing (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2003\u003c/span\u003e), Messick (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e1989\u003c/span\u003e) and the current Standards for Educational and Psychological Testing (2014), we undertook a 4-phase process to collect validity evidence for the China Medical Professionalism Inventory (CMPI): Phase I) systematic review and synthesis of the literature to develop an item pool; Phase II) an expert survey to evaluate the inventory\u0026rsquo;s content-based evidence; Phase III) two rounds of pilot studies to determine psychometric properties; and Phase IV) an expert survey and pilot study to refine and potentially shorten the instrument. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the methods, participants, and items involved.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e The protocol was approved by the Bioethics Advisory Commission, the Institutional Review Board of China Medical University (Identification number: 2017075).\u003c/p\u003e \u003cp\u003e(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e should be put here)\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhase I: Systematic review and synthesis of professionalism instruments\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWe reviewed the literature reporting instruments that measure MP. At that time, our search of the Chinese-language literature revealed no Chinese MP tools with validation evidence. We systematically searched the English language literature using PubMed, Web of Science, and PsycINFO databases to identify studies and instruments assessing MP between January 1, 1990 and December 31, 2015 (Li et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Applying Terwee\u0026rsquo;s search construct (Terwee et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2009\u003c/span\u003e), our strategy combined key terms: \u003cem\u003eprofessionalism\u003c/em\u003e AND \u003cem\u003ephysicians\u003c/em\u003e AND \u003cem\u003einstruments or assessing\u003c/em\u003e AND \u003cem\u003epsychometric properties\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eTo create the initial item pool, three researchers (H.L., J.J., N.J.) extracted items from existing instruments assessing MP that had been identified by the systematic review (Li et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). We eliminated duplicate items using the professionalism framework of Lesser et al (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2010\u003c/span\u003e), which categorized items into four domains: compassionate, respectful, and collaborative orientation; integrity and accountability; pursuit of excellence; and fair and ethical stewardship of health care resources. Items that did not fit into these four domains, we categorized together as \u0026ldquo;other.\u0026rdquo;\u003c/p\u003e \u003cp\u003eWe translated all maintained items into Chinese. To develop evidence for cross-cultural validity, we followed Brislin\u0026rsquo;s modified model (Lee et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Bicultural, bilingual members of the research team who are Chinese (H.L. and N.D.) and Chinese-Canadian (N.J.), created the item pool through several rounds of blinded forward and back translation. For the last step, two pairs of researchers (H.L. with D.M. and H.L. with D.A.H.) separately ensured the final English and Chinese translations met standards for content, semantic, technical, criterion, and conceptual equivalence (Lee et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2009\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo support this instrument\u0026rsquo;s representativeness and alignment with the Chinese healthcare context, we supplemented the item pool with items from published Chinese government policies related to MP (e.g., \u0026ldquo;Physicians should avoid conducting non-scientific or unethical research supported by commercial sponsorship.\u0026rdquo;) (CMDA, 2016; CMDA, 2014; NHFPC, 2012). We converted all items expressing attitudes or values into behavioral terms (e.g., \u0026ldquo;have commitment\u0026rdquo; was changed to \u0026ldquo;demonstrate responsibility for\u0026rdquo;), to create CMPI Version 1 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhase II: National experts survey\u003c/b\u003e \u003c/p\u003e \u003cp\u003eTo gather evidence based on content and to enhance item quality, we followed a standard practice for providing validity evidence (Cook et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Lawshe, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e1975\u003c/span\u003e; Boateng et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) by inviting experts to review the items individually. We invited 40 nationally prominent Chinese healthcare leaders using the following criteria: 1) Expertise in medical education, health system science, medical ethics, or MP; 2) Diversity of geographical location to include all seven administrative regions of China; and 3) Associate Professors or higher academic rank. Our expert review had additional importance in connecting to context (AERA et al., 2014; Cook et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) given that nearly the entire item pool was derived from studies outside of China. We asked experts to evaluate each item according to whether it fit the Chinese context (1\u0026thinsp;=\u0026thinsp;Yes and 2\u0026thinsp;=\u0026thinsp;No) and its relevance and importance to MP in China (1\u0026thinsp;=\u0026thinsp;very low and 5\u0026thinsp;=\u0026thinsp;very high). Items were phrased to indicate behaviors with stems that began, \u0026ldquo;The physician [action verb]\u0026hellip;\u0026rdquo;. Because it is a standard approach for determining content-based evidence (AERA et al., 2014), experts also had opportunities to consider revisions or propose additional items. Following accepted standards for defining consensus (Diamond et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) and expert review of item content (Polit \u0026amp; Beck, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2006\u003c/span\u003e), we kept those items when \u0026gt;\u0026thinsp;90% of the experts determined the item fit the Chinese context. We then calculated mean scores for relevance and importance and retained only items with scores for both relevance and importance\u0026thinsp;\u0026gt;\u0026thinsp;4. This process resulted in CMPI Version 2 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhase III: Pilot surveys\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eParticipants and questionnaire\u003c/em\u003e \u003c/p\u003e \u003cp\u003eFor the first pilot survey, we distributed the CMPI Version 2 to 390 physicians from two tertiary teaching hospitals: China Medical University First Affiliated Hospital and Sheng-Jing Hospital. These two hospitals are located in Shenyang, Liaoning Province and serve the general adult and pediatric population of this region of \u0026gt;\u0026thinsp;43\u0026nbsp;million people (LSB, 2020). We selected a stratified random sample of participants with equal proportions of physicians from major specialty disciplines (medicine, surgery, obstetrics and gynecology, pediatrics, radiology, and acute care). This self-administered survey asked participants to indicate the frequency they have demonstrated each item in practice, using a 5-point Likert-style scale (1\u0026thinsp;=\u0026thinsp;not at all to 5\u0026thinsp;=\u0026thinsp;very much). The sum of all items provided the total score, with higher scores indicating higher frequency of self-reported MP behaviors. The results of the psychometric analysis after the first pilot survey produced the CMPI Version 3.\u003c/p\u003e \u003cp\u003eUsing the identical set of items from the first pilot study, the second pilot again used a stratified cluster sampling method, administering Version 3 to 4,070 physicians from nine diverse hospitals (i.e., their location, size, mission, ranking) in eight cities in Liaoning. This second pilot survey was also self-administered. This step aimed to determine the CMPI\u0026rsquo;s relationship to other variables, in particular to investigate convergent evidence. (AERA et al., 2014; Downing, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2003\u003c/span\u003e)\u003csup\u003e30,32\u003c/sup\u003e Using a previously published Chinese version of the Penn State College of Medicine Professionalism Questionnaire (PSPQ),(Song et al., \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2019\u003c/span\u003e)\u003csup\u003e51\u003c/sup\u003e a recognized MP instrument originally developed in the West, we expected a moderate correlation with the CMPI. Also, because prior studies have reported that physicians\u0026rsquo; burnout level \u003cem\u003enegatively\u003c/em\u003e correlates with MP,(Wang et al., \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Dyrbye et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2020\u003c/span\u003e)\u003csup\u003e3,52\u003c/sup\u003e we administered the short version of the Maslach Burnout Inventory (MBI),(West et al., \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e2009\u003c/span\u003e)\u003csup\u003e53\u003c/sup\u003e expecting an association (negatively) with this scale as well. We collected demographic information and the specialty of the physicians in the two pilot surveys.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThis phase included statistical analyses (we explain statistical terms in Appendix 1). For the first pilot study in Phase III, we calculated corrected item-total correlations (CITC) for the CMPI\u0026rsquo;s four domains to identify the degree to which items correlate with each domain. A CITC greater than 0.5 is acceptable. We determined the Cronbach\u0026rsquo;s Alpha if Item Deleted (CAID) to delete items with a CAID higher than the total scale Cronbach\u0026rsquo;s alpha.\u003c/p\u003e \u003cp\u003eTo evaluate the performance of individual items and to further describe the underlying structure of CMPI, we performed exploratory factor analysis (EFA) (AERA et al., 2014; Cook \u0026amp; Beckman, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Downing, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). We conducted principal component factor extraction with a varimax rotation with the factor pattern matrix to extract the factors. We evaluated assumptions regarding matrix identity and sampling adequacy using the Bartlett Test of Sphericity and the Kaiser\u0026ndash;Meyer\u0026ndash;Olkin (KMO) test. To be included in the inventory, each factor needed to have an eigenvalue\u0026thinsp;\u0026gt;\u0026thinsp;1 and at least three items, and each item needed to have a factor loading\u0026thinsp;≧\u0026thinsp;0.45. We used Cronbach\u0026rsquo;s alpha to determine internal consistency for the total scale and each factor in EFA (Cook \u0026amp; Beckman, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). We considered alpha values larger than 0.7 to be acceptable.\u003c/p\u003e \u003cp\u003eFor the second pilot study in Phase III, we examined evidence based on internal structure of the scale using confirmatory factor analysis (CFA) to assess model fit (Cook \u0026amp; Beckman, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). We fit the covariance matrix of the data with the 4-domain model from the empirical findings of the EFA in the first pilot study and deleted items with a factor loading of \u0026lt;\u0026thinsp;0.45. To determine model fit, we used the following five indices: normed \u003cem\u003eχ\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e statistic (\u0026lt;\u0026thinsp;5), comparative fit index (CFI) (\u0026gt;\u0026thinsp;0.90), Tucker-Lewis index (TLI) (\u0026gt;\u0026thinsp;0.80), and standardized root mean square error of approximation (RMSEA) (\u0026lt;\u0026thinsp;0.08), and Standardized root mean square residual (SRMR) (\u0026lt;\u0026thinsp;0.08) (Hooper et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Li-tze \u0026amp; Bentler, 1999). We analyzed for convergent evidence to determine CMPI\u0026rsquo;s relation to other variables using Pearson correlation coefficients (AERA et al., 2014; Cook \u0026amp; Beckman, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Downing, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). We used the results of statistical analysis in the two pilot studies to create the Long Version CMPI.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhase IV: Instrument refinement\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWe undertook a process to refine the survey and consider its length following the guidance of Galesic and Bosnjak (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). To maintain reliability while potentially shortening the survey, we used a \u0026ldquo;content evaluation panel\u0026rdquo; described by Lawshe (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e1975\u003c/span\u003e). We sent the Long Version CMPI to 120 experts from 19 clinical disciplines in 17 medical universities across China. We considered \u0026ldquo;experts\u0026rdquo; as educators who are eligible to consult with China\u0026rsquo;s National Medical Examination Center (NMEC)\u0026mdash;the national organization that oversees the medical licensing examination in China. The NMEC chooses these consultants for their high expertise in clinical medicine, medical education, and assessment. We asked the experts to select the 5 most important MP items for doctors to demonstrate for each domain determined by EFA and CFA. We decided in advance to maintain only the top 50% of items as determined by the number of experts who agreed to keep the item. This process modified Lawshe\u0026rsquo;s guidance (1975); we chose this 50% standard because we anticipated that the number of items chosen would exceed Lawshe\u0026rsquo;s range and therefore potentially leave redundant items in the survey.\u003c/p\u003e \u003cp\u003eAs a final step, we distributed the shortened CMPI to 1,002 physicians selected by stratified random sampling, with equal proportions from 8 tertiary hospitals in Liaoning Province. We collected demographic information and the specialty of the physicians. We used CFA to assess for evidence based on internal structure and Cronbach\u0026rsquo;s alpha to assess for internal consistency of the Short Version CMPI (Cook \u0026amp; Beckman, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Group differences were tested by independent sample t-test and one-way ANOVA. To account for multiple comparisons given the four demographic features, we used a Bonferroni-corrected significance threshold of .0125 (.05/4).\u003c/p\u003e \u003cp\u003eAll statistical analyses were carried out by IBM SPSS (IBM Corp. Released 2011, Version 20.0. Armonk, NY: IBM Corp. Chicago, IL, USA) and Amos Version 21.0 (Chicago: IBM SPSS. Released 2012) for CFA.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cb\u003ePhase I: Item pool generation\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWe extracted 1537 individual items from the 63 scales that met our search criteria. As planned, to facilitate removal of duplicate items, we organized the items into 4 domains described by Lesser (2010). These included 535 items in \u0026ldquo;compassionate, respectful, and collaborative orientation\u0026rdquo;; 431 in \u0026ldquo;integrity and accountability\u0026rdquo;; 123 in \u0026ldquo;pursuit of excellence\u0026rdquo;; and 345 in \u0026ldquo;fair and ethical stewardship of health care resources.\u0026rdquo; We also removed duplicate items for the 103 \u0026ldquo;other\u0026rdquo; items that did not fit into the four categories. Elimination of duplicate items resulted in a pool of 110 items. The Chinese official policies produced 28 additional items to supplement the pool. The final CMPI Version 1 included 138 items.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhase II: National expert survey\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWe received completed questionnaires from 34 (85%) of the national examination experts. Experts represented 27 medical schools, each ranked among the \u0026ldquo;first class\u0026rdquo; universities in China on the government\u0026rsquo;s official recommendation list. The experts determined 82 items (11 from Chinese policies and 71 from our original literature review) to be less related or less important. These items were eliminated, resulting in a pool of 56 items including 17 items sourced from policy documents. The experts recommended two additional items: \u0026ldquo;respects patient autonomy and their informed decisions\u0026rdquo; and \u0026ldquo;shares experience, skills, and knowledge with junior colleagues,\u0026rdquo; resulting in CMPI Version 2 with 58 items (Appendix 2A).\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhase III: Two pilot surveys\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThree hundred and sixty physicians (response rate, 92.3%) returned the first pilot survey and 3653 physicians (response rate, 89.8%) returned the second pilot survey. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e (columns 3 and 4) depicts the socio-demographic characteristics of physicians in the two pilot surveys.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of physicians from two pilot surveys and the Short Version China Medical Professionalism Inventory (CMPI), 2017\u0026ndash;2018\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1st pilot survey,\u003c/p\u003e \u003cp\u003en (% of 360 physicians)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2nd pilot survey,\u003c/p\u003e \u003cp\u003en (% of 3653 physicians)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eShort Version CMPI survey, n (% of 955 physicians)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e183 (50.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1777 (48.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e472 (49.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e176 (48.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1870 (51.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e480 (50.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e84 (23.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e927 (25.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e176 (18.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e181 (50.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1420 (38.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e497 (52.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e69 (19.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e789 (21.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e200 (21.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e433 (11.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e66(7.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5 (0.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eEducational level \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDoctorate degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e179 (47.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e750 (20.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e214 (22.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaster\u0026rsquo;s degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e175 (48.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1690 (46.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e490 (51.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBachelor\u0026rsquo;s degree (MBBS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1152 (31.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e225 (23.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLower degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11 (1.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eSpecialization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInternal medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e139 (38.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1543 (42.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e392 (41.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e145 (40.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1207 (33.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e367 (38.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObstetrics and Gynecology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e203 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e61 (6.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePediatrics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e113 (3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e42 (4.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntensive care and other \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39 (10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e378 (10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e74 (7.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003ea\u003c/sup\u003e 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\u0026rsquo;s degree is in addition to MBBS and PhD is in addition to MBBS or master\u0026rsquo;s degree.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003eb\u003c/sup\u003e The category \u0026ldquo;other\u0026rdquo; includes Dermatology, Otorhinolaryngology, Intensive Care, etc.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e(Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e should be put here)\u003c/p\u003e \u003cp\u003eFor the first pilot survey, we removed 19 surveys (5%) with missing data and analyzed 341 responses for EFA. We deleted 14 items that did not meet the criteria of the CITC and CAID analyses (8, 2, 2, and 2 items in the four domains, respectively) including six items from Chinese policies (#15, #18, #30, #36, #46, #54) (Appendix 2B). Forty-four items remained for the EFA. Both the Bartlett Test of Sphericity (\u003cem\u003eχ\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;16,281, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) and the KMO test (0.98) indicated that the correlation matrix was factorable. The final result of the EFA determined 4 factors with eigenvalues greater than 1.0.\u003c/p\u003e \u003cp\u003eThree items did not meet the predetermined standard for factor loading; we retained 41 items with factor loading\u0026thinsp;≧\u0026thinsp;0.45 (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). These items made up the CMPI Version 3 used in the second pilot study. For each domain, the research team labeled the 4 factors according to the basis of the relatedness of their items: \u0026ldquo;Respect, Compassion, and Communication\u0026rdquo;; \u0026ldquo;Integrity\u0026rdquo;; \u0026ldquo;Excellence\u0026rdquo;; and \u0026ldquo;Responsibility.\u0026rdquo; The four domains account for a total of 66.65% of the scale variance, an acceptable standard. With one exception, none of the items were \u0026ldquo;factorially complex\u0026rdquo; (i.e., loaded\u0026thinsp;\u0026gt;\u0026thinsp;.50 in more than one domain). However, we observe that item 26 loaded 0.45 in \u0026ldquo;Integrity\u0026rdquo; and 0.46 in \u0026ldquo;Excellence.\u0026rdquo; Cronbach\u0026rsquo;s alpha coefficients for each factor were greater than 0.9 (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactor loadings for the 41 items of the China Medical Professionalism Inventory (CMPI) Version 3 resulting from the exploratory factor analysis, with Cronbach\u0026rsquo;s alpha for each factor, 2017 (n\u0026thinsp;=\u0026thinsp;341 physicians)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCMPI element (item number\u003csup\u003e$\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eItem loadings by domain\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCronbach\u0026rsquo;s ɑ by domain\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRCC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInt\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExc\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePlease check how often you have demonstrated the following behaviors in practice\u003c/em\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGreets patients warmly; calling them by the names they prefer; be friendly, never crabby or rude. (item 11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"13\" rowspan=\"14\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemonstrates respect for patient autonomy and their informed decisions. (item 8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTakes the patient\u0026rsquo;s embarrassment, shyness, and reluctance into account and provides timely emotional support when necessary. (item 7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExplains to the patient what they need to know about their problems, how and why they occurred, and what to expect next. (item 6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresents professional opinion to the patient in a way the patient can understand. (item 3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoes not discriminate against or refuse to treat a patient due to gender, race, religion, nationality, family background, sexual orientation, or economic status. (item 10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiscusses options with patients, asks their opinions, offers choices, and lets them decide what to do before making decisions. (item 14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorks collaboratively across disciplines to complete medical responsibilities. (item 20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollows the regulations and procedures for declaration of a patient\u0026rsquo;s death and takes care of the family's emotions to give proper comfort. (item 13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaintains a positive rapport with the whole healthcare team and provides emotional support for colleagues. (item 19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemonstrates respect for clinical assistants, such as nurses and other staff. (item 21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemonstrates trust in the professional knowledge and skills of coworkers. (item 22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResolves interdisciplinary conflicts in a collegial and respectful manner. (item 23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollows the patient\u0026rsquo;s preference to accept or refuse any clinical treatment. (item 16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAvoids conducting non-scientific or unethical research supported by commercial sponsorship. (item 31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"9\" rowspan=\"10\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoes not sell any medical products or prescribe drugs for personal benefit. (item 32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoes not attract patients through misleading advertising. (item 34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTakes responsibility for their own clinical decisions and medical practices (i.e., not seek to evade responsibility). (item 28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipates in peer evaluations of the quality of care provided by colleagues objectively. (item 35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaintains patient/physician relationships that do not exploit personal financial gain, privacy, or sexual advantages. (item 25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProvides appropriate and clear information to colleagues for follow-up patient care. (item 38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoes not give patients false hope and fully explains treatment risks to them. (item 37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoes not participate in commercially sponsored banquets, tourism, training, or other activities that may lead to medical bias. (item 33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAvoids discussing and revealing confidential patient information in public. (item 24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePromotes the welfare and career of junior faculty. (item 47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShares experience, skills, and knowledge with junior colleagues. (item 48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEngages in continuous professional development. (CPD). (item 45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcknowledges the meaning and relative value of scientific evidence in decision-making. (item 41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUses practical experience as a basis for critical self-reflection. (item 42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApplies new clinical practice guidelines into patient care actively. (item 40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollows scientific standards and bases decisions on scientific evidence and experience. (item 39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsults other medical colleagues to manage a situation that is beyond one\u0026rsquo;s ability. (item 43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActively reports any personal medical or research errors. (item 26)\u003csup\u003e\u0026yen;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistinguishes between accepted treatment and experimental activities and abides by ethical standards. (item 55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFocuses on the risk factors that may threaten the safety of the patient and actively provide early warning and improvement suggestions to the relevant authority. (item 49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChooses appropriate medical treatment for a patient with financial constraints and helps them in finding other means of assistance.\u003c/p\u003e \u003cp\u003e(item 58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoes 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. (item 56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnsures that the patient understands the content and meaning of the informed consent correctly and fully. (item 53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollaborates with peers to avoid unnecessary tests and optimizes the use of medical resources. (item 57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdvocates for public health and transfers knowledge of public health to patients. (item 52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoes not provide unnecessary or excessive testing or medical treatment. (item 50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003e\u0026dagger;\u003c/sup\u003e Abbreviations of domains: RCC indicates respect, compassion, and communication; Int, integity; Exc, excellence; and Res, responsibility. In this table, bold Cronbach\u0026rsquo;s alpha values correspond to bold item loadings in each domain.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e Number of physicians (n) represents respondents with missing data removed, the number of surveys used for exploratory factor analysis (EFA).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003e$\u003c/sup\u003e Item numbers correspond to the 58-item CMPI Version 2, the first of three pilot studies (listed in Appendix 2).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003e\u0026yen;\u003c/sup\u003eThe CFA provided a satisfactory fit to the 4-domain model (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) by deleting the one item (item 26), with a factor loading that was nearly identically strong in two domains on EFA\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e(Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e should be put here)\u003c/p\u003e \u003cp\u003eFor the Phase III second pilot survey, we removed 149 surveys (4%) because of missing data and analyzed 3504 responses for CFA. The CFA provided a satisfactory fit to the 4-domain model (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) by deleting the one item (item 26), with a factor loading that was nearly identically strong in two domains on EFA. This process resulted in the Long Version CMPI with 40 items (see Appendix 3 and 4 respectively for the Long Version CMPI in English and Chinese). Cronbach\u0026rsquo;s alpha coefficients for each factor ranged from 0.92\u0026ndash;0.96. The results of the survey produced a Long Version CMPI mean score of 182.5 (SD\u0026thinsp;=\u0026thinsp;20.46), a median of 188, and the range of actual scores from 54 to 200.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMeasures of fit for two rounds confirmatory factor analysis (CFA)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e, \u003cem\u003edf\u003c/em\u003e,\u003c/p\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value, Normed χ\u003csup\u003e2 a\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCFI\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTLI\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRMSEA\u003c/p\u003e \u003cp\u003e(95% CI)\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSRMR\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhase III: Second pilot study CFA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;3305.3, \u003cem\u003edf\u0026thinsp;=\u003c/em\u003e\u0026thinsp;735,\u003c/p\u003e \u003cp\u003e\u003cem\u003eP\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.0001, Normed χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;4.50\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.059\u003c/p\u003e \u003cp\u003e(0.053\u0026ndash;0.066)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhase IV: Pilot study CFA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;660.5, \u003cem\u003edf\u0026thinsp;=\u003c/em\u003e\u0026thinsp;166,\u003c/p\u003e \u003cp\u003e\u003cem\u003eP\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.0001, Normed χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;3.98\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.060\u003c/p\u003e \u003cp\u003e(0.054\u0026ndash;0.066)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eAbbreviations: χ\u003csup\u003e2\u003c/sup\u003e, Chi-square test; \u003cem\u003edf\u003c/em\u003e, 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.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ea\u003c/sup\u003e For model fit, when calculating χ\u003csup\u003e2\u003c/sup\u003e for CFA, a \u003cem\u003eP\u003c/em\u003e-value\u0026thinsp;\u0026gt;\u0026thinsp;0.05 is considered \u0026ldquo;significant\u0026rdquo; suggesting the proposed model represents the data; this standard, however, is affected by sample size. With samples sizes\u0026thinsp;\u0026gt;\u0026thinsp;200 (e.g., as in our study: we sampled 3504 and 803 in our two CFAs), the \u003cem\u003eP\u003c/em\u003e-value will nearly always be \u0026gt;\u0026thinsp;0.05 which undermines the utility of using χ\u003csup\u003e2\u003c/sup\u003e for CFA. The recommended statistical approach is to use \u0026ldquo;normed\u0026rdquo; χ\u003csup\u003e2\u003c/sup\u003e wherein \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 is acceptable.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003eb\u003c/sup\u003e 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-squared 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.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ec\u003c/sup\u003e TLI is one of several calculations to determine \u0026ldquo;model fit.\u0026rdquo; 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 Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). TLI values of \u0026gt;\u0026thinsp;0.80 are usually considered acceptable.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ed\u003c/sup\u003e RMSEA is one of several calculations to determine \u0026ldquo;model fit.\u0026rdquo; 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\u0026thinsp;\u0026lt;\u0026thinsp;0.08 are considered an acceptable fit of the data to the proposed model.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ee\u003c/sup\u003e SRMR is one of several calculations to determine \u0026ldquo;model fit.\u0026rdquo; 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\u0026thinsp;\u0026lt;\u0026thinsp;0.08 are considered an acceptable fit of the data to the proposed model.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e(Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e should be put here)\u003c/p\u003e \u003cp\u003eAs expected, our results indicated that the CMPI correlated positively with the Chinese version of the PSPQ (Pearson \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.77, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01) and correlated negatively with the short version MBI (Pearson \u003cem\u003er\u003c/em\u003e = -0.22, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01). Appendix 1 offers explanations of statistical analyses.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhase IV: Creating the Short Version CMPI\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSeventy-six national clinical experts (response rate, 63%) completed the survey to rank the importance of each item. We retained the top 50% of items in each domain to generate the shortened CMPI containing 20 items (see Appendix 5 and 6 respectively for the Short Version CMPI in English and Chinese).\u003c/p\u003e \u003cp\u003eIn the Phase IV pilot study, 955 clinicians (response rate, 95.3%) completed the Short Version CMPI. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e (column 5) presents the socio-demographic characteristics of these physician respondents. We removed 152 surveys (15.9%) because of missing data and analyzed 803 responses for CFA.\u003c/p\u003e \u003cp\u003eAfter we adjusted for correlated item pairs based on the modification index, the subsequent CFA indicated that all 20 items loaded significantly (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01) on their respective factors (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The CFA provided a satisfactory fit to the 4-domain model (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The internal consistency of the total scale and four domains are all in a satisfactory level (Cronbach\u0026rsquo;s alpha\u0026thinsp;\u0026gt;\u0026thinsp;.7) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The fit of the model to the data indicates that a 4-domain structure was suitably descriptive of the data.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInterfactor correlations and Cronbach\u0026rsquo;s alpha coefficients of a confirmatory factor analysis of the Short Version China Medical Professionalism Inventory (CMPI) by factors, 2018 (n\u0026thinsp;=\u0026thinsp;803 physicians)*\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCMPI domains\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ek\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eM (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003eInterfactor Correlations:\u003c/p\u003e \u003cp\u003ePearson \u003cem\u003er\u003c/em\u003e (Cronbach\u0026rsquo;s alpha)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRCC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInt\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eExc\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespect, Compassion,\u003c/p\u003e \u003cp\u003eand Communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.41 (0.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(0.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntegrity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.50 (0.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.61\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(0.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExcellence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.43 (0.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.53\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.72\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(0.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResponsibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.45 (0.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.57\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.75\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.82\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(0.87)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eAbbreviations: RCC indicates respect, compassion, and communication; Int, integity; Exc, excellence; Res, responsibility; M, mean; SD, standard deviation.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e* Number of physicians (n) represents respondents with missing data removed, the number of surveys used for confirmatory factor analysis (CFA).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003ea\u003c/sup\u003e Cronbach\u0026rsquo;s alpha values are those in parentheses on the diagonal.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003eb\u003c/sup\u003e \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e(Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e should be put here)\u003c/p\u003e \u003cp\u003e(Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e should be put here)\u003c/p\u003e \u003cp\u003eThe results of this pilot survey produced a Short Version CMPI mean score of 88.3 (SD\u0026thinsp;=\u0026thinsp;20.47), a median of 89, and a range of actual scores from 60 to 100. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e demonstrates the mean score of items for each domain and interfactor correlations. Appendix 7 reports the mean scores for each individual item.\u003c/p\u003e \u003cp\u003eOn the Short Version CMPI, female physicians scored higher than males (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, Cohen\u0026rsquo;s \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.21). Respondents less than 30 years old had lower professionalism scores than physicians over 30 years old (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, Cohen\u0026rsquo;s \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.28). Respondents identifying as surgeons had lower scores than physicians working in internal medicine (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, Cohen\u0026rsquo;s \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.23).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe developed a long (40 item) and short (20 item) version of the Chinese Medical Professionalism Inventory (CMPI) to assess MP of Chinese physicians and collected validity evidence from two rounds of expert surveys and three pilot studies. Our analysis suggests that the process of developing the CMPI included supportive evidence based on content and internal structure in the Chinese context. Our EFA and CFA processes determined that CMPI has four domains (\u0026ldquo;Respect, Compassion, and Communication,\u0026rdquo; \u0026ldquo;Integrity,\u0026rdquo; \u0026ldquo;Excellence,\u0026rdquo; and \u0026ldquo;Responsibility\u0026rdquo;). To our knowledge, the CMPI is the first behaviorally-referenced MP scale incorporating Chinese health system policies and engaging Chinese experts in scale development. Below, we summarize our processes of collecting evidence for validity, comment about future use and connect our findings to recent healthcare reforms in China.\u003c/p\u003e \u003cp\u003eWe aimed to describe the sources of validity evidence for this inventory systematically. We present our findings according to the framework presented by Cook and Beckman (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) and Downing (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2003\u003c/span\u003e) following Messick (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e1989\u003c/span\u003e) and the American Psychological Association (APA) Standards for Educational and Psychological Testing (2014). Following Messick and the Standards, we organize our results using five criteria for characterizing an instrument\u0026rsquo;s validity evidence: content, response process, internal structure, relationship to other variables, and consequences (Messick, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e1989\u003c/span\u003e; AERA et al., 2014). We developed evidence based on content by surveying two distinct groups of national experts from across China to rate and provide feedback on each item\u0026rsquo;s importance and relevance. Considering evidence based on response process, we engaged experts in Phase IV of this study who are practicing clinicians and likely had similar experiences with study participants and with the intended recipients of this inventory; thus, their views may represent the \u0026ldquo;thought processes of subjects\u0026rdquo; suggested by Cook and Beckman (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). We administered pilot studies to physicians to provide evidence based on internal structure of the 4-domain model. Each of the 4 domains and the total scale score showed high internal consistency based on Cronbach\u0026rsquo;s alpha. For analysis of relationships to other variables, we determined convergent evidence. The CMPI showed a strong positive correlation with the PSPQ that assesses MP attitudes and a negative correlation, albeit weak, with the MBI that assesses physician burnout.\u003c/p\u003e \u003cp\u003eCook and Beckman (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) suggest that evidence of consequential validity may \u0026ldquo;explore whether desired results have been achieved and unintended effects avoided\u0026rdquo; (p. 166.e12). Our desire is that the items in this inventory can contribute to MP measurement in China by generating formative feedback and discourse for professional development. Currently, the CMPI should be used formatively for self-evaluation in conjunction with other MP-related activities: for example, as part of a Professionalism Mini-Evaluation Exercise (P-MEX) (Cruess et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2006\u003c/span\u003e), \u0026ldquo;360-degree\u0026rdquo; activities (Kwan et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), OSCEs, or peer-peer discussions. Although we used self-reports of behavior for the purpose of scale development, we believe that subsequent versions of the CMPI may have the future potential to make a contribution as an \u003cem\u003eobservational tool\u003c/em\u003e to assess the professional behaviors of others. We caution about applying the current CMPI as an observational tool or with individuals or groups that have not been studied in this research (e.g. students, other health professionals) and without developing validation evidence in other Chinese, other Eastern, or other non-Eastern contexts. Because of possible consequences and implications of using MP scales, we further caution about using CMPI for summative judgments (e.g., determining academic advancement or patients\u0026rsquo; or colleagues\u0026rsquo; assessments of competency) without further research determining validity evidence with such new uses and new contexts.\u003c/p\u003e \u003cp\u003eWe conclude our summary of validity evidence by highlighting Kane\u0026rsquo;s (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) work that informed our approach and drives our conclusions. Specifically, we consider the long and short versions of the CMPI to support \u003cem\u003ethe beginning\u003c/em\u003e of a process of MP assessment in China, and potentially beyond, which may lead to developing observational tools (Kwan et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), and ideally, tools to support MP that improves patient outcomes (Tay et al., 2018). Subsequent iterations of the CMPI will require new validation evidence in the context of its use, judgement about scoring, generalization, extrapolation, and implication, and incorporation of \u0026ldquo;qualitative and subjective data\u0026rdquo; from \u0026ldquo;multiple assessment data points\u0026rdquo;(p. 561).(Cook et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2015\u003c/span\u003e)\u003csup\u003e33\u003c/sup\u003e Ultimately, we agree with Artino et al., (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) summarizing Kane, who remind that assessing validity evidence involves \u0026ldquo;the accumulation of evidence across time, settings and samples to build a scientifically sound validity argument. Thus, establishing validity is an ongoing process of gathering evidence\u0026rdquo; (p. 465).\u003c/p\u003e \u003cp\u003e \u003cb\u003eCMPI and the Chinese healthcare context\u003c/b\u003e \u003c/p\u003e \u003cp\u003eTo create a contextually-derived instrument (Ho, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Ho et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Pan et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Nie et al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Nilchaikovit et al., \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e1993\u003c/span\u003e), our process resulted in items that connect to the recent 10-year healthcare reform in China (Yip et al., \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; SC, 2017; Mao et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Tao et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Chen et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) and to China\u0026rsquo;s changing doctor-patient relationship (Tang \u0026amp; Guan, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Ting et al., \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Xiao et al., 2022; Nie et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).The recent Chinese national healthcare reform includes new payment policies and fee schedules\u0026mdash;specifically, cutting the relationship between physicians\u0026rsquo; income and drug dispensing and laboratory examinations (Yip et al., \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Mao et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In Phase I and Phase II of our process, we reviewed official Chinese documents and conducted expert review; this process resulted in the CMPI incorporating items involving personal and financial integrity emphasized in China\u0026rsquo;s current healthcare system reform (Yip et al., \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Mao et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). As well, the CMPI includes a high proportion of items related to communication, shared decision-making, and respecting patient autonomy, domains that connect to changing conceptualizations of the doctor-patient relationship in China and the East (Tang \u0026amp; Guan, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Ting et al., \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) This approach to MP would reflect a change from earlier Eastern medical practice which was more hierarchical and paternalistic, whereby patients viewed doctors as authority figures who direct the treatment strategy (Nilchaikovit et al., \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e1993\u003c/span\u003e; Hu et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eStrengths\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOur study has methodological strengths. We followed processes described by Messick (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e1989\u003c/span\u003e) and the APA Standards (2014) and incorporated Kane\u0026rsquo;s guidance (2006). After our search found no Chinese-derived items in MP instruments with validity evidence in the Chinese literature, we extracted items by following a recommended process (Terwee et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) of structured literature review of the English-language literature; our search collected 1537 items from 63 sources, including tools developed for or applied in other health professions. We used Lesser\u0026rsquo;s MP behavioral framework (2010) to ensure we covered the domains of MP and avoided redundancy. Our translation strictly followed standard processes to provide evidence for cross cultural validity (Lee et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). We used two expert surveys using standard processes (AERA et al., 2014; Boateng et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Polit \u0026amp; Beck, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2006\u003c/span\u003e).The first expert review included 34 diverse and nationally renowned experts and incorporated MP elements related to the China\u0026rsquo;s current healthcare policies. The second expert review included 76 diverse experts from 19 clinical disciplines in 17 medical schools. We undertook three pilot studies that included over 5000 practicing physicians (response rates 92.3%, 89.8%, and 95.3%), from multiple and diverse institutions in different cities. We worded items to be behaviorally-referenced so future development of the tool could determine validation evidence for observational use (Kwan et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMP is contextual and dynamic and includes cultural values and expectations of the profession and the public (Ho, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Ho et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Pan et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Nie et al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Nilchaikovit et al., \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e1993\u003c/span\u003e; Goddard \u0026amp; Brockbank, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Historically in China, MP has been assessed indirectly using related constructs such as empathy, lifelong learning, and teamwork. In 2016, Wang et al. reported results of their scoping review of MP research published in the Chinese language. The authors concluded that there is \u0026ldquo;little empirical evidence informing the state of medical professionalism in China\u0026rdquo; (p. 8) (Wang et al., \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Since 2016, our review finds 4 papers that developed empirically-derived tools to assess MP in China: three in the English language literature (Wang et al., \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Chen et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Yu et al., \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) and one in the Chinese language literature (Sun et al., 2021). The three English language studies (Wang et al., \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Chen et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Yu et al., \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), like earlier works (Kwan et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), adapted tools developed in Western cultures or adapted tools developed outside of the medical context. The Chinese language study evaluates \u0026ldquo;professional cognition\u0026rdquo; of medical students. None of the four instruments focused on behaviors, and each study missed steps in the recommended methodological processes that guided our work (Messick, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e1989\u003c/span\u003e; AERA et al., 2014; Cook \u0026amp; Beckman, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Downing, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2003\u003c/span\u003e; 34). To facilitate comparison of the CMPI with MP instruments from our searches, we present instruments with direct observation of behaviors, instruments applied in the Chinese context, and instruments determined to have top validity evidence (Li et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) in Appendix 8. The CMPI offers a new instrument, with supportive validity evidence, attentive to the Chinese context, studied in practicing physicians.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study has limitations. The pilot surveys were conducted in Liaoning Province, and regional factors could influence elements of MP. We compared our sample demographics with the 2017 China Health Statistics Yearbook (2017), and the sample appears representative of China\u0026rsquo;s overall physician population demographics, but unmeasured factors could still influence results. We only surveyed physicians from tertiary hospitals and missed perspectives of healthcare providers in rural practices. In Phase II, we relied on a cohort of multidisciplinary experts; although diverse geographically and diversely experienced, these experts were primarily urban and tertiary-trained professionals.\u003c/p\u003e \u003cp\u003eRegarding evidence based on internal structure, our three rounds of surveys relied on participants\u0026rsquo; self-report of behavioral frequency which has limitations (Eva \u0026amp; Regehr, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2008\u003c/span\u003e) and offers potential for social desirability bias. We attempted to reduce this possibility by wording questions for physicians as frequencies (i.e., how often), by wording questions for expert reviewers indirectly (Fisher, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e1993\u003c/span\u003e) (\u0026ldquo;what \u003cem\u003eshould\u003c/em\u003e a physician demonstrate\u0026rdquo;), and by ensuring that all pilot participants and experts were informed that surveys were anonymous and that they were not being individually judged, rated, or assessed. In Phase IV, we created a shortened version of the CMPI; although the CMPI\u0026rsquo;s Cronbach\u0026rsquo;s alpha suggests room to reduce the number of items, our use of Lawshe\u0026rsquo;s approach (1975) could result in leaving too many or too few items in the 20-item Short Version. If future research develops CMPI as an observational tool, to assess the professional behaviors of other physicians (not oneself), the process of reducing the items could use information on the relative test-retest and interrater reliability of the items. We offer both 40 and 20 item versions in appendices to allow for future study and refinement.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTo better characterize, support, and foster MP in China, leaders within and outside of medicine will require trustworthy instruments. Such tools should be culturally-aligned with ongoing rigorous considerations of validity evidence within the context of their use. We created the CMPI as a behaviorally-referenced tool to meet these requirements. Recognizing the practice of applying Western MP tools in the East, we hope the contextually-derived CMPI may support MP in China, and potentially further our understanding of professionalism more broadly as \u0026ldquo;East meets West.\u0026rdquo;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRCC indicates respect\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecompassion,and communication\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eInt\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eintegity\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eExc\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eexcellence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eand Res\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eresponsibility.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting Interests and Funding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eProject of the Education Department of Liaoning Province (LJKMR20221216). The authors have no financial or competing interests directly or indirectly related to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrevious presentations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn early presentation as \u0026ldquo;research-in-progress\u0026rdquo; was presented internally within China Medical University, Li Honghe\u0026rsquo;s institution, in their institute for Health Professions Education and Research in 2021.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank Dr. Yanan Ma for his statistical consultation and for assistance in establishing the representativeness of the survey. The authors also express their gratitude to Ms. Wang Bin and Dr. Zhang Xu for supporting participant enrolment. The authors acknowledge and thank Adele Weaver, MA, a PhD candidate in the Department of Psychology at The University of Rhode Island, and Dr. Judith Hall, University Distinguished Professor Emeritus Northeastern University College of Science, for their thoughtful review of our explanations of statistical terms. The authors thank Glenn Regehr, PhD for his generous and deeply instructive critical review of the final manuscript. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHonghe Li and Deliang Wen conceived of the study and study design. Deliang Wen supported data collection. Honghe Li led the data collection, data management, and data analysis. David Hirsh participated in data analysis and co-wrote and co-edited the manuscript with Honghe Li, with equal contributions from each. Jing Jin participated in data collection and data management. Edward Krupat contributed to the data analysis, writing, editing, and critical appraisal of the manuscript. Nan Jiang contributed to editing and critical appraisal of the manuscript. Ning Ding contributed to the data analysis and critical appraisal of the manuscript. Ming Jung Ho and\u0026nbsp;Dianne\u0026nbsp;Manning contributed to critical appraisal and editing the final manuscript. All authors read and confirmed the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ethical review board of the Academic Committee of China Medical University approved this study. After explaining the aim and purpose of the study, the voluntary nature and the confidentiality of participants, we obtained the informed consent for all procedures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmerican Educational Research Association-American Psychological Association-National Council on Measurement in Education (2014). \u003cem\u003eStandards for Educational and Psychological Testing.\u003c/em\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArtino, A. R. Jr., Rochelle, L., Dezee, J. S., K. J., \u0026amp; Gehlbach, H. (2014). 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Development and Validation of a Simplified Chinese Version of the Assessment Tool for Students' Perceptions of Medical Professionalism. \u003cem\u003eCurrent medical science\u003c/em\u003e, \u003cem\u003e39\u003c/em\u003e(4), 670\u0026ndash;678. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11596-019-2090-7\u003c/span\u003e\u003cspan address=\"10.1007/s11596-019-2090-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Medical professionalism, Measurement, Behaviors, Validity Evidence, China, Scale","lastPublishedDoi":"10.21203/rs.3.rs-3810250/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3810250/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe characteristics of medical professionalism (MP) vary across cultural contexts. Theories of professionalism and MP tools currently rely on Western cultural perspectives. The authors developed the China Medical Professionalism Inventory (CMPI) using standard processes through four steps: Phase I) systematic review and synthesis of the literature to develop an item pool; Phase II) survey of Chinese clinical and educational experts to develop evidence based on test content; Phase III) two rounds of pilot studies of practicing physicians to measure internal structure and internal consistency; and Phase IV) refinement of the instrument using an expert survey and pilot study. Systematic review of the English- and Chinese-language literature identified 1537 professionalism-specific items from 63 sources as foundation of the item pool. The authors conducted two rounds of expert review, including surveying nationally prominent Chinese healthcare leaders (n\u0026thinsp;=\u0026thinsp;34, response rate 85%, and n\u0026thinsp;=\u0026thinsp;76, response rate 63%). The authors conducted three pilot studies of practicing Chinese physicians (n\u0026thinsp;=\u0026thinsp;360, response rate 92%; n\u0026thinsp;=\u0026thinsp;3653, response rate 89%; and n\u0026thinsp;=\u0026thinsp;955, response rate 95%). The results generated a 40-item CMPI and a shortened 20-item CMPI, with four domains \u0026ldquo;Respect, Compassion, and Communication; Integrity; Excellence; and Responsibility.\u0026rdquo; Applying the standards of Messick, the American Psychological Association, and Kane, the authors present the CMPI's validity evidence related to content, response process, internal structure, relationship to other variables, and consequences. This study aims to extend the conceptualization and reach of MP measurement.\u003c/p\u003e","manuscriptTitle":"East Meets West: Evidence for Validity for the China Medical Professionalism Inventory","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-01 10:00:51","doi":"10.21203/rs.3.rs-3810250/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"753f65b4-9e51-4530-8c36-d89d06d2d149","owner":[],"postedDate":"January 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-03T15:45:39+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-01 10:00:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3810250","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3810250","identity":"rs-3810250","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}