Study On The Implementation Status and Countermeasures of The Standardized Resident Training System in China

Zixin Li Weifang Medical University Songyi Liu Weifang Medical University Wenqi Meng Weifang Medical University Fuyanshan Campus: Weifang Medical University Xiaoli Jiang Weifang Medical University Haibo Peng Weifang Medical University Qianqian Yu (  yqq_7921@163.com ) Weifang Medical University https://orcid.org/0000-0001-8439-4366 Wenqiang Yin Weifang Medical University Zhongming Chen Weifang Medical University Dongping Ma Weifang Medical University Junwei Song Weifang hospital of traditional Chinese medicine

standardized specialist training was carried out according to the training standards and requirements of each specialist. Finally, the third phase, referred to as the national will stage, commenced in 2013 and persists to date. The "Opinions of the State Council of the CPC Central Committee on Deepening the Reform of the Medical and Health System" issued by the CPC Central Committee and the State Council in 2009 clearly highlight the need for "establishing a standardized resident training system and strengthening the continuing medical education" [21]. To further reform China's medical and health system and medical education program, in 2013, seven ministries and commissions of the State Council jointly issued the "Guidance on Establishing a Standardized Resident Training System" and emphasized the connection between professional medical education and standardized resident training [22]. This marked the formal establishment and implementation of the standardized resident training system in China, as well as the establishment of a medical personnel training system that was suited to meet national healthcare requirements.
It is expected that standardized resident training will become a key factor and breakthrough in the journey towards promoting new healthcare reforms in China. The government is trying to meet international standards through a standardized reform of resident training, to improve the level of healthcare in China's medical institutions, narrow the gap between different medical institutions, and achieve equalization of public health services.
After the promulgation of the "Guidance on Establishing a Standardized Resident Training System," the National Health and Family Planning Commission successively issued a series of supporting documents, such as "Methods for the Management of Standardized Resident Training (trial)" [23], "Standard for Accreditation of Standardized Resident Training Bases (Trial)" [24], "Contents and Standards of Standardized Resident Training (Trial)" [25], "Implementation Methods of Recruitment for Standardized Resident Training" [26], and the "Implementation Methods of Standardized Resident Training Assessment" [27]. Through these, the policy system for standardized resident training was rst constructed. All provinces (autonomous regions and municipalities directly under the central government) were required to fully switch to standardized resident training by 2015 and completely establish the standardized resident training system by 2020. All clinicians with a bachelor's degree or higher who took on medical practice positions for the rst time were required to receive standardized resident training.

Main Features of the Standardized Resident Training Policy in China
According to the relevant policies of the standardized resident training system in China [22][23][24][25][26][27], the following were to be monitored and established: funding, recruitment, training bases, training curriculum, training assessment, and management and treatment of trainees.

Funding guarantees
The standardized resident training system in China is supported by a multi-input mode of funding, which includes government investment, self-nancing, and social support. Central nance grants provide a one-time subsidy of RMB 5 million per training base for the purchase of equipment for residents at the standardized training base. Each resident receives a subsidy of RMB 30000 per year.

Recruitment
Recruitment targets include those who intend to be involved in medical practice at medical colleges and universities (including clinical medicine, stomatology, traditional Chinese medicine, and integrated traditional Chinese and western medicine). This spectrum includes graduates with a bachelor's degree or above; personnel who have engaged in medical work, quali ed to be medical practitioners, and need to receive training; and other personnel who require training.

Training bases
Standardized training for residents can be held at training bases and professional bases. Training bases are medical and health institutions where standardized training of residents is undertaken, and these are composed of quali ed professional bases. Professional bases are led by quali ed professional departments. At professional bases, the relevant departments coordinate and jointly complete training tasks. Training bases are required to meet a few basic criteria, including hospital accreditation, appropriate training facilities and equipment, and an established training system. The training bases are required to meet the basic requirements of teaching staff, department construction and training plan setting. There are 34 specialties in standardized resident training, such as internal medicine, pediatrics, emergency department, dermatology, etc.

Training curriculum
The core of standardized resident training is to competency cultivation. According to the guidelines of standardized resident training, training in different areas, including medical ethics, policies and regulations, clinical practice, medical theory, and interpersonal communication, is imparted. The focus is on improving the ability of clinicians to perform standardized diagnosis and treatment, while giving due consideration to medical teaching and awareness of scienti c research.

Training assessment
Training assessment includes process assessment and graduation assessment. Process assessment involves daily assessment, departmental assessment, and annual assessment of medical ethics, clinical professionalism, attendance, and clinical practice skills. Graduation assessment is divided into two parts. Residents who have obtained the Doctor Quali cation Certi cate and passed the training process assessment can apply for the graduation assessment. Those who pass standardized resident training are issued a combined certi cate of quali cation for the standardized resident training.

Management and treatment of trainees
During the training period, the original personnel (staff) and salary agreements of the trainees appointed by the unit remain unchanged; the appointed unit, training base, and trainees sign a training agreement; and the difference between the salary paid by the appointed unit and the salary of residents working under the same conditions is paid out by the training base. The trainees sign training agreements with the training base, and their living allowances during the training period are paid by the training base. The allowance standards are determined based on the salary received by residents working under the same conditions at the training base. The trainees who are postgraduates are required to meet the relevant state provisions on postgraduate education, and the training base may grant them appropriate living allowances according to the training assessment.

Respondents and tools
According to the type and scale of standardized resident training hospitals, the principle of strati ed random sampling was adopted to select 5 standardized resident training bases in Shandong Province, and 1060 residents were selected for standardized training. The questionnaire on students' cognitive evaluation of participating in standardized resident training prepared by the research group was used as a measurement tool for quantitative investigation, the main contents of the questionnaire include personal basic information, cognition of standardized resident training, evaluation of standardized resident training and satisfaction with standardized resident training. Finally, 1048 valid questionnaires were collected, and the effective recovery rate was 98.9%.
According to the principle of information saturation, the qualitative interview uses the method of personal in-depth interview to collect data. Through interviewing 42 residents, we can understand the problems existing in the implementation of standardized resident training. The core contents of the interview include: (1) the basic situation of residents (gender, age, training time, Department, monthly average training subsidy, etc.), (2) During your participation in the standardized resident training, what did you do not meet your expectations and requirements? (3) What bene ts and disadvantages do you think the current standardized resident training has for you? (4) Combined with the actual training, how do you think the standardized resident training policy can be improved? In a quiet and undisturbed environment, the researcher rst introduces his identity, research project, interview purpose and interview content, and ensures the con dentiality of the interview content. After obtaining the consent of the interviewee, the interview starts and records. The interview time is 20-30min. The speci c time varies according to the wishes of the interviewers. Finally, the recording code is given and the recording is stopped.

Analysis method
In the quantitative study, SPSS software was used for data entry and statistical processing. The data were analyzed by simple rate, constituent ratio and binary logistic regression. The difference was statistically signi cant (P < 0.05). In the qualitative research, two researchers are independently responsible for recording, transcribing, and checking the text data. According to the interview outline design, the data are classi ed and extracted according to the theme synthesis method, the similar and related topics are summarized into one category, and the results of qualitative analysis are displayed by using sh bone diagram and other methods.

1.Basic information of respondents
A total of 1048 trainees were investigated, most of them were women (61.2%) and less were men (37.9%); 89% were aged 30 years and below, with an average age of 27.01 ± 2.663 years; The marriage situation was mainly unmarried, accounting for 68.3%; 99.2% of the students have the highest degree of Bachelor degree or above, and only 0.2% of the trainees have the lowest degree of college; The average monthly living and training subsidy is less than RMB 1000, accounting for 53.3%; The monthly average living and training subsidy of RMB 5000 or above is the lowest, accounting for 0.8%. 63.9% obtained the quali cation certi cate of practicing assistant doctor or practicing doctor, and 35.6% did not obtain any quali cation certi cate. Most of the reasons for choosing this training base are the fame of the hospital, accounting for 40.1%; others recommended at least 5.1%. Table 1 shows the detailed results.

2.Trainees' awareness of training policy
The trainees' awareness of the three-year rotation system, the residential training policy of their hospital, the training content at each stage, the training policy and the relevant laws and regulations accounted for 57.2%, 50.5%, 48.6%, 46.9% and 31.0% respectively. The residents' awareness of the relevant contents of residential training is low. Table 2 shows the detailed results.

3.The ways trainees participate in the training
The main training methods for trainees were rotation with related departments (95.2%), department lecture (89.7%), case discussion (82.0%), and hospital knowledge lecture (77.3%). Meanwhile, attending academic conference (63.9%) was also an important training method. Table 3 shows the detailed results.  Table 4 shows the detailed results.  Table 5 shows the detailed results.  Table 6 shows the detailed results. In this study, binary logistic regression analysis was used to analyze the factors that might affect residents' satisfaction with their training institutions. Taking overall satisfaction with training work as the dependent variable, gender, age, marital status, to the hospital rules from policy, rules' understanding of the culture content, the rotation system three years, to the necessity of standardization training for their own judgment, and the standardization training content, training methods, training schedule, training teachers, training base facilities, compensation, training effect factors as independent variables, satisfaction with the degree of binary variables were coded with 0 and 1, and multi-classi cation ordered variables were coded with natural values, and binary logistic regression analysis was performed. The regression results showed that the degree of understanding of standardized training in the hospital, the judgment of the necessity of participating in standardized training, the degree of satisfaction with standardized training content, training faculty, training salary and treatment were the factors that affected the overall satisfaction of residents with the work of residential training. Table 7 shows the detailed results.

8.Qualitative interview results
According to the principle of information saturation, 42 trainees from different departments were selected from the residential training base for qualitative interview. The interview mainly included the degree of consistency between their expectations and requirements during the residency training, the bene ts, and disadvantages of participating in the standardized training for residents, and their opinions and suggestions on the current standardized training policies for residents, etc.
After nishing induction, found that the contents of the interview by attending, resident standardization training clinical ability, theory and practice of personnel live in the culture was improved doctor-patient communication skills, but most of the students re ect in the process of living culture, training arrangement, the salary, the teaching consciousness, training content and examination still exist certain problems. Figure 1 shows the detailed results.
Clinical theory and practice ability have been improved During live culture, living culture researchers to further consolidate their professional knowledge, accumulated more clinical experience and clinical thinking, professional technical ability and practical operation level are better exercise, had a deeper understanding for the diagnosis and treatment of disease, improve the ability of its diagnosis and treatment, to the medical work better for the future laid a solid foundation.

Doctor-patient communication ability has been trained
Interpersonal communication ability is one of the main contents of standardized training for Resident doctors in China. Through the training in this aspect, residents can listen to patients and family members patiently, and control their own emotional response, their communication skills, cooperation ability, a nity for patients have been improved to varying degrees.
Unreasonable training arrangements.
First, the department rotation is not scienti c. The rotation time in my own department is short, but the rotation time in other departments is long, which cannot fully meet my own key training needs; Second, during the training period, attend too many meetings unrelated to the training content, making the real time for training shrink, affecting the quality and effect of training; Third, it is di cult to work. Because some patients' conditions are more complex, it is di cult for students who have just graduated or still lack work experience to cope with and deal with it in a short time. Fourth, the work intensity is high. Some departments have strict requirements on students who live and train, and arrange them to work night shifts even though they are busy during the day, resulting in excessive work pressure for some students.
Salary and living security need to be improved.
Some students believe that the medical industry is characterized by high risk and intensity, and the salary and treatment cannot reasonably re ect their own value in the actual training, the income cannot meet the psychological expectation, and the overtime allowance is less, so it is di cult to effectively mobilize their training enthusiasm. In some training bases, students still need to solve the problem of accommodation by themselves, and the high rental fees have caused a certain economic burden to the trainees. Compared with other students of the same age, some students of master's degree programs have to support their families, which leads to greater psychological pressure

Lack of awareness of teaching
In addition, due to the lack of incentive mechanism for guiding teachers in the standardized training residents, their teaching enthusiasm is not high. Therefore, some guiding teachers take clinical work as their work focus and have less teaching time for residents. For the consideration of safety and other factors, some teacher "only looking at but not letting go" mode of teaching, cannot give full play to the initiative of students.
The training content and assessment are not fully implemented The training requirements in the training manual cannot be fully implemented in the actual training work, the training content is not professional and targeted, doctors in residential training have few opportunities to operate professionally, they are often engaged in unskilled simple manual labor, and their professional skills cannot be greatly improved; The process assessment supervision is not strict, there is a The trainees must spend most of their time and energy on the work in the hospital, and for self-study, rest and free allocation is squeezed, resulting in great physical and psychological pressure on the trainees.
Mu QN' s study found that unscienti c training arrangements could affect training effectiveness to some extent [34].
3.The remuneration and living security of the trainees are not met 605 (71.9 percent) trainees were not satis ed with remuneration during the training period and had the lowest satisfaction in all survey projects. Through the binary logistic regression analysis, it is found that the satisfaction with salary affects its overall satisfaction with the training work. Trainees' income cannot meet their expectations, resulting in psychological unbalance, training enthusiasm cannot be fully mobilized, affecting the effectiveness and quality of standardized training. The trainees surveyed were concentrated between the ages of 28 and 32, playing more roles and responsibilities, considering less family time and low levels of subsistence allowance on the premise of greater intensity of work, resulting in multiple pressures from all levels seriously weakening their enthusiasm for training. Dai XT, Li XT and other scholars have found that the lack of satisfaction of salary will make some trainees have a certain degree of resistance to training [35][36][37][38]. In addition, the facilities, equipment, accommodation, transportation and other security of residential training units are limited, which cannot meet the needs of trainees, and also affects their enthusiasm for training. Huang T and Qi DF believed that if the basic living conditions of the trainees were not guaranteed during the training, they would seriously affect their enthusiasm, initiative, focus, and thus lead to the training quality failing to reach the expectation [39][40].

4.Teachers in residential training units lack awareness of teaching
On the one hand, the teacher "only looking at but not letting go", the teacher neglects the clinical practice training of the trainees, cannot 'let go' let the trainees get full exercise, the clinical thinking and post competency of the trainees are insu cient. On the other hand, a small number of teachers do not attach importance to the quality and level of teaching work in ideology, and only arrange repetitive work such as writing medical records and dressing change for trainees. They seldom give targeted guidance to students in professional knowledge and lack communication with trainees, which makes it di cult for trainees to improve their ability substantially. In the base evaluation work, it is found that there is no exit and incentive mechanism for the selection and evaluation of standardized resident training teachers. In the absence of incentive mechanism in the teaching work of residents, at the same time, due to the busy clinical work, high pressure, and undertake other levels of teaching tasks, complete personal scienti c research, promotion needs and other 'complicated' work, some teachers are not enthusiastic about teaching work. Ji HL and Gong Y et al. also found that the lack of incentive policies made teachers not enthusiastic enough about clinical teaching, and believed that due rewards were not paid, resulting in the low enthusiasm of some teachers in teaching [41][42]. Wen L and Su FW et al. found that teachers, as clinicians, need to go to the front line of clinical work, receive and see doctors every day, and work is very busy. In the long run, there will be con icts between clinical work and teaching tasks, so that clinicians with heavy clinical work will increase the additional workload [43][44][45].
5.The training content and assessment work are not in place 35

2.Improving trainees' salary and guaranteeing their living standard
The government should increase nancial support and coordinate the establishment of special funds by resident personnel units, training bases and other relevant departments; formulate capital management and use methods to improve capital use e ciency [49]; establish a sound training scholarship system, quantify scores according to established standards, regularly select excellent residents to encourage scholarships, effectively improve the life treatment of residents during training and enhance the enthusiasm of residents [50]. To meet the reasonable needs of trainees in accommodation and transportation as much as possible, and provide reliable material and spiritual guarantee for better training.
3.Raising the awareness of teachers' responsibility and improving teaching quality The base should train full-time teaching teachers, update the list of teachers in time, bring quali ed personnel into the teaching team, reduce the pressure to complete clinical work and consider the teaching, promote teachers to focus on residential training and teaching, strengthen the incentive and restraint mechanism of teaching. In "Standard for standardized resident training bases (revised 2020)" [50], the speci c requirements of incentive and exit of teacher selection training evaluation are put forward, and the training task and teaching quality are taken as important indicators to guide the performance of physicians, evaluate the priority and promote the professional title, and are included in the overall evaluation system of the hospital. Strengthen the interaction between teachers and trainees, trainees should regularly report to teachers learning, timely detection of problems, to ensure the pertinence, effectiveness, and professionalism of the guidance work [51]. 4.Strengthening the implementation of training content and improving the assessment system The training base should strengthen the implementation of relevant policies, develop reasonable training case that meet the needs of the trainees, develop personalized training case for different levels of trainees, avoid "one size ts all", teach trainees in accordance with their aptitude, and truly meet the learning and growth needs of different levels of trainees [52][53]. The training base should improve and perfect the standardized training and assessment system of residents, establish a uni ed standard, scienti c and reasonable assessment content, make the assessment index as objective as possible [54], and strengthen the supervision and supervision of daily assessment, department assessment and other process assessment, improve the objectivity and impartiality of assessment work, and put an end to the "human relationship score". The establishment of humanistic care mechanism and the creation of an overall medical humanistic education environment can properly add the humanistic practice skill examination to the standardized training and assessment project of residents [55][56], actively penetrate humanistic care and guide the conscious improvement of humanistic quality of residents [57][58].

Conclusions
The standardized resident training system in China is the Breakthrough and Key Link of the China's New Medical Reform. The government tries to align the international standards through the standardized reform of resident training, to improve the health service level of medical institutions in China, narrow the gap between different medical institutions, and achieve the goal of equalization of public health services. The Standardized resident training system plays an important role in improving doctors' clinical ability and doctor-patient communication skills. However, with the gradual progress and deepening of the work, many problems have been found in the survey, such as unreasonable training arrangements, low salary and living security level, insu cient awareness of teachers' responsibility, and imperfect training content and evaluation system.

Research Limitations
This review is based on the development process and practice of standardized resident training system in Declarations ZL, SL, WM, and QY conceptualized the study and analyzed the data. ZL, SL, and WM wrote the rst draft of the manuscript together, WY, ZC, DM, SJ, HP and JS commented on the manuscript critically. All authors read and approved the nal manuscript.

Authors' information
All the authors are from Management School of Weifang Medical University except JS is from Weifang Hospital of Traditional Chinese Medicine. QY is the professor whose research interests are health policy and health economic evaluation. WY is the professor whose research interest is health care management. ZC is the associate professor whose research interest is social medicine. DM is a lecturer whose research interests are health emergency management and health economics. ZL, SL, WM, SJ and HP are graduate students majoring in social medicine and health service management. JS is a lecturer whose work is management of standardized resident training program.