Satisfaction of the Clinical Teachers on Standardized Residency Training Program (SRTP) in China

Background: Standardized Residency Training Program (SRTP) is a signicant initiative to deepen health systems and medical education in developed countries like China. Despite prompting the SRTP nationwide and implementing it with various improvements, Chinese continuous medical education is still in its infancy. Compared with the residents, little is known about clinical teachers under SRTP in China; but clinical teachers effectively determine the training quality as a critical disseminator of knowledge, skills, and values in medical practice. Thus, the study aims to analyze critical factors affecting their cognitive job satisfaction and provide continuous improvements for SRTP. Methods: From December 1, 2018, to May 31, 2019, we conducted a self-design questionnaire from 13 SRTPs (including both training bases and professional bases) in Shaoxing city to evaluate participants' satisfaction. Altogether, 574 clinical teachers responded to the survey with generally high overall satisfaction. We adopted Chi-square Test and Fisher's Exact Test to evaluate the single impact factors affecting the satisfaction of clinical teachers. The multiple factors analysis applied the Logistic Regression model. Results: The male clinical teachers had signicant differences in satisfaction of teaching content (OR: 0.675, [95%CI: 0.477~0.953]), conicts between study and work (OR: 0.542, [95%CI: 0.371~0.791]), the attention of leaders (OR: 0.403, [95%CI: 0.252~0.645]) and subsidies of teachers (OR: 0.527, [95%CI: 0.347~0.805]). Compared with internal medicine, clinical teachers from Surgery (OR: 2.396, [95%CI: 1.365-4.206]) and other departments (OR: 2.409, [95%CI: 1.406-4.129]) were more satised when considered residents have high motivation on training. Besides, compared with attending physician, deputy chief physician (OR: 0.493, [95%CI: 0.310- 0.783]) and chief physician (OR: 0.683, [95%CI: 0.471-0.991]) more disagreed that residents' wage is good enough. Conclusion:

enlarging clinical cases as teaching contents. According to the reports from National Medical Examination Center (NMEC), the pass rates of residents who participated in the SRTP in 2018 for the rst time in the clinical practice quali cation examination were 20% higher than those who did not receive pieces of training from SRTP. 15 From 2017 to 2018, a total of 120,000 residents have successfully passed the complete examination and obtained training certi cates. 15

Clinical Teachers
Clinical teaching is the cornerstone for medical students' professional development; thus, clinical teachers effectively determine the training quality as a critical disseminator of knowledge, skills, and values in medical practice. SRTP involves clinical teachers with rigorous certi cation-only the physician with at least three years of experience as an attending physician or above can work as a clinical teacher. 10 The faculty training requires teachers to receive uniform quali cations, to be familiar with the standardized training regulations. 10, 13,14 Further, the SRTP limits the number of supervised residents from each clinical teacher who cannot train more than three simultaneously. 9,10 Despite prompting the SRTP nationwide and implementing it with various improvements, Chinese continuous medical education is still in its infancy. In the developed stage, the training to become resident doctors depends on the hospitals employed, leading to differential medical levels across regions. Moreover, the imbalance and inadequacy in its development have con icted with increasing medical demand. 16 Thus, the SRTP has increasingly attracted more attention from all walks of life, primarily academic studies. In the previous studies, many researchers sought to understand residents' perceptions about SRTP and observe their mental health. [16][17][18][19] Moreover, many studies are mature to test residents' satisfaction and collect their evaluations regarding training organizations 20,21,16 -training from the SRTP is bene cial. Approximately one-third of learning in the clinical setting comes from clinical teachers. 1 However, compared with our knowledge of residents, little is known about clinical teachers under SRTP in China. The limited studies discussed the clinical teachers have close relationships with their resident students to provide optimal teaching approaches, contribute a lot to the residents' studies, and even spend up to one-fourth of time supervising, instructing, and evaluating students. 1,3 The positive teaching approach and perceived high-quality education for residents are undoubtedly associated with high overall satisfaction with SRTP. 20 Herein, this study aimed to investigate the status quo and affecting factors of clinical teachers' cognitive job satisfaction and provide proper advice and measures for the sustainable development of standardized training. Also, we believe in standing on another perspective of the clinical teachers. Analyzing their satisfaction with the SRTP is bene cial for recommending strategies for the national resident training.

Methods
Using a simple random sampling method, we set out to evaluate cognitive job satisfaction amongst clinical teachers of 13 residency standardization bases in Shaoxing, Zhejiang Province. The evaluated results were collected by asking all of the involved participants to answer a self-designed survey.

Sampling and participants
From December 1, 2018, to May 31, 2019, 600 questionnaires were distributed online in the study duration. Among 13 training bases, clinical teachers with over one year of teaching experience were approached for participation. Speci cally, the recruitment provided a brief synopsis of the research aims and design and enrolled clinical teachers who were available, willing, and interested. Altogether, participants consisted of 574 senior faculty members who read and signed informed content and completed the survey independently, representing 95.7%.

Instruments
The questionnaire was designed by reviewing much relevant literature and consulting relevant experts for modi cation. The selfadministered questionnaire had 19 items, respectively, which included three sections: (1) demographic information, (2) career information, and (3) perceived cognitive job satisfaction.

Measurements
Cognitive job satisfaction. The cognitive job satisfaction aimed to evaluate participants' cognitions about the job. 22 The study divided satisfaction into positive attitude (PA) and negative attitude (NA), including ten items. The answers from participants were collected into "yes" and "no" for PA and NA, respectively. When evaluating teachers' satisfaction with the teaching subsidies and training base supplements, the original response options were "very satis ed," "satis ed," "a little satis ed," "dissatis ed," and "very dissatis ed." The ve options were divided into "PA" ("very satis ed," "satis ed," and "a little satis ed") and "NA" ("dissatis ed" and "very dissatis ed").
Individual Covariates. Section 1 consisted of necessary socio-demographic information: gender, age, marital status (recoded into married and other [including unmarried, divorced, and widowed]), and education level (junior college or college, and postgraduate or above). The covariates about career information in Section 2 included working experience (10-year categories), professional titles (attending physician, deputy chief physician, and chief physician), hospital types (TCM hospital, specialized hospital, and general hospital), hospital levels (tertiary hospital, and non-tertiary hospital), and clinical departments (department of internal medicine, surgical department, and others).

Statistical analyses
The study calculated frequency, percentage, mean, and standard deviation (SD) to describe the demographic and career information. The study tested univariate analysis by applying the Chi-square test and Fisher's Exact test rstly. Signi cant variables (p-value of ≤0.05) from the univariate analysis were subjected to multivariate analysis. Moreover, the study employed Logistic Regression Analysis to explore the association between the covariates and satisfactions. All statistical analyses were performed using SPSS18.0 software, and a variable with a p-value ≤ 0.05 was considered statistically signi cant. The adjusted odds ratios (ORs) and their 95% con dence intervals (CIs) of independent variables were estimated.

Institutional ethics exemption
The study registered as an institutional ethics exemption, which involves the use of educational tests (cognitive, diagnostic, aptitude, or achievement tests). 23,24 Considered minimizing the study's risks and to protect subjects' identities are protected, researchers provided informed content to all recruited participants and presented a brief description of the study before answering the questionnaires, including the purpose, time commitment, and any risks. All members of the research team completed the required online training module through the Collaborative Institutional Training Initiative (CITI) Program. 23

Demographic and career information
In this study, 530 (92.3%) clinical teachers were under 50 years old. Around half of the participants were female (50.2%), and 97.6% of the instructors were married or cohabited. Of the 574 participants, 76% of clinical teachers graduated from junior college or college. Four-fths (79.1%) of participants had been teaching for 1~10 years. Besides, two-thirds (66.4%) of participants worked in general hospitals, and 228 (39.7%) clinical teachers worked in tertiary hospitals. More than half (59.8%) of the teachers had deputy chief physician or chief physician titles. Participants were recruited from different hospital departments-67 (11.7%) teachers in the internal medicine department, 204 (35.5%) teachers work in the surgical department, and 52.8% in other departments. The study evaluated the clinical teachers' satisfaction according to the PA and NA prevalence from ten items (shown in Table 2). Lots of the items received a higher percentage of PA. In detail, 86.9% of clinical teachers responded positively to the program design, and 86.4% thought the training and promotion design was reasonable. Almost all teachers (96.3%) believed the provided contents met teaching requirements, and 94.6% of them evaluated the SRTP as helpful for students. Besides, 83.1% of teachers thought administrators had paid enough attention to training, and 60.8% of clinical teachers thought students were enthusiastic about studying in the SRTP. Also, 80.5% of teachers were satis ed with their subsidies. However, more than half of the clinical teachers (54.7%) believed that students' wages were insu cient. Around half of the participants (47.4%) felt the training period was too long.
Nearly one-third (39.2%) of teachers thought students had con icts between study and work. Factors affecting the teacher's cognitive job satisfaction As shown in Table 3, gender, marital status, and educational level signi cantly affected clinical teachers' satisfaction. Signi cant differences existed between male and female clinical teachers' satisfaction regarding teaching subsidies (p=0.003), and when evaluating items of "There is no con ict between studies and work" (p=0.006) and "Leaders of medical institutions attach great importance to SRTP" (p<0.001). According to the item "The SRTP does not cause con icts between residents' studies and work," clinical teachers who were married or cohabited reported higher agreement (p=0.044), and teachers who graduated from the junior college or college also reported the higher agreement (p=0.003). Speci cally, titles affected teachers' satisfaction with students' wages (p=0.008). Among different hospital levels, the signi cant differences of teachers' recognition were calculated from 4 items: "The SRTP does not cause con icts between residents' studies and work" (p= 0.038); "Leaders of medical institutions attach great importance to SRTP" (p= 0.009); "The required training period for residents is not too long in the SRTP" (p=0.017); "The residents' wage is good enough provided by SRTP" (p=0.035). There had signi cant differences among teachers in different hospital types regarding whether training was too long (p=0.020), whether there was no problem with the training and promotion design(p=0.005), whether there was a con ict between study and work (p=0.025), and whether students' payments were good enough (p= 0.035). Also, different working departments in uenced teachers' satisfaction about whether there were con icts between study and work (p= 0.046) and whether students were highly motivated (p=0.003).
Univariate analysis of all variables was detailed in Supplementary File 1.

Logistic regression analysis of teachers' cognitive job satisfaction
In univariate analysis, variables with statistical signi cance to clinical teachers' satisfaction among demographic and career variables were obtained and applied in the logistic regression model.  Table 4). Initially, the results reported that the male clinical teachers' evaluations were low because of the unsatisfactory teaching content and caused con icts between students' study and work. Also, comparing with the female counterparts, more male teachers evaluated the SRTP receive little attention from the leaders, and the provided subsidies to teachers are not good. Undoubtedly, job satisfaction is a function of individual differences, and some studies discussed that males and females relied on different cognitive-emotional regulation strategies, receiving different satisfaction degrees. 26-29 For example, American women reported more meditation, catastrophizing, refocusing actively, 27 refocusing on planning, and positive reappraisal. In contrast, American men scored higher in blaming others. Chinese culture's gendered social role expectations are another reason. 20,30 The cultural traditions and religious convictions shaped men's role, who receives society expected to be the chief breadwinner and responsible for supporting their families. 31,32 On the contrary, the traditional community assumes women to do household work such as child-rearing and day-to-day life chores. Although some evidence stated that promoting gender equality of working already improved women's status, the traditional gender roles still appeared pervasively. Chinese female employees experienced more con icts from their roles at home and the workplace. Because of the contradictory expectations from gender roles, men and women evaluated job satisfaction with different factors. 30 We believed that it was the primary explanation for the lower satisfaction of the male. According to the previous ndings, male considered main determinants include income, responsibility, and professional development opportunities. In contrast, women considered job stability, the balance between work and family, and the professional status more critically. Also, some studies reported that Chinese men attached higher importance to challenging work and valued professional development opportunities than their female counterparts. 27 Recent research examined the incentives to help improve clinical teachers' motivation; it found that educators were highly motivated when they felt their leaders value the work of teaching. 33 Therefore, the study recommended that SRTP manage and spread diverse work types with different gender. Also, the management in the SRTP can develop more reward policies to increase the incentive mechanism and then improve clinical teachers' sense of responsibility and honor. 17 The results also indicated that most clinical teachers believe that the residents' enthusiasm for studying in the SRTP is high. However, compared with the Surgery and other departments' clinical teachers, the clinical teachers who worked as the internal medicine physicians were less satis ed when considered "The residents have high motivations to attend daily training." Almost all internal medicine departments work on geriatric chronic diseases and severe and complicated cases in China. The current situation leads the typical patients with milder conditions to be few, which causes clinical teachers to apply related diseases that cover differential diagnoses and treatments as teaching cases. 34 Therefore, the nal purpose of attending physicians to provide training in the SRTP is to earn rewards to be promoted as deputy chief physicians.
For many deputy and chief physicians, the promotion no longer has an incentive effect on them. Instead, broadening the academic eld, mastering cutting-edge theories and methods, and seeking medical talents have become their potential needs. Also, many hospitals with SRTP maintain the appropriate proportion of chief physicians to deputy chief physicians to attending physicians to residents at the ratio of 1:2:4:8. 38 Under this distribution, except supervising interns and residents as an instructor in the SRTPs, the deputy chief and chief physicians also needed to act as administrative leaders in clinical departments. They are more concerned about residents' situations, besides their income. The study recommended that leaders incorporate resident physicians' performance appraisal as a reference basis for salary distribution and give resident physicians certain material rewards with excellent daily routines. 42,44 Study Limitations Several limitations of this study still occurred and should be addressed in the future. Firstly, this study used a simple random sampling design to recruit clinical teachers within a single city in Zhejiang province. Thus, considering the bias from different regions, adding more areas in the future study to verify the current ndings can be applied and interpreted nationwide. Secondly, the questionnaire in this study was self-designed. Although the literature research and the interviews with the rst-lined managers of SRTP supported the primary evidence of the content validity of the scale items, the scale development and measurement of relevant concepts should be improved for further study. Furthermore, future research might take more contextual factors and curriculum planning in different clinical settings into consideration. 34,35,38,43 Conclusion In summary, the broad implication of the present research leads to the following conclusions: the gender difference between the clinical teachers induced different satisfactions; the clinical teachers who worked in various departments presented different evaluations to the SRTP; the working titles of the clinical teachers also in uenced their satisfaction with the SRTP. Therefore, several suggested strategies were provided: to increase the incentive mechanism to improve the sense of responsibility and honor of clinical teachers, enforce the education about communications between residents and patients, and provide more welfares to solve the issue of low payments to residents. Declarations primary data, analyzed results, and designed exhibits. XYJ and HMW contributed to the critical review of the manuscript. All authors reviewed and approved the nal version.

Funding
The study was developed without funding supports. There are no nancial con icts of interest to disclose.

Availability of data and materials
The online survey collected all data used via using Wenjuanxing Platform. (https://www.wjx.cn/app/survey.aspx). More detailed data used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate
Since involving the use of educational tests (cognitive, diagnostic, aptitude, or achievement tests), this study was registered as an institutional ethics exemption and was waived the need for ethic approval by the Zhejiang Medical Ethics Committee (https://lunli.wsjkw.zj.gov.cn/). Goal to minimize the study's risks and protect subjects' identities, the study provided informed content to all recruited participants and presented a brief description of the study, including the purpose, time commitment, and any risks. All participants involved in the study analysis have read and signed the informed context before starting the survey. All research team members completed the required online training module through the Collaborative Institutional Training Initiative (CITI Program). Data were linked and analyzed only by authors who contributed to writing the article.

Consent for publication
Not applicable.