Most clinical teachers hold a positive attitude and have widely accepted the SRTP based on their evaluation of each item. However, teachers with different personality traits present different opinions after exploring the items in detail. The main findings indicated that most teachers with different genders, working departments, and professional titles have significant differences in satisfaction levels. While only evaluating the clinical teachers' overall satisfaction is inaccurate to find issues of SRTP,25 the possible influential factors and caused reasons combined Chinese society characteristics might provide valued recommendations to develop SRTP in the future.
Initially, the results reported that the male clinical teachers' evaluations were low because of the unsatisfactory teaching content and caused conflicts 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 conflicts 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 findings, 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 satisfied 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.34,35 However, the training period of the above studies are limited to residents. During the entire 33 months, residents must attend 29 months of rotation training in the various subspecialties (Cardiology, Nephrology, Gastroenterology, etc.) and 4 months of rotation training in the elective subjects under the internal medicine department.7,10,36. Except to participate in outpatient and emergency work and various teaching activities (teaching visits, case discussions, professional lectures, etc.), residents also have to complete the required number of diseases and basic skills. In short, excessive concentration of learning during the short-term rotation period burdens residents' pressure to make their residency training more challenging.
Communication between residents and patients during outpatient training may be another reason. Many internal medicine patients have to suffer long-term illnesses and repeated hospitalization.36,37 Thus, their minds and emotion are the most depressed. A previous study stated that many patients resent residents; they are reluctant to accept residents' consultation, body investigation and diagnosis, and treatment operations. That might be a barrier to affect the residents' studying to a certain extent.37 Therefore, the study recommended that the SRTP strengthened communication with patients to obtain their cooperation and chose typical cases that were relatively mild and easy to communicate. Specifically, all clinical teachers can select patients to be involved in the clinical practice teaching. What is more, the educators can communicate with the patients before the class to explain the time, purpose, and time of teaching, obtaining the patients' and their families' understanding.
At least, the deputy chief physician and chief physician disagreed that students' wages are good enough compared with the attending physician. The caused reason may be that different professionals' roles are played in providing teaching quality in the SRTP. As the mild-level title, attending physicians are the main forces of clinical care in Chinese hospitals. However, most of them who work in the inpatient setting remain at this stage for the better part of their careers due to the vice chief physician requirements.38 Under the system with high competitiveness, the contribution work to develop SRTP is an opportunity to attending physicians. Until now, many SRTP training bases already applied rewarding and punishing policies to evaluate teachers' performance, includes the number of teaching residents and the passing rate of the complete assessment. Most importantly, these results are often related to the reputation of the teachers, such as promotion, salary increase, evaluation, and dismissal.36–41 Therefore, the final 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 field, 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 findings can be applied and interpreted nationwide. Secondly, the questionnaire in this study was self-designed. Although the literature research and the interviews with the first-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