Clinical training in China needs to be improved: A cross-sectional study of MD graduates

Background: China is experiencing medical education reform to construct national quality standards, modernise and standardise health professionals, and advance health delivery system requirements. Graduate medical education (GME) is being piloted as a merger of Doctor of Medicine (MD) and PhD programs to improve academic research and clinical training. However, the academic degree-centred system has led to a preoccupation with academic research rather than clinical training. Quality information regarding the clinical training of MD graduates from Chinese medical schools is lacking. This general investigation aims to provide an overview from the perspective of recent MD graduates in China. Methods: Self-reports on MD clinical training were obtained from 432 MD graduates in 2017 via an online survey. The reports included information on overall satisfaction, educational supervision, supervised learning events, curriculum coverage, local teaching, teamwork, educational governance, workload, supportiveness of the environment, feedback, clinical experience, patient safety, handovers, and reporting systems. Descriptive analysis was used to summarise the outcome. Results: Of the 432 MD graduates surveyed, only 37.4% reported satisfaction with the overall clinical training quality; 54.6% rated the informal and bedside quality as “good”; 64.4% reported that they knew who provided clinical supervision; only 35.5% highly rated the quality of clinical supervision; 51.8% reported that they judged senior physicians as “not competent”; 48.1% believed that their concerns about education and training would be addressed; 41.9% agreed that the staff treated each other respectfully; 97.4% admitted that they worked beyond the mandatory hours and claimed they were regularly short of sleep; 84.2% raised concerns about patient safety; 45.3% reported that they received regular informal feedback. Conclusions: This study suggests that the quality of clinical training for MD graduates needs to be improved; however, even though most participants seemed satised with their clinical training. The overall satisfaction with the teaching quality was acceptable, whereas the quality of many clinical training aspects was scored poorly. Each aspect may encourage a deeper investigation into the understanding of causes and possible remediation. Some suggestions include improving safe and effective care, providing positive clinical supervision, offering appropriate practice opportunities, providing health care services, and maintaining optimal patient safety.

The Medical Scientist Training Programs (MSTPs) train physician-scientists who play crucial roles in medical research and education [7], and have enhanced science in medical education in the US by integrating MD-PhD training in the context of dual-degree programs [4]. MD graduates will be future physician-scientists in China and worldwide. These graduates make important contributions to basic and medical research, and contribute to most research and publications. Although clinical training is a core competency required to be a physician-scientist, the goal of the MD in China is to cultivate scienti c research and academic competency [8]. Concerns have been raised regarding the current clinical competency of MD graduates who have de cits in clinical practice as compared with peer physicians [9], although changes have been made to develop new training similar to that of original well-educated, developed countries.
To date, comprehensive quality data regarding the clinical training of MD graduates are unavailable in China. To sustainably cultivate physician-scientists, their clinical training needs to be studied. This study investigates the clinical training of MD graduates, examines crucial evidence to improve MD cultivation quality, and explores cultivation trends in GME to contribute to policy considerations to underpin the GME. This study may help identify optimal clinical training and the areas that fail to meet acceptable standards. This study provides insight into the different areas of clinical training as experienced in different contexts (e.g., physician-scientists in the US). The obtained data provide the opportunity to address the issues raised in evaluating the MD program.

Participants
This study was a cross-sectional study in which a self-report questionnaire was used to evaluate the clinical training of MD graduates. The inclusion criteria included participants studying in different disciplines and at different training stages, and those who were interested in this study. Purposive sampling was conducted [10], and, based on a pilot study, the calculated sample size was 341. An attempt was made to achieve as much diversity as possible in the research size and medical schools, and questionnaires requesting participation were sent to the administrators at a national medical education conference. MD graduates were de ned as those studying at the time that this research was conducted; 432 MD graduates from informal student organisations in 10 universities agreed to participate from 1 January to 1 March 2017 via an online survey. As compensation, participants received an incentive worth 10.00 on the website.

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The questionnaire was modi ed from the General Medical Council (GMC) National Trainee Survey [11], which monitors the quality of clinical training and education of doctors in the UK [12]. This training survey is a core part of the effort to monitor and report the quality of postgraduate medical education and doctors in clinical training every year. The participants in this study were MD graduates, most of them had Chinese medical licences, and the questionnaire was deemed optimal for this group based on a literature review. The questionnaire included questions on basic information and the indicators of "overall satisfaction," "adequate experience," "workload," "clinical supervision," and "educational supervision". The questionnaire comprehensively evaluates the quality of clinical practice. Two bilingual researchers translated the initial questionnaire from English to Chinese using the back-translation technique based on a literature review [13]. Discrepancies between the original English and back-translated Chinese versions were discussed among the bilingual researchers until they reached a consensus regarding the linguistic and cultural equivalences.
The questionnaire was pretested on ten participants in advance to ensure that it was easily understood before undertaking the pilot study. A pilot study for the questionnaire was conducted to improve its clarity, consistency, and validity; it included the participation of fteen participants who were representative of the target population, and the questionnaire was not changed after the pilot study. The questionnaire was reviewed and validated by nine experts, and the inclusion criteria included experts working in different Chinese GME disciplines and MD supervisors who were interested in the study and willing to participate. The H-coe cient and Cronbach's alpha were used to assess internal reliability (Cronbach's alpha = 0.78) according to the pilot study.
The eleven components of the nal questionnaire focused primarily on clinical training, and included demographic data (gender, age, working time, professional title, living situation), overall satisfaction, educational supervision, supervised learning events, curriculum coverage, local teaching, teamwork, educational governance, workload, supportiveness of the environment, feedback, clinical experience, patient safety, handover, and reporting systems. Response formats included multiple choices with three to six options, yes/no responses, Likert-type scales, and open-ended questions.
To improve responses and obtain the target number of participants, participants completed the questionnaire via computers or smart devices. If participants attempted to move on to the next question without answering the current question, a warning appeared and they were directed back to the unanswered question. The IP addresses identi ed and eliminated duplicate participant responses. Responses were examined for indications of systematic response bias (e.g., clicking the same response option to move rapidly through the questionnaire).
Potential participants were provided with an electronic summary of this study that detailed the research aim, procedure, expected outcomes, risks, bene ts, and their rights to not participate. Participants were recruited online; the rst page of the online questionnaire provided an outline and guide to the study, and all data were anonymised with regards to data protection and the storage of personal data [14]. This study received ethical approval, and informed consent was provided after the study guide. All participants signed their names on the online informed consent form.

Statistical analysis
The data were analysed using Microsoft Excel 2016 (Microsoft Corporation, Redmond, Washington, USA) for Windows. Descriptive analysis (means, standard deviations, and percentages) was used to quantify the responses and summarise the outcome variables.

Results
The participants' mean age was 28 ± 3.6 years, and 54.4% were married, 64.0% were men, 24.9% stated that they have never had a job, 69.5% obtained professional MM degrees, and 88.9% obtained SRT certi cates. Of the participants, 45.4% reported that they received informal feedback from senior physicians at least once a month, while 22.6% responded that they never receive informal feedback. Moreover, 51.8% reported that they had received feedback about their progress from their educational supervisors, 37.7% did not consider their feedback to be useful, and 32.6% reported that they had received useful formal assessments of performance in the workplace. Additionally, 61.2% agreed on educational objectives with their educational supervisors, and 64.4% admitted they had a training agreement with their educational supervisors that set their respective responsibilities. Furthermore, 84.2% had raised concerns about patient safety, and 74.4% reported that their concerns had been resolved or were being addressed.  (Table 1) shows that 37.4% of the participants were satis ed with the overall quality of clinical training, 61.2% believed an MD career would ensure that they acquired the competencies they needed, and 64.4% agreed an MD career would be useful for their future career.  (Table 1) shows that 57.9% of the participants agreed or strongly agreed that "my organisation encourages teamwork culture between multidiscipline health care professionals"; 67.7% reported the same about the teamwork culture between clinical departments; 54.7% were con dent that they would receive help if they turned to other departments; 41.8% agreed or strongly agreed with the statement, "I am con dent that I know how to raise a concern about my education and training". When they raised concerns about the education and training, 48.1% believed the concerns would be addressed; 54.9% agreed or strongly agreed with the statement "I know how or could nd out how to escalate such a concern if I felt it wasn't being addressed"; 70.8% agreed or strongly agreed that the training environment was fully supportive; 29.1% agreed or strongly agreed that staff was always treated fairly; 41.9% agreed or strongly agreed that staff treated each other with respect; 41.9% obtained support to build con dence in the training environment. When the participants disagreed with senior physicians, 38.6% reported that their views would be treated openly, and 54.7% reported that they knew who to approach if they had personal or training concerns.
As shown in Figure 4 ( Table 1), 80.7% of the participants agreed that supervised learning events (SLEs) made them re ect on clinical practice; 77.5% agreed that SLEs had helped them to identify and develop clinical practice gaps; 80.7% were con dent that SLEs enabled them to improve clinical practice; 61.2% reported that it was easy to obtain SLEs from proper physicians; 64.4% reported that they could contact onsite senior physicians at all times; 67.7% agreed that senior physicians could advise them on any clinical situation. Regarding curriculum coverage, 51.39% of the participants were con dent that the curriculum would meet their objectives related to professional experience (leadership, teaching, research, and quality improvement); 48.14% agreed that an MD career would meet their objectives for clinical practical experience for procedures and treatments, with 54.65% reporting the same regarding clinical experience.
As Figure 5 ( Table 1) shows, 74.19% of the participants agreed or strongly agreed that handover arrangements always ensured the continuity of patients' care between shifts; 74.2% agreed or strongly agreed that handover arrangements always ensured the continuity of patients' care between departments; 64.4% agreed or strongly agreed that appropriate multidisciplinary members were included in handover. Additionally, 67.5% were aware of how to report patient safety incidents and near-misses; 51.4% reported a culture of proactively reporting concerns; 67.4% reported a culture of learning lessons from concerns raised; 64.2% were con dent that concerns were effectively dealt with when they were raised; 64.2% believed that the subsequent actions were fed back appropriately.  Table 2) shows that 64.4% of the participants rated the local or departmental teaching quality as "good" or "excellent"; 54.7% rated the clinical teaching quality including informal and bedside teaching, as well as formal and organised sessions as "good" or "excellent"; 35.6% rated the clinical supervision quality as "good" or "excellent"; 64.4% reported that they knew who provided clinical supervision when they were working; 32.1% rated the clinical experience quality as "good" or "excellent"; 45.1% rated the practical experience as "good" or "excellent". As Figure 7 (Table 3) shows, 51.9% of the participants reported being supervised by incompetent senior physicians, with 39.0% reporting that this phenomenon happened at least monthly; 26.0% responded that they felt forced to cope with clinical problems beyond their competence or experience weekly or daily; 77.2% reported being expected to obtain consent for procedures for which they did not understand the risks of the proposed intervention. All participants admitted that they worked out of hours, including night shifts and weekends. All claimed to be short on sleep while at work in their current working pattern; 35.6% reported feeling short of sleep on a daily basis, while 38.6% reported that this occurred weekly.

Discussion
To the best of the authors' knowledge, this is the rst analysis to explore the quality of the clinical training of Chinese MD graduates from a range of specialties and at different stages, and to include foundation, core, and specialty clinical training. This study indicates that the participating MD graduates were a young group with primary titles, and most had experienced short-term clinical training before entering the MD program. The ndings suggest that the quality of overall satisfaction, the training environment, feedback, clinical experiences, clinical teaching, and supervision should be improved. During challenging times, it would be deeply concerning and understandable to evaluate the quality of clinical training that MD graduates receive, as well as what would be necessary to sustain this training pathway.
Clinical training challenges GME reform is backed by substantial public nancing because of the uniqueness of the Chinese medical education context. Change is extremely challenging to implement, and imbalances exist between public expectation, rapid economic and social development, and the lagging medical education. China has recently strengthened the coordination between the NHFPC and the MoE, but achieving coordination with nance, human resources, and civil affairs is di cult. The State Commission O ce for Public Sector Reform (SCOPSR) and the government ministries in China have many diverse and complicated facets, such as the household registration system, the general workforce, employment, and income management. To improve the sustainable quality of clinical training and the roles of professional development, the administrative power of educational institutions at all levels should be clari ed and strengthened. Some piloted reforms are being launched in some super-universities, such as those in Beijing and Shanghai, but some medical education resources, such as hospital training quality and quali ed clinical preceptors and graduates, are not replicable at other universities. Clinical training focuses on patient care and cooperation with patients, family members, physicians, and other health professionals, and different care settings affect overall satisfaction. Policymakers should issue policies and regulations, as professional bodies have not been active in ensuring clinical training quality across different universities.
MD graduates have remained silos of professional practice with little horizontal professional mobility or quality assurance. Technological innovation should be promoted across health care systems, and the quality of clinical training is substantially below the standard. Most MD graduates are broadly accepting of the clinical training they received; however, they received inadequate training time and support. MD graduates desire high-quality and effective clinical training, which does not align perfectly with academic competency. A pragmatic alternative is to combine the degree and clinical training, although clinical competency is inherently associated with academic research. This study identi ed some challenges in clinical training that need to be addressed. The clinical competency of Chinese physicians, even those with higher academic degrees, is often judged due to the demands for academic degrees and a lack of well-established clinical training and teaching. MD graduates face higher demands of academic research than clinical training; normally, one detrimental graduation condition is to publish English papers in journals with high impact factors. Every MD graduate must complete a great deal of research, thus losing clinical training time. MD graduates are challenged by interruptions in their clinical training [2], and do not receive the optimal combination of clinical training and academic research in China [15]. In this study, MD graduates stated that they need more support to balance clinical training and academic research, which is consistent with the situation in the US. The boundary is unclear, and MD-PhD programs in the US encourage the integration of clinical and academic training. Additionally, academic research training has been neglected in the US [6]; another study reported that graduates from 24 MD-PhD programs spent 75% to 80% of their time conducting academic research [3].
Most MD graduates that participated in this study had previous job experience, which is inconsistent with MD-PhD students in the US [3]; however, professionalism is insu cient and requires improvement [17,18].
The inadequate instructional abilities and professionalism of preceptors were commented on frequently by MD graduates, which is consistent with a study conducted in the US [2]. The present study revealed that the clinical training of MD graduates, especially supervision and feedback, requires urgent improvement. Poor levels of clinical supervision create an unsafe and unsupportive clinical environment, and improper clinical supervision may impact patient safety and health outcomes. Although MD graduates expressed satisfaction with preceptor quality, it seemed that the levels of preceptors were proper. This study indicates the importance of highlighting clinical supervision and raises concerns about frequent and effective feedback. Clinical training environments present challenges including patient care and multidisciplinary pressures on clinical training and supervision [19]. Pressure exists in health care service across China and preceptors are experiencing similar pressures, thus raising concerns about the balance between clinical training and routine clinical work [20]. Our responsibility is to protect, enhance, and recognise the importance of preceptors, and to provide consistent ongoing support. MD graduates and preceptors are working together to improve health care service, and it is clear that medical education is a priority. Health care service provision and medical education are inextricably linked, and a lack of training opportunities and a busy working environment in uence patient safety and care. Another important area to explore is the health and wellbeing of MD graduates, and the growing concerns about the impact of the working environment on individuals.
Physicians with higher-level degrees are more likely to nd higher-paying jobs in higher-level hospitals and larger cities, where they could also obtain high-quality and organised clinical training associated with medical career progression and increased future income. Therefore, very few MD physicians serve in rural areas [3], which is consistent with the results of this study. A considerable proportion of Shanghai master trainees dropped out of the SRT to enter an MD program; a doctorate is more attractive than an SRT certi cate [1]. Without a valid 3-year MM with SRT, graduates cannot enter an X-year program or MD program. MD graduates normally complete an examination organised by universities and have a curriculum vitae and expert recommendation letters. After passing the examination, candidates are interviewed by an expert panel, including supervisors. The admission for MD graduates transfers to the application to enter an MD program without an entrance examination, in contrast to the previous strict national entrance examination. These silo positions are extremely competitive; to ensure fairness, the US Medical College Admission Test (MCAT) is valid for admission [16].

Recommendations for the improvement of training in clinical practice
Sorting through these challenges that are unique to China will take time. How can cultivation quality in the combination of an MD degree and SST be ensured? Complicated clinical environments challenge contemporary clinical training, emergency patient care, advanced technology, and multidisciplinary cooperation for mentoring [19]. The accreditation of SRT and SST training institutions is essential and China is constructing and following the medical education systems of developed countries. The Chinese Medical Doctor Association (CMDA) has been designated to manage accreditation; within a very short period, it has accredited approximately 500 training bases spread geographically [1]. This crucial work may need to be strengthened with regard to professional expertise, acceptance of its authority, and nancial resources.
Criticisms that have arisen concern the length of clinical training and low compensation. MD-PhD programs in the US and institutional, federal, and societal programs provide full tuition and a stipend to support their graduates' training [3]. MD graduates in the US obtain funding to support laboratory-based research [3], which is inconsistent with the situation in China. Most graduates conduct clinical research and obtain research funding from their supervisors, which might limit their research interests and delay the time at which they conduct independent research. The standards of SRT and SST cannot satisfy the clinical competencies of MD graduates. High-quality professional expertise is only present in a few top hospitals; therefore, a new certi cation mechanism needs to be established [1]. Moreover, with the support of the China Medical Board (CMB), seven leading teaching hospitals of 24 demonstration bases have recently developed the China Consortium of Elite. Medical education reform is led by the government, but may depend upon the capacity of Chinese professional associations in the future.
The questionnaire comments provided recommendations for improving the MD program. Most MD graduates appreciated the MD program and stated that its strengths were that combining the SST with the degree saves time, and that they acquired a range of clinical cases and experiences. However, the quality of the clinical training remained the most important point; issues were raised regarding whether MD graduates achieved clinical training standards, and whether the MD program was safe and supportive for MD graduates, preceptors, and patient care. The educational culture should be caring, compassionate, and provide optimal patient care, value, and support. Educators, researchers, and administrators should pay close attention to those who disagree with the responsibilities of MD graduates, and preceptors should be selected, inducted, trained, and appraised to re ect clinical training. They should receive support, resources, and time to meet cultivation responsibilities. MD graduates stated that their preceptors lacked the time to supervise, and policies should support them in optimally completing their clinical training plans. This study integrates some suggestions, including improving safe and effective care, providing positive clinical supervision, offering appropriate practice opportunities, providing health care services, and maintaining optimal patient safety in challenging times.

Implications for future MD program development
Knowing the clinical training status characteristics could help predict and prevent problems at an earlier stage. Policymakers should cooperate with stakeholders before the quality worsens and causes harm to patient care and undermines clinical training. More effective recommendations in this critical area should be actively considered. All training hospitals should depend on local conditions and have the approval and the capacity to support the clinical training of MD graduates, which would help them develop adequate competencies and maintain optimal clinical training. Policymakers should re ect current clinical training to provide and re ne sustainable guidance to assist MD preceptors, work with preceptors to make improvements where necessary, and consider more exible clinical training programs. The training standards should outline how MD graduates can be treated more professionally at all training stages and individuals clinical training components [6].
MD graduates receive lengthy training and inadequate funding support China. In contrast, in the US, medical students receive public and private funding for year-long research opportunities [21]. To design subspecialties and their respective lengths based on existing SRT specialties, the monitoring, evaluation, and integration of SST with an MD degree must be researched systematically and sustainably. Our mission is to provide a supportive and sustainable training environment. Impactful recommendations include (a) providing targeted funds or rewards for academic and clinical training, and (b) establishing a supervising team to guide clinical training. A clinical scientist committee should be established to help overcome challenges at various training stages [22], especially funding, individual training, supervision, and feedback [23].
Overall, MD graduates in China do not receive the optimal combination of clinical training and academic research. Supervision of, and feedback on, clinical training for MD graduates need to be improved. Only a few top hospitals present high-quality professional expertise, and a new certi cation mechanism needs to be established. Policymakers should pay close attention to those who disagree with the cultivation responsibilities of MD graduates. Preceptors should be selected, inducted, trained, and appraised to re ect clinical training. Some suggestions include improving safe and effective care, providing positive clinical supervision, offering appropriate practice opportunities, providing health care services, and maintaining optimal patient safety in challenging times. Current clinical training should provide re ned and sustainable guidance to make improvements where necessary.

Limitations
This cross-sectional study was based on purposive sampling and self-reporting. Although this study was limited by a small sample size, and therefore cannot be generalised to all Chinese MD graduates, the strengths of this study included its investigation of clinical training independently from academic research. In subsequent research, optimal integrated clinical training and academic aspects should be developed. All comments were collected from open-ended questions, and interviews were not conducted; however, this would be useful in future studies. A national cohort study is needed, and it is suggested that in-depth and national clinical training cohort studies be conducted yearly.

Conclusions
With the combination of an MD degree and SST certi cate in this round of GME reform, Chinese MD graduates do not receive the optimal combination of clinical training and academic research. This study

Consent for publication
Not applicable.

Availability of data and material
The datasets that support the ndings of this study are available from the corresponding author upon reasonable request.  Chinese "5+3+X" model Overall satisfaction and adequate experience. O1: I am satis ed with the quality of training in clinical practice. O2: I am con dent that MD career will help me acquire the competencies I need at my current stage of training. O3: This post will be useful for my future career.

Figure 3
Teamwork, educational governance and supportive environment. T1: My organization encourages teamwork culture between multidiscipline healthcare professionals. T2: My organization encourages teamwork culture between clinical departments. T3: If I asked for help from outside my department, I'm con dent I would receive it. T4: I am con dent that I know how, or could nd out how, to raise a concern about my education and training. T5: If I were to raise a concern about my education and training, I'm con dent it would be addressed. T6: I am con dent that I know how, or could nd out how, to escalate such a concern if I felt it wasn't being addressed. T7: The training environment is fully supportive. T8: Staff is always treated fairly. T9: Staff always treats each other with respect. T10: The training environment is one that fully supports the con dence building of physicians in training. T11: If I were to disagree with senior physicians, they would be open to my opinion. T12: If I had any concerns (personal or educational) I would know who to approach to talk to in con dence.

Figure 4
Curriculum coverage and supervised learning events. C1: I'm con dent that this post will give the opportunities to meet cultivation objectives in: PROFESSIONAL EXPERIENCE (leadership, teaching, research, and quality improvement etc.). C2: I'm con dent that this post will give the opportunities to meet cultivation objectives in: PRACTICAL EXPERIENCE (procedures and treatments of chest drains, passing NG tubes, minor surgeries under local anesthetic, biopsies, tting coils, injections, psychological therapies etc.). C3: I'm con dent that this post will give the opportunities to meet cultivation objectives in: CLINICAL EXPERIENCE (examination skills, taking a history, deciding investigations and management, seeing a variety of patients in different settings etc.). C4: Supervised learning events (SLEs) have led to me re ecting on my clinical practice. C5: SLEs have helped me to identify areas in which I need to develop.
C6: SLEs have enabled me to improve my practice. C7: How easy or di cult was it to get a suitable physician to complete an SLE with you? C8: I have access to a senior physician who is onsite at all times. C9: The senior physician onsite could advise on any clinical situation.

Figure 5
Handover and reporting systems. H1: Handover arrangements always ensure continuity of care for patients between shifts. H2: Handover arrangements always ensure continuity of care for patients between departments. H3: Appropriate members of the multidisciplinary team are included in handover. H4: I have been made aware of how to report patient safety incidents and near misses. H5: There is a culture of proactively reporting concerns. H6: There is a culture of learning lessons from concerns raised.
H7: I am con dent that concerns are effectively dealt with. H8: When concerns are raised, the subsequent actions are fed back appropriately.