To our knowledge, this is the first analysis to explore the quality of clinical training among Chinese MD graduates from a range of specialties and different stages and included foundation, core and specialty clinical training. This study indicated that MD graduates were a young group with primary titles, and most had experienced short-term clinical training before entering MD program. The quality of overall satisfaction, 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 received as well as what would be necessary to sustain the cultivation pathway.
Clinical training challenges
GME reform is backed by substantial public financing 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 finance, human resources, and civil affairs is difficult. The State Commission Office for Public Sector Reform (SCOPSR) and the government ministries have many mixed and complicated characteristics in China, 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, administration power should be clarified and strengthened. Some piloted reform is being launched in some super universities, such as those in Beijing and Shanghai, but some medical education resources are not replicable at other universities, such as hospital training quality and qualified clinical preceptors and graduates. Clinical training focuses on patient care and cooperation with patients, family members, physicians, and other health professionals. The different care settings affect overall satisfaction. Policy makers should issue policies and regulations, as professional bodies have not been actively in ensured clinical training quality across different universities.
This study identified some challenges in clinical training that must be addressed. Technological innovation should be promoted across health care system, 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 lost training time and support. The criticisms 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. A pragmatic alternative is to combine the degree and clinical training, although clinical competency is inherently associated with academic research. MD graduates desire high quality and effective clinical training, which does not align perfectly with academic competency.
MD graduates have remained silos of professional practice with little horizontal professional mobility or quality assurance. Clinical competency of Chinese physicians is often judged, even for those with higher academic degrees, due to the demands for academic degrees and a lack of well-established clinical training and teaching. MD graduates are challenged by interruptions in their clinical training 2. MD graduates face high demands of academic research than clinical training. MD graduates do not receive the optimal combination of clinical training and academic research in China 14, 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. In this study, MD graduates stated that they needed more support in balancing clinical training and academic research. The boundary was unclear, and MD-PhD programs in the US encourage integrating clinical and academic training. 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.
Physicians with higher degrees were more likely to find higher paying job in a higher level hospital and a larger size city where they could also obtain high-quality and organized clinical training associated with medical career progression and 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 the MD program. A doctorate degree is more attractive than an SRT certificate 1. Without a valid 3-year MM with SRT, graduates cannot enter ‘X’ or an MD program. MD graduates normally must attend an examination organizing by universities and have a curriculum vita and expert recommendation letters. After passing examination, candidates are interviewed by an expert panel, included supervisors. The admission for MD graduates gradually transfers to the application, with no entrance examination. These silo positions are extremely competitive, to ensure fairness, the US’s Medical College Admission Test (MCAT) is validity for admission 16.
Most MD graduates had job experiences in this study, which was inconsistent with MD-PhD students in the US 3, however, professionalism was insufficient 17 and needed improvement 18. Inadequate instructional abilities and professionalism of preceptors were commented on frequently by MD graduates, which was consistent with a study in the US 2. This study showed that clinical training of MD graduates requires urgent improvement, especially of supervision and feedback. Poor levels of clinical supervision made 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 indicated the importance of highlighting clinical supervision and raised concerns about frequent and effective feedback. Clinical training environments present challenges, such as patient care and multidisciplinary, pressures about clinical training and supervision 19. We must acknowledge the pressures in health care service across China and understand that preceptors are experiencing similar pressures, raising concerns about the balance between clinical training and routine clinical work 20. Our responsibility is to protect, enhance and recognize the critical statuses of preceptors, and we must support preceptors consistently. MD graduates and preceptors are working together to improve health care services, we must make it 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 influence patient safety and care. Another important area to explore is the health and wellbeing of MD graduates and growing concerns about the impact of the working environment on individuals. Pressure can lead to burnout and negatively impact mental health. We did not obtain the dropout rate of MD graduates in this study. This rate was approximately 3% to 34% in a study in the US 3.
Recommendations for improvement training in clinical practice
Sorting through these challenges unique to China will take time. How can we ensure cultivation quality in combination an MD degree with SST? Complicated clinical environments challenge contemporary clinical training, emergency patient care, advanced technology, and multidisciplinary cooperation for mentoring 19. Accreditation of SRT and SST training institutions is essential. 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, the CMDA has accredited approximately 500 training bases geographically 1. This crucial work may need to be strengthened with regard to professional expertise, acceptance of its authority, and financial resources. MD graduates in the US obtain funding to support doing laboratory-based research 3, which is inconsistent with China. Most conduct clinical research and obtain research funding from their supervisors, which might limit their research interests and delay the time they conduct independent research. The standards of SRT and SST cannot satisfy the clinical competencies of MD graduates. High-quality professional expertise is only presented in a few top hospitals; therefore, a new certification mechanism must be established 1. Moreover, with the support of China Medical Board (CMB), seven leading teaching hospitals of these 24 demonstration bases have just developed the China Consortium of Elite. Medical education reform is led by government. Does the reform depend upon capacity building 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 the strengths were that combining the SST with the degree saves time, and they obtained a range of clinical cases and experiences. However, the quality of the clinical training remained the most important point, 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 disagreed with the cultivation responsibilities of MD graduates, and preceptors should be selected, inducted, trained and appraised to reflect clinical training. They should receive support, resources and time to meet cultivation responsibilities. MD graduates stated their preceptors lacked the time to supervise, and policies should support them in completing their clinical training plans optimally. We integrated some suggestions, including improving safe and effective care, positive clinical supervision, appropriate practice opportunities, providing health care services and maintaining optimal patient safety in challenging times.
Implications for MD program next development
Knowing the clinical training status characteristics could help predict and prevent problems at an earlier stage. Policy makers should cooperate with stakeholders before the quality worsens and causes harm to clinical training and patient care. We should actively consider more effective recommendations in this critical area. All training hospitals depend on local conditions and must have the approval and the capacity to support clinical training of MD graduates, which would help them develop adequate competencies and maintain optimal clinical training. Policy makers should reflect current clinical training to provide and refine sustainable guidance to assist MD preceptors, work with preceptors to improve where necessary, and consider more flexible clinical training program. The training standards should outline how MD graduates can be treated more professionally at all training stages and individualize clinical training components 6.
MD graduates receive lengthy training and inadequate funding support China. 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, monitoring, evaluation and integration of an SST with an MD must be researched systematically and sustainably. Our mission is to provide a supportive and sustainable training environment. Recommendations that maybe impactful include (a) targeted funds or rewards for academic and clinical training; and (b) 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 do not receive the optimal combination of clinical training and academic research. Supervision and feedback on clinical training for MD graduates must be improved. A few top hospitals present high-quality professional expertise. A new certification mechanism must be established. Policy makers should pay close attention to those who disagree with the cultivation responsibilities of MD graduates. Preceptors should be selected, inducted, trained and appraised to reflect clinical training. Some suggestions included improving safe and effective care, positive clinical supervision, appropriate practice opportunities, providing health care services and maintaining optimal patient safety in challenging times. Current clinical training should provide refined and sustainable guidance to improve where necessary.
This cross-sectional study was based on purposive sampling and self-reported. The findings were limited by a small sample size, which may restrict generalizability; therefore, a national cohort study is needed. We suggested that in-depth and national clinical training cohort studies should be conducted yearly. All comments were from open-ended questions, and interviews were not conducted. This must be engaged in future studies. This study investigated clinical training independently from academic research. Optimal integrated clinical training and academic aspects should be develop next.