To the best of the authors’ knowledge, this is the first 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 findings 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 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 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 clarified 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 qualified 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 identified 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 , and do not receive the optimal combination of clinical training and academic research in China . 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 ; another study reported that graduates from 24 MD-PhD programs spent 75% to 80% of their time conducting academic research .
Most MD graduates that participated in this study had previous job experience, which is inconsistent with MD-PhD students in the US ; however, professionalism is insufficient 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 . 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 . 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 . 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 influence 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 find 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 , 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 certificate . 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 .
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 . 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 . This crucial work may need to be strengthened with regard to professional expertise, acceptance of its authority, and financial 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 . MD graduates in the US obtain funding to support laboratory-based research , 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 certification mechanism needs to be established . 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 reflect 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 reflect current clinical training to provide and refine sustainable guidance to assist MD preceptors, work with preceptors to make improvements where necessary, and consider more flexible 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 .
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 . 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 , especially funding, individual training, supervision, and feedback .
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 certification 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 reflect 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 refined and sustainable guidance to make improvements where necessary.
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.