In the study, we conducted the graduation survey among IMSs at 4 Chinese universities using the questionnaire based on AAMC GQ. The study evaluated the effectiveness of the undergraduate program for IMSs in China from multi-aspects and highlighted the influence of language barrier on IMSs’ education experience, giving useful information for policymakers and university authorities to make important curricular decisions concerning international medical education catering for Asian and African students.
Although IMSs’ rating result of the basic science education was overall positive, it still indicates relatively insufficient interdisciplinarity and clinical relevance in the basic science subjects. Similar circumstances have also been reported in researches from India  and Nepal . In fact, just like China, many Asian and African countries traditionally divide the medical curriculum into two separate parts (basic sciences and clinical sciences) and follow discipline-based teaching pattern [25-27], causing basic sciences to be delivered as individual subjects with least cross-subject interaction or clinical practice integration. To address these weaknesses, problem-based learning (PBL) was introduced for a better learning outcome , and it is increasingly popular in Asia and Africa [27, 29-32]. China’s medical schools began to adopt this experimental teaching approach on Chinese medical students from the mid-80s , and started to adopt it on IMSs more recently with positive results [34-36], although the teaching faculties still have to overcome the language challenge reportedly .
In the study, we found anatomy and physiology received the highest percentage of agreement in regard of underpinning IMSs’ clerkship. These two subjects also ranked top in other GQs in the USA , Canada , Iran , Israel  and Taiwan of China . As anatomy, physiology and pharmacology are among the fundamental sciences to medical practice , these subjects’ importance should hardly need repeating. Besides, there might also be another feasible reason; medical students are found to undergo a considerable knowledge loss of basic sciences in their later years of education [39-40], and pathophysiology-related basic subjects are more memorised , because the constant reference to clinical application could reinforce students’ insight into these subjects .
By contrast, statistics, epidemiology and genetics, despite their close connection with clinical diseases, were among the least helpful preclinical subjects for medical practice in our survey as well as some other surveys conducted elsewhere [16, 18, 22-23]. Students’ mastery of statistics and epidemiology largely depends on their mathematical abilities. If teachers in China prepare lessons based on the general academic background of Chinese students, who are known for good command of mathematics, there might be a mismatch between the difficulty of the lessons imparted by teachers and that accepted by IMSs. As for genetics, a rapidly developing discipline involving state-of-the-art concepts and latest research findings, IMSs will be discontent if the teachers cannot stay abreast of the relevant scientific advances. Besides, due to the inadequate application of evidence-based medicine in some countries, IMSs might have not realized the importance of this subject.
Many participants gave negative responses to the benefits of natural sciences for medical practice in our study, which is supported by evidence from published literature [10, 23], possibly attributed to the poor knowledge retention of the related subjects and a loose partnership between the natural science and clinical application. However, Goldszmidt et al.  argue that using natural science knowledge, such as physics, to illustrate clinical phenomena can produce a causal explanation of the latter, which promotes medical students’ memory for clinical details.
Our findings are in consonance with the reports that the education experience in internal medicine, obstetrics-gynaecology, surgery and paediatrics ranked top 4 among all the clinical courses [10, 21]. However, the quality of community medicine was considered the lowest in our study, which is also the case with the study in Taiwan of China , whereas medical students in surveys conducted in Canada and Iran speak highly of this subject [18, 22]. Moreover, the fact that a high percentage of IMSs deemed the study hours devoted to community medicine was scanty further illustrated their dissatisfaction with this course.
Medical education policies in different counties are influenced by the respective health care systems. In China, the health care system is hospital-based and the tiered medical services are highly underdeveloped , which explains the inadequate role played by community medicine in public health maintenance. As a result, conceivably, the major hospital-based disciplines are fully supported with abundant teaching resources, while the education related to primary care is behindhand. However, IMSs’ home countries are generally medically underserved, where the population need to benefit from enhancement of primary care and an increase in general practitioners [44-45]. In fact, community-oriented approaches have already been emphasized at medical schools in many Asian and African countries, including India , Nepal [47-48], Pakistan  and Ghana , with the aim to produce health professionals with competencies and values to serve in local communities, particularly rural areas . Given the vital position of community medicine in IMSs’ home countries, policy planners and educators in China should consider reorienting the medical education tailored to IMSs to some degree, putting more effort to fortify theoretical teaching of community medicine and create more practice opportunities in a community setting, to meet the medical conditions of IMSs’ home countries.
The results regarding quality and outcome of clinical education in our study denote that the clinical training of IMSs in China is still insufficient, and in particular, linguistically demanding tasks tend to obtain lower ratings. A case in point is that talking ethical topics in depth involves using sophisticated words, and correspondingly, over 40% of our participants provided a negative response towards ethical discussions during their clerkship. For another instance, using the Chinese language skilfully is critical to patient administration for interns in China, which goes with the result that a high percentage of our participants complained about the inadequate role they played during the internship. Our findings also demonstrate that, IMSs’ speaking skills and communication manner, compared to HSK levels, have a greater impact on their clinical experience and competence. Medical schools in China are therefore advised to strengthen the oral Chinese teaching for IMSs and encourage students to take initiative to speak, since doing so will facilitate the likelihood of a quality time in their clinical clerkship and rotations.
IMSs’ clinical study is also affected by cross-cultural issues. Although the respondents were very positive towards the access to the variety of patients and procedures during their clerkship, they had comparatively low confidence in the clinical skills they had acquired. Apart from the language barrier, local patients’ strong awareness of self-protection and privacy may pose difficulties for IMSs’ hands-on experiences during the process . To cope with the obstacles, simulations have been highly recommended by researchers and applied in many medical schools in China as an effective method for clinical teaching for IMSs [51-52]. Cross-cultural factors are influential for ethics teaching too, since ethical topics are highly culture-specific, and thus the ethical standards for IMSs are diversified. So IMSs will not be able to successfully obtain an appropriate and deep understanding of ethical topics without practicing in their home countries or other destination countries.