This study conducted a graduation survey among IMSs in 4 Chinese universities using a questionnaire referring to AAMC GQ  and other graduation surveys [10, 18, 21-23]. We evaluated the effectiveness of the undergraduate program for IMSs in China from multiple aspects and highlighted the influence of language barrier on IMSs’ education experiences. This was conducted to provide useful information for policymakers and university authorities to make important curricular decisions about international medical education for Asian and African students.
Regarding the basic science education, the ratings of IMSs were generally positive, although it still indicates relatively insufficient interdisciplinarity and clinical relevance in the basic science subjects. Studies in India  and Nepal  also reported similar findings. Similar to China, many Asian and African countries conventionally divide the medical curriculum into 2 separate parts (basic sciences and clinical sciences) and follow discipline-based teaching pattern [26-28]. Consequently, basic sciences are delivered as individual subjects with the least cross-subject interaction or clinical practice integration. To address these weaknesses, problem-based learning (PBL) was introduced for a better integration of the basic medical and clinical contents , and it is increasingly popular in Asia and Africa [28, 30-33]. Medical schools in China began to adopt PBL teaching strategy on Chinese medical students since the mid-80s , and started to adopt this approach on IMSs more recently with positive results [35-37]. However, it has been reported that the teaching faculties have yet to overcome the language challenge .
Among the basic science courses, anatomy and physiology received the highest percentage of agreement in regard to underpinning IMSs’ clerkship. These two subjects also ranked top in other GQs in the USA , Canada , Iran  and Israel . As anatomy, physiology and pharmacology are among the fundamental sciences to medical practice , the importance of these subjects is unquestionable. Another possible reason for the high rating is that medical students undergo a significant knowledge loss of basic sciences in their later years of education [40-41], but pathophysiology-related basic subjects are better remembered , because the constant reference to clinical application could reinforce students’ insight into these subjects .
In contrast, despite their close relationship with clinical diseases, statistics, epidemiology and genetics 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]. Notably, students need mathematical knowledge to understand statistics and epidemiology. 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 exist a mismatch between the difficulty of the lessons imparted by teachers and that accepted by IMSs. Genetics is a rapidly advancing discipline involving state-of-the-art concepts and latest research findings, so IMSs will be discontent if the teachers cannot stay abreast of the relevant scientific advances. Furthermore, due to the inadequate application of evidence-based medicine in some countries, IMSs may have not recognized the importance of this subject.
Here, many participants gave negative responses to the benefits of natural sciences for medical practice, a finding supported by evidence from published literature [10, 23]. This is possibly attributed to the poor knowledge retention of the related subjects and a poor integration between natural science and clinical application. However, Goldszmidt et al.  argued that using the knowledge of natural science, such as physics, to illustrate clinical phenomena could produce a causal explanation of the latter, which would promote medical students’ memory for clinical details.
For clinical medical education, 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]. Nevertheless, the quality of community medicine was considered the lowest in our study, whereas medical students in surveys conducted in Canada and Iran spoke highly of this subject [18, 22]. Moreover, the large percentage of IMSs who deemed the study hours for community medicine were inadequate further illustrated the participants’ dissatisfaction with this course.
The low rating of IMSs in community medicine could be partially attributed to the large difference in the concepts and contents of this course between China and their countries of origin. In the eyes of IMSs, community medicine is supposed to be a course encompassing all the knowledge and practice related to primary care. However, in China, the primary care contents are integrated into the respective clinical disciplines (e.g. internal medicine, paediatrics, obstetrics-genecology, geriatrics). This is primarily because the health care system in China is hospital-based and the general practitioner based primary care and referral system is highly underdeveloped . This could give IMSs an impression of deficiency in community medicine education. In IMSs’ countries of origin, which are generally medically underserved, the population need to benefit from the enhancement of primary care and an increase in general practitioners [45-46]. Thus, the medical schools in these countries have been emphasizing community-oriented approaches [28, 47-50], aiming at producing 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 are advised to consider reorienting the related syllabus in line with the need of IMSs, putting more primary care contents into the community medicine course and creating more practice opportunities in a community setting.
Our findings regarding the quality and outcome of clinical education imply that the clinical training of IMSs in China is still insufficient. Specifically, linguistically demanding tasks tend to receive 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. Moreover, as patient administration requires a high level of Chinese language proficiency, it was not surprising that a high percentage of our participants complained that they were not assigned an appropriate role in patient care during the internship. Our findings also demonstrate that, IMSs’ speaking skills and communication initiatives, compared to HSK levels, have a greater impact on their clinical experiences and competence. Therefore, medical schools in China are advised to strengthen the oral Chinese teaching for IMSs and encourage students to take initiative in speaking, since doing so will promote a productive time and good education experiences for the students in their clinical clerkship and rotations.
Moreover, IMSs’ clinical study is also influenced by cross-cultural issues. Firstly, although the respondents were quite positive towards the access to various patients and procedures during their clerkship, they had relatively low confidence in the clinical skills they had acquired. In addition to the language barrier, local patients’ strong awareness of self-protection and privacy could present difficulties to IMSs’ hands-on experiences during the process . As a remedy, simulations have been highly recommended by researchers and applied in many medical schools in China as an effective method for clinical teaching for IMSs [52-53]. Secondly, cross-cultural factors are also influential for ethics teaching, since ethical topics are highly culture-specific, and thus the ethical standards for IMSs are diversified. Therefore, IMSs will not be able to obtain an appropriate and deep understanding of ethical topics without practicing in their home countries or other destination countries.