Establishment of an evaluation index system of competencies for graduating students in general practice medicine

Background: The competencies of graduating students in general practice medicine have attracted attention. This study aimed to construct an evaluation index system of competencies for graduating students in general practice medicine and to promote the reform and optimization of training programs for general medicine talent in colleges. Methods: The two-round Delphi method was used to determine the evaluation index system of competencies for graduating students in general practice medicine, and the analytic hierarchy process (AHP) was used to calculate the weights of all levels of elements. Results: The evaluation index system of competencies for graduating students in general practice medicine was established with 3 primary factors, 9 secondary factors and 32 tertiary factors. The Delphi results revealed that the active coecient of experts was 1 and the authority coecient was 0.858. The 3 primary factors were knowledge level, job skills and professionalism with weights of 0.1532, 0.4207 and 0.4261, respectively. Among the secondary factors, the top three weight coecients were professional ethics (0.2614), community practice (0.1526) and communication skills (0.1308). Among tertiary factors, "scientic research" exhibited the lowest value with a weight coecient of 0.0049. Conclusion: In this study, we constructed an evaluation index system of competencies for graduating students in general practice medicine. The consensus on the content of the competencies of graduating students in general practice medicine suggests that these elements are necessary for those who will become general practitioners. This system can be used as the basis to evaluate the ability of graduating students in general practice medicine and provide guidance for the cultivation and evaluation of general medicine talent.

students in general practice medicine. The consensus on the content of the competencies of graduating students in general practice medicine suggests that these elements are necessary for those who will become general practitioners. This system can be used as the basis to evaluate the ability of graduating students in general practice medicine and provide guidance for the cultivation and evaluation of general medicine talent.

Background
With the rapid development of the economy and signi cant improvement in people's living standards in China, it is urgent to develop general practice education [1]. To promote the development of general practitioner (GP) systems, GPs should form the core of general medicine talent [2]. GPs play an essential role in improving people's health; thus, high levels of competencies are required for GPs [3]. It is well known that colleges and universities are the primary gateways to train GPs. Over the past 20 years, general practice medicine and the role of GPs in medical education have aroused great attention [4]. It is of great signi cance for the cultivation of general practice medical students' ability and quality to promote the sustainable development of general medicine. Currently, the establishment of a competence model for medical students has been increasingly optimised [5][6]. However, research on the comprehensive quality of graduating students in general practice medicine is rare, and evaluation methods suitable for measuring quality do not exist in China and cannot further guide the reform of talent cultivation and reform in general medicine in colleges and universities. In this study, we co-opted the theories and methods of Bloom et al. for the measurement of competencies of graduating students in general practice medicine [7]. The competencies were divided into three aspects: knowledge level, working skill and professional accomplishment. Based on the survey results of the current situation and needs of GPs in Anhui Province, the evaluation index system of GPs' competencies was constructed.

Objects
Anhui provincial health administrative departments, higher medical colleges, medical and health institutions at all levels and other relevant experts were selected for consultation. A total of 20 experts were chosen, including 8 education researchers in general medicine of Anhui higher medical colleges, 3 municipal/county health administrative personnel, 5 principals of primary medical and health service institutions, and 4 primary GPs.

Initial establishment of evaluation index system
The comprehensive competencies of GPs were based on the experiences of domestic and foreign scholars and combined with China's national conditions and the actual local situation. The subtopics under each topic were identi ed by Bloom's Taxonomy, and the levels of cognition necessary for learners' ability were demonstrated. The ascending levels of memory, understanding, application, analysis, evaluation, and creation were de ned. Finally, the evaluation index system of competencies for graduating students in general practice medicine was preliminarily constructed, including 3 primary elements, 10 secondary elements and 38 level-3 elements.

Delphi method[8]
The Delphi method was applied to perform two rounds of expert consultation. The rst round of expert consultation consisted of the following: (1) collection of basic information of experts, including gender, age, education background, professional title, working years, professional occupation and familiarity with evaluation elements; (2) experts' opinions on the initial evaluation index system [9], which used a 5-point Likert scale to assess the importance degree of the index elements at all levels, which was divided into 5 grades, including very important, relatively important, general important, not too important and not important with 5, 4, 3, 2 and 1 points, respectively. In addition, there was a column for suggestion to supplement or modify the various elements. The second round of expert consultation consisted of the following: after the elements at all levels were revised and improved, the second expert consultation was conducted, and the importance of the elements was scored again. According to the analysis of two rounds of expert consultation, the index elements of the evaluation system were clari ed.

Analytic hierarchy process (AHP)
AHP was proposed and established by the famous American operations research scientist Saaty. AHP is a common method used to evaluate the relative importance of in uencing factors based on qualitative and quantitative analysis of their risks and bene ts [10]. Evaluation of the abilities of graduating students in general medicine is a comprehensive process and involves many factors. Compared with traditional evaluation methods, this method establishes multidimensional evaluation standards with competencies for graduating students in general medicine as the core, and this method has a good degree of differentiation and considerable and reasonable evaluation data and plays a promoting and guiding role in the cultivation of competencies for graduating students in general practice medicine. Yaahp software is a visual modelling and calculation software based on the principle of AHP, providing functions, such as hierarchy model construction, judgement matrix and ranking weight [11].
The main steps to construct the evaluation index system using AHP include the following: (1) Establishment of hierarchical model: The elements involved in the evaluation index system of competencies were divided into several levels, and a hierarchical model of multiple levels was developed.
(2) Construction of the judgement matrix: The pairwise importance of elements was compared and analysed by comparing factors at the same level. The 1-9 AHP Saaty's scale was adopted [12].
(3) Establishment of index weight: Yaahp software was used to calculate the ranking weight of the overall target and subtarget.
(4) Consistency test: A consistency test was used to determine whether the weight allocation was Yaahp software was used to perform the consistency test. When the consistency index CI of the judgement matrix was less than 0.1 and the random consistency ratio CR was less than 0.1, it was believed that the judgement of each weight of the index had no logical error, had satisfactory consistency, and passed the test.

Statistical method
Excel 2010 software was used to process relevant data. SPSS 18.0 software and Yaahp 11.1 software were used for statistical analysis. P< 0.05 was considered signi cant.

Basic information on experts
Twenty experts participated in this study, and their basic information is shown in Table 1.

The active and authority coe cient of the experts
The active coe cient is the active degree of experts who participated in this research, which is measured by the returns ratio of the questionnaires [13]. In the rst round of this survey, 20 questionnaires were sent out, and 20 were collected, yielding a recovery rate of 100%. In the second round, 20 questionnaires were issued, and 20 were collected, yielding a recovery rate of 100%. This nding indicates that the experts were highly motivated.
The authority coe cient of experts is mainly affected by the judgement basis (Ca) and the familiarity (Cs) of the elements [14]. The judgement basis of experts was divided into practical experience (assignment 0.5, 0.4, 0.3), theoretical analysis (assignment 0.3, 0.2, 0.1), literature understanding (assignment 0.1, 0.1, 0.05), and subjective feeling (assignment 0.1, 0.1, 0.05). The three levels of expert familiarity were assigned 1.0, 0.5 and 0.0. The authority coe cient of experts is the arithmetic mean value of the familiarity coe cient and judgement coe cient, which is between 0 and 1. The higher the authority coe cient, the higher the authority degree of experts. In the rst round, the coe cient of expert authority was 0.803 (Ca=0.830, Cs=0.775). In the second round, the coe cient of expert authority was 0.858 (Ca=0.845, Cs=0.870).

The degree of concentration and coordination of expert opinions
The Kendall coordination coe cients (W) of the two rounds of expert consultation were 0.506 and 0.619, respectively, and the difference was statistically signi cant (P<0.01).

Results of the rst round of expert consultation
According to the opinions of the consulting experts, three rst-level elements, 10 second-level elements and 38 third-level elements of the evaluation index system were modi ed as follows: (1) elements removed: "system analysis" in secondary elements was deleted. Five items in tertiary elements were also deleted: "using health information to guide the community working ability", "analysis of the ability of health", "the skills of using evidence-based medicine", "the ability to apply the law to solve disputes" and "the ability to solicit advice and suggestion from others"; (2) modi ed elements: "basic pharmacological knowledge" was changed to "pharmacological knowledge and clinical rational drug use", "health management knowledge" changed to "grassroots health management knowledge", "good communication skills with the patient" changed to "good communication skills with patients and family members", and "health records management skills" changed to "establishment, use and management of health records". "The ability to carry out the work of teaching" and "the ability to launch scienti c research work" were integrated into "scienti c research".

Results of the second round of expert consultation
On the basis of the rst round of expert consultation, the evaluation index system was modi ed, and 3 rst-level elements, 9 second-level elements and 32 third-level elements were formed. In the second round of expert consultation, the second-level element "continuous self-directed learning" was revised to "educational learning". According to the opinions of two rounds of expert consultation and discussion by the research group, the evaluation index system was nally determined, including 3 rst-level elements, 9 second-level elements and 32 third-level elements.

Evaluate index weight results
Yaahp software was used to establish the hierarchical structure model, with the "evaluation index system of competencies for graduating students in general practice medicine" as the decision-making target, the rst-and second-level elements as the middle layer, and 32 third-level elements as the scheme layer.
Yaahp software generates a judgement matrix of decision objectives and intermediate elements based on the model. Combined with the weight of experts, each judgement matrix was scored in group decisionmaking, and the weight results of each index element were obtained by calculation and analysis ( Table  2).

Discussion
Graduating students in general practice medicine are future general practitioners, the competencies of whom can determine the future of basic health care in our country. Therefore, the establishment of an evaluation index system of competencies for graduating students in general practice medicine is of great signi cance. In this study, the Delphi expert consultation method and AHP method were combined to construct an evaluation index system of competencies for graduating students in general practice medicine. The two methods of application were based on the theoretical knowledge and practical experience of consulting experts. AHP was used to combine subjective evaluation with mathematical evaluation, and the data were statistically processed on the basis of subjective judgement of experts, all of which increased the logic and scienti c nature of this study [15]. The results of this study showed that CI, CR and the judgement matrix of index elements at all levels were all less than 0.1, suggesting that the ranking of each level exhibited satisfactory consistency, and the evaluation index and hierarchy structure constructed was objective and scienti c.
After two rounds of expert consultation, 3 primary elements, 9 secondary elements and 32 tertiary elements were ultimately determined. The relative weight of each element was statistically analysed.
First, among the rst-level elements, "professional quality" had the highest weight with a weight coe cient of 0.4261. Three secondary factors were established under this index, and the weight coe cient of "professional ethics" was at the top of the three with a weight coe cient of 0.2614. The results suggested that professional quality was the most important ability of graduating students in general practice medicine. The goal of general practice was to advocate the human-centred and biopsychosocial medical model as guidance, respect the needs of patients and families, pay attention to the physical and mental health of individuals and families, and pay attention to the care of the inner quality of life [16]. In the context of the poor doctor-patient relationship and increasing medical disputes, doctors' professional ethics, as a soft service, were increasingly valued, which directly impacted the improvement of medical service quality [17]. It is critical for graduating students in general practice medicine to strengthen their professional quality during professional learning. Under the in uence of the role-oriented environment of doctors' profession, graduating students gradually internalize and form stable and e cient professional ethics, which is a prerequisite for a good job as a general practitioner.
Second, weight coe cient of "community practice" was at the second highest level in the secondary factors with a weight coe cient of 0.1526. As the main force of primary medical care, GPs' community practice skills are essential. With the reform of the medical system, a basic medical and health system covering both urban and rural residents should be established and improved, and the medical concept of "minor diseases are at the grassroots level, serious diseases are in hospitals, and rehabilitation is returned to the community" should be implemented [18]. For this purpose, GPs need to be pro cient in the use of general practice principles and integrate them in practice. According to the ndings of this study, the weight coe cient of "High blood pressure, diabetes, mental illness and other health education skills" was the highest in "community practice" with a weight coe cient of 0.0475. The prevention and management of chronic disease is a priority for primary care services [19]. One of the most important skills of GPs, which was different from other physicians, was health education and the development of a high-quality preventive service, aiming to prevent diseases and improve residents' self-management ability and quality of life [20]. Therefore, graduating students in general practice medicine should pay attention to the cultivation of health education skills when cultivating their competencies. In addition, among the secondary factors, experts agreed that communication skills are one of the important elements in evaluating competencies for graduating students in general practice medicine. In particular, the ability to communicate well with patients and their families has received increasing attention, and good and effective communication is the basis and guarantee for increasing patients' subjective initiative. When potential con icts occur between doctors and patients and between doctors and patients' family members, doctors are also required to have a skilled communication and coordination ability to resolve con icts. Therefore, good communication skills are an effective method to improve the service quality of GPs, and the learning of good communication skills is essential for graduating students in general practice medicine [21].
In addition, among the secondary factors, the weight coe cient of "educational learning" was the lowest with a weight coe cient of 0.0346. Four third-level elements were constructed in this factor. Among them, "scienti c research" was the lowest to be required with a weight coe cient of 0.0049. This may be related to the scienti c research system of general practice and the teaching and scienti c research level of general practitioners in China [20]. The development of scienti c research in general practice could improve the visualization of general medicine and the sense of achievement of GPs and facilitate the development of general practice medicine [22]. To improve the scienti c research ability of GPs in different manners and establish a close relationship between clinical practice and scienti c research, colleges and universities should strengthen the cultivation of scienti c research ability for students in general practice medicine, improve their thinking ability for scienti c research, enable them to combine their own characteristics when facing speci c working environments and clinical problems and apply the scienti c research results to practical work [23].

Conclusion
In this study, we constructed an evaluation index system of competencies for graduating students in general practice medicine. The consensus on the content of the competencies of graduating students in general practice medicine suggests that these elements are necessary for those who will become general practitioners. This system can be used as the basis to evaluate the ability of graduating students in general practice medicine. and provide guidance for the cultivation and evaluation of general medicine talent. However, due to the limitations of the research scope and conditions, this research was only carried out in Anhui Province; thus, further in-depth measures are needed for nationwide promotion.

Declarations
Ethics approval and consent to participate The experimental protocol was established, according to the ethical guidelines of the Helsinki Declaration and was approved by the Ethics Committee of Bengbu Medical College. Written informed consent was obtained from individual or guardian participants.

Consent for publication
Not Applicable in Consent for publication.

Availability of data and material
All data generated or analysed during this study are included in this published article.

Competing interest
The authors declare that they have no competing interests Authors' contributions FL and KZ designed this project. KZ conducted literature review. RZ is responsible for data collection and paper writing. KZ did the statistical analysis. All authors read and approved the nal manuscript.
Last but not the least, my gratitude also extends to my family who have been assisting, supporting and caring for me all of my life.