First-round accreditation and pass rates on licensing examination at different medical schools in China: Closing the performance gap.

BACKGROUND: Although the accreditation approach is widely used to ensure the quality of medical education in many countries, there is scant empirical evidence on whether and how it improves actual medical school performance. We focused on conditions in China, which introduced an accreditation system during the 2010s. Specifically, we examined the relationship between first-round accreditation and actual performance based on the results of medical licensing examinations. Referring to organisation theory, we hypothesised that the impacts of accreditation would depend on existing performance gaps. METHOD: In 2022, we analysed panel data from 105 Chinese medical schools during accreditation (2012 to 2021) and pass rates on medical licensing examinations (2011 to 2019), as matched into 834 school-year records in a window of years before and after accreditation. We employed fixed-effects regression models with a comparison group to exclude factors that may have confounded the impacts of accreditation time. We also demonstrated the heterogeneous effects of accreditation by tier and performance gap of medical schools. RESULTS: The conservative estimates showed a substantial cumulative improvement (over 15 percentage points) in pass rates during the years before accreditation, with no clear trend indicating performance drops in the years after accreditation. Lower-tiered medical schools gained greater benefits from accreditation. Medical schools with a larger prior performance gap achieved a greater percentage point increase in pass rates with the passage of time in pre-accreditation years. CONCLUSIONS: This is the first empirical study to investigate whether accreditation has bridged performance gaps among medical schools. The results support the value of accreditation in China, a country that recently established the system, and might work as a substitute for missing information on early accreditation history in countries with long-established accreditation systems. We encourage more studies in countries that have recently introduced accreditation systems.

Medical students' rural practice intention: Academic performance matters.

INTRODUCTION: Many countries are driving forward policies and practices to train medical students for later rural practice. Previous research has investigated individual (e.g., rural upbringing) and structural factors (e.g., curricular exposure) associated with rural practice intention. However, the relationship between academic performance in medical school and rural practice intention has been neglected, although optimisation theory suggests there may be a relationship. To address this gap, our aim was to identify the relationship between academic performance and rural practice intention. METHODS: Data were collected via a cross-sectional (self-report) survey in 2021. Participants were students from 60 of the 96 rural order directed (RODs) medical programmes across China. We asked students their rural practice intention. We conducted univariate analyses to test for associations between rural practice intention and independent variables, including socio-demographics, ROD location, grade year and academic performance measures. We used multilevel logistic regression models to test whether students' academic performance in medical school could be used to predict rural practice intention, holding the other factors constant. RESULTS: There were 13 123 respondents, representing roughly 77.6% of the student population from the 60 schools. There was a statistically significant relationship between student (self)-reported academic performance in medical school and rural practice intention. Higher performers had a lower likelihood (ORs: 0.65-0.78) of rural practice intention. This held across all performance measures (GPA rank, academic awards and student leadership) and for the sub-group with rural upbringing (ORs: 0.68-0.78). DISCUSSION: This is the first study to identify a relationship between medical school performance and rural practice intention. The findings suggest that students maximise their utility when choosing career options, with higher performers having lower rural practice intention. These data provide insight into the complexity of medical career decision making and can be used by medical school and workforce planners to inform rural training, recruitment and retention strategies.

The association between medical student research engagement with learning outcomes.

Medical student research engagement has been considered as a critical component of undergraduate medical education. However, evidence on the association between medical student research engagement with learning outcomes is lacking. The objectives of our study are: (1) to outline the landscape of medical student research engagement in China; (2) to explore the association between medical student research engagement and learning outcomes, and whether this association is different among students with different characteristics. A paper questionnaire was developed, piloted, and administered to medical students at 33 medical schools in China. Research engagement was measured by the times students engaged in research projects while learning outcomes referred to learning outcomes contained in the Standards for Basic Medical Education in China. Chi-square tests were used to measure statistical significance between research engagement and the characteristics of participants. We analysed relationships between research engagement and learning outcomes using multivariate linear regression with medical school fixed effects. The overall response rate was 86.7%. 10,062 medical students completed the questionnaire, 55.5% of which had participated in one or more research projects. Research engagement differed by the length of the program, gender, and academic performance. Research engagement was also positively associated with students' overall learning outcomes, especially in the Science and Scholarship domain (once, ß = 0.20, P < 0.001; twice or more, ß = 0.43, P < 0.001) and the Professionalism domain (once, ß = 0.12, P < 0.05; twice or more, ß = 0.25, P < 0.01). The relationships between research engagement and learning outcomes differed significantly by gender. Medical student research engagement is significantly positively associated with medical students' learning outcomes, especially in the Science and Scholarship domain and the Professionalism domain. Besides, men benefit more from engaging in research projects, particularly in the Science and scholarship domain.

Professional Identity of 0.24 Million Medical Students in China Before and During the COVID-19 Pandemic: Three Waves of National Cross-Sectional Studies.

Background: Professional identity (PI) influences the doctor's thoughts and behaviors. Thus, PI formation (PIF) plays an important role in medical students' education. Major changes to the learning environment could impact PIF, but the influence of the novel coronavirus disease 2019 (COVID-19) pandemic on medical students' PI had confusing conclusions in previous studies. We aimed to compare PI of medical students by using the data from three waves of national cross-sectional surveys conducted in China in 2019, 2020, and 2021, and to examine factors that influence PIF. Method: We used data from the China Medical Student Survey (CMSS) which has conducted three national cross-sectional surveys. From 2019 to 2021, CMCC retrieved data on PI from a nationally representative sample of medical students from 33, 121, and 123 colleges, respectively. We analyzed the data using Chi-square test, analysis of variance, and multivariable logistic regression according to sociodemographic characteristics, pre-university experience, college characteristics, and college experience. Results: A total of 244,040 medical students in China participated in the surveys. The overall score of PI increased from 3.80 in 2019 to 3.85 in 2021. Medical students with family medical background, high intrinsic and extrinsic motivation of major selection, teachers' positive role model, and high personal comprehensive quality ranking were more likely to have higher PI (all p < 0.05). The more attention students paid to the COVID-19 pandemic, the higher PI they would have (aOR 1.93, 95% CI 1.67-2.24 for more attention; aOR 2.31, 95% CI 2.00-2.68 for the most attention). However, parents' participation on the front lines of COVID-19 pandemic negatively influenced the PI of medical students (aOR 0.72, 95% CI 0.57-0.93). Conclusions: PI of medical students increased during the COVID-19 pandemic. The impact of the pandemic on PI was complex. To improve the PI of medical students, the education sector, health sector and the society need to make concerted efforts.

Still want to be a doctor? Medical student dropout in the era of COVID-19.

This research examines the intention of undergraduate medical students to withdraw from the medical profession and pursue a career in a different field upon graduation during COVID-19. We leverage the first and most comprehensive nationwide survey for medical education in China, which covered 98,668 enrolled undergraduate students from 90 out of 181 Chinese medical schools in 2020. We focus on these students' self-reported intention to leave the healthcare industry (the "dropout intention") before and after the outbreak of the epidemic. We also designed a randomized experiment to test whether and to what extent medical students dropout intention responded to an information nudge that highlighted the prosociality of health professionals in the fight against the virus. Results from a difference-in-differences model and a student fixed effect model suggest that after the onset of COVID-19, the proportion of Chinese undergraduate medical students with a dropout intention declined from 13.7% to 6.8%. Furthermore, the nudge information reduced the intent-to-drop-out probability by 0.8 additional percentage points for students in their early college years. There was large heterogeneity underneath the treatment effect. Specifically, we find that prior dropout intention and exposures to COVID-19-related information tended to mitigate the nudge effects. Data on students' actual dropout outcomes support our findings.

Students' initial perspectives on online learning experience in China during the COVID-19 outbreak: expanding online education for future doctors on a national scale.

BACKGROUND: During the early stage of COVID-19 outbreak in China, most medical undergraduate programs have to eventually embrace the maneuver of transferring to nearly 100% online-learning as a new routine for different curricula. And there is a lack of empirical evidence of effective medical education curriculum that has been completely implemented in an online format. This study summarizes medical students' perspectives regarding online-learning experience during the COVID-19 outbreak and presents reflection on medical education. METHODS: From February 21st to March 14th, 2020, the authors conducted survey of a nationally representative sample of undergraduate medical students from 90 medical schools in China. Participant demographics and responses were tabulated, and independent sample t-tests as well as multiple logistic regression models were used to assess the associations of demographic characteristics, prior online learning experience, and orientation with students' perspectives on the online learning experience. RESULTS: Among 118,030 medical students participated in the survey (response rate 52.4%), 99,559 provided valid data for the analysis. The sample is fairly nationally representative. 65.7% (65,389/99,559) supported great orientation and 62.1% (61,818/99,559) reported that they were satisfied with the ongoing online-learning experience. The most common problem students would encounter was the network congestion (76,277/99,559; 76.6%). Demographics, learning phases, and academic performance were associated with online-learning engagement and perceptions. Formal orientation and prior PU (perceived usefulness of online learning) were significantly positively associated with the satisfaction and evaluation of the online learning experience (p <  0.001). CONCLUSIONS: Data from this national survey indicates a relatively positive role of online learning as a formal teaching/learning approach in medical education. Considerations should be made regarding such application in aspects of students' different learning phases. We suggest that further policy interventions should be taken from technological, organizational, environmental, as well as individual aspects, to help improve the outcome of online learning for future doctors.

An update on current EPAs in graduate medical education: A scoping review.

The purpose of this scoping review is to update the recent progress of EPAs research in GME, focusing on the topical concern of EPAs effectiveness, and to provide a reference for medical researchers in countries/regions interested in introducing EPAs. Guided by Arksey and O'Malley's framework regarding scoping reviews, the researchers, in January 2021, conducted a search in five databases to ensure the comprehensiveness of the literature. After the predetermined process, 29 articles in total were included in this study. The most common areas for the implementation and evaluation of EPAs were Surgery (n = 7,24.1%), Pediatric (n = 5,17.2%) and Internal medicine (n = 4,13.8%), a result that shows a relatively large change in the research trend of EPAs in the last two years. Prior to 2018, EPAs research focused on internal medicine, psychiatry, family medicine, and primary care. The articles in the category of EPAs implementation and evaluation had four main themes: (1) validation of EPAs (n = 16,55.2%); (2) describing the experience of implementing EPAs (n = 11,37.9%); (3) examining the factors and barriers that influence the implementation and evaluation of EPAs (n = 6,20.6%); and (4) researching the experiences of faculty, interns, and other relevant personnel in using EPAs. Training programs were the most common EPAs implementation setting (n = 26,89.6%); direct observation and evaluation (n = 12,41.4%), and evaluation by scoring reports (n = 5,17.2%) were the two most common means of assessing physicians' EPA levels; 19 papers (65.5%) used faculty evaluation, and nine of these papers also used self-assessment (31.0%); the most frequently used tools in the evaluation of EPAs were mainly researcher-made instruments (n = 37.9%), assessment form (n = 7,24.1%), and mobile application (n = 6,20.7%). Although EPAs occupy an increasingly important place in international medical education, this study concludes that the implementation and diffusion of EPAs on a larger scale is still difficult.

Evaluation of Eight-Item Vancomycin Prescribing Confidence Questionnaire Among Junior Doctors.

Background: Assessing the preparedness of junior doctors to use vancomycin is important in medical education. Preparedness is typically evaluated by self-reported confidence surveys. Materials and Methods: An eight-item vancomycin prescribing confidence questionnaire was developed, piloted, and evaluated. The questionnaire responses were collected from 195 junior doctors and a series of statistical techniques, such as principal component analysis and confirmatory factor analysis, and were implemented to examine the validity and reliability. Results: The principal component analysis supported a one-factor structure, which was fed into a confirmatory factor analysis model resulting in a good fit [comparative fit index (CFI) = 0.99, Tucker-Lewis index (TLI) = 0.99, root mean square error of approximation (RMSEA) = 0.08, standardized root mean square residual (SRMR) = 0.04]. Ordinal-based α was 0.95, and various ωs were all above 0.93, indicating a high reliability level. The questionnaire responses were further proved to be robust to extreme response patterns via item response tree modeling. Jonckheere-Terpstra test results (z = 6.5237, p = 3.429e-11) showed that vancomycin prescribing confidence differed based on the experience in order (i.e., four ordinal independent groups: "≤10 times," "11-20 times," "21-30 times," and "≥31 times") and therefore provided external validity evidences for the questionnaire. Conclusions: The questionnaire is valid and reliable such that teaching hospitals can consider using it to assess junior doctors' vancomycin prescribing confidence. Further investigation of the questionnaire can point to the relationship between the prescribing confidence and the actual performance.

Funding of health professional education: China's 20-year process and a global comparison.

CONTEXT: Funding is an essential requirement for ensuring the quality of health professional education worldwide. Adequate funding is of immense significance in training health professionals. Due to the difficulty of accessing relevant data, quantitative research of the kind is scarce. OBJECTIVES: This study aims at analysing the trends of funding levels and funding sources for health professional institutions in China spanning the past 20 years and making a global comparison. METHODS: We used data from Ministry of Education (MOE) of the People's Republic of China to analyse its funding level and structure of funding sources of health professional education in China during 1998-2017. When analysing funding level, we used two indicators: total funding and funding per student. We chose the United States, and analysed its funding level and structure to allow easy comparison to the situation in China. The data from a Lancet report (Lancet, 376, 2010, 1923) were also used to analyse global funding status to make an international comparison. RESULTS: Funding levels of health professional institutions in China has increased significantly in the past 20 years, while the average annual growth rate of funding per student (4.5%) is lower than that of total funding (19.9%). In terms of the structure of funding sources, fiscal appropriation accounts for 51.1% on average, and tuition, fees and scientific research income explains 37.0%. CONCLUSION: From 1998 to 2017, the total funding and funding per student of HPE in China increased continuously, and the total funding increased at a faster rate. The increase in funding of HPE in China is closely related to the efforts of the Chinese government and the implementation of relevant policies. Even so, funding of HPE in China is likely to remain relatively low compared to other countries.

Twelve tips for teaching medical students online under COVID-19.

Universities worldwide are pausing in an attempt to contain COVID-19's spread. In February 2019, universities in China took the lead, cancelling all in-person classes and switching to virtual classrooms, with a wave of other institutes globally following suit. The shift to online platform poses serious challenges to medical education so that understanding best practices shared by pilot institutes may help medical educators improve teaching. Provide 12 tips to highlight strategies intended to help on-site medical classes moving completely online under the pandemic. We collected 'best practices' reports from 40 medical schools in China that were submitted to the National Centre for Health Professions Education Development. Experts' review-to-summary cycle was used to finalize the best practices in teaching medical students online that can benefit peer institutions most, under the unprecedented circumstances of the COVID-19 outbreak. The 12 tips presented offer-specific strategies to optimize teaching medical students online under COVID-19, specifically highlighting the tech-based pedagogy, counselling, motivation, and ethics, as well as the assessment and modification. Learning experiences shared by pilot medical schools and customized properly are instructive to ensure a successful transition to e-learning.

Association between medical students' prior experiences and perceptions of formal online education developed in response to COVID-19: a cross-sectional study in China.

OBJECTIVES: (1) Understanding the characteristics of online learning experiences of Chinese undergraduate medical students; (2) Investigating students' perceptions of ongoing online education developed in response to COVID-19 and (3) Exploring how prior online learning experiences are associated with students' perceptions. DESIGN: Students' familiarity with online learning modes and corresponding perceived usefulness (PU) according to their previous experiences were investigated using an online survey. The survey also collected data on students' perceptions through their evaluation of and satisfaction with current online learning. SETTING: In response to the educational challenges created by COVID-19, medical schools in China have adopted formal online courses for students. PARTICIPANTS: The questionnaire was sent to 225 329 students, of whom 52.38% (118 080/225 329) replied, with valid data available for 44.18% (99 559/225 329). METHODS: Pearson correlations and t-tests were used to examine the relationship between familiarity and PU. Multiple linear regression and logistic regression analyses were used to determine the impact of prior learning experiences and its interactions with gender, area, learning phase and academic performance on students' perceptions. RESULTS: Students' PU had a significant positive correlation with their familiarity with online learning modes (p<0.01). Students' evaluation of and satisfaction with their current online education were positively associated with their familiarity (ß=0.46, 95% CI 0.45 to 0.48, p<0.01; OR 1.14, 95% CI 1.13 to 1.14, p<0.01) with and PU (ß=3.11, 95% CI 2.92 to 3.30, p<0.01; OR 2.55, 95% CI 2.37 to 2.75, p<0.01) of online learning. Moreover, the higher the students' learning phases, the lower the associations between PU and students' evaluation of and satisfaction with ongoing online education. CONCLUSIONS: Medical students in China have experiences with various online learning modes. Prior learning experiences are positively associated with students' evaluation of and satisfaction with current online education. Higher learning phases, in which clinical practices are crucial, and high academic performance led to lower evaluation and satisfaction scores.