Background

With the national health policy change in China, and the impact of public health emergencies on the medical and health industries, colleges and universities were required to continuously adjust talent training programmes and cultivate clinicians who met the needs of clinical positions. The construction objectives and tasks of ‘Healthy China’ were first proposed at the Health and Wellness Conference held in China in 2016. The main thrust of the Chinese healthcare system was to achieve the transformation from treating diseases as the core of healthcare to providing health and wellness services throughout a person’s life cycle [1]. Accordingly, this required colleges and universities to cultivate medical talents, not only to teach them to treat patients, but also to allow them to master the knowledge of prevention and provide full-cycle services for their patients’ health. In October 2018, to implement the spirit of national policy documents, the Ministry of Education of China, the National Health and Health Commission, and the State Administration of Traditional Chinese Medicine issued ‘The Opinions on Strengthening the Collaboration between Medicine and Education to Implement the Excellent Doctor Education and Training Program 2.0’. This was a proposal to promote competency-oriented education and teaching reformation, thereby focusing on improving the professional literacy and clinical practice ability of medical students [2]. At the beginning of 2020, the coronavirus disease 2019 (COVID-19) pandemic spread, and the medical industry faced huge pressures and challenges. While doctors remained at their posts, they experienced problems in their work, such as lack of public health knowledge [3], interruption of health care services [4], insufficient self-protection ability [33] believed that assessing learning needs was a key step in continuing education. Lifelong learning ability combined the knowledge needs of clinical specialists and general practitioners and extracted the humanistic learning content, such as psychology, mental health, and law, that clinicians in China lacked [34]. Moreover, it included community health management abilities such as the treatment, management, and health education of common community diseases [35].

Thinking and judgement ability

Referring to Li Zhongyan’s [36] elaboration on the concept and definition of clinical thinking ability by domestic and foreign scholars, thinking and judgement ability summarised and prepared items that could reflect the thinking and judgement ability of doctors in the process of clinical diagnosis and treatment. This included procedures such as establishing auxiliary examinations, offering differential diagnoses, and making clinical decisions in combination with the clinical information of patients.

Medical humanistic literacy

Public health emergencies and frequent medical disputes exposed the existing problems in the improvement of humanistic literacy in medical education in China. It was then considered necessary to pay attention to the cultivation of quality, including medical service spirit, doctor-patient communication ability, medical ethics, and medical psychological skills [37,38,39].

International exchange vision

The document, ‘Promoting the Joint Construction of ‘One Belt and One Road’ Education Action’ issued by the Ministry of Education of China in 2017, mentions that universities along the line were encouraged and supported to jointly cultivate medical professionals. This endeavour highlighted the direction for medical education to cultivate medical talents with international vision, such as international knowledge reserve, cross-cultural communication ability, and world vision [40, 41]. Table 1 shows specific scale dimensions and measurement items.

Table 1 An initial model of clinician training elements in the new era
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Subjects

Before we conducted this study, the design method was approved by the ethics review committee of the school. All the participants were informed of the purpose of the study and volunteered to take part in it. Their personal information was kept anonymous.

We operated according to the principle that the sample size should be greater than five times the number of items in the scale. Therefore, from July 7, 2022, to August 10, 2022, a stratified sampling survey method was used to investigate the clinicians in Chinese medical posts using Sojump, an online crowdsourcing platform in mainland China. This service provides functions equivalent to Amazon Mechanical Turk (MTurk) to receive and send the questionnaire; additionally, the survey scope involved the eastern, central, and western regions of China with certain representativeness. A total of 1,086 questionnaires were distributed, and 1,068 valid questionnaires were received, with an effectivity rate of 98.34%, hence the quantity met the requirements. Among them, the sex distribution was 515 males (48.2%) and 553 females (51.8%). The age distribution was as follows: 335 (31.4%) aged 30 and below; 267 (25%) aged 30 to 35 years old; 205 (19.2%) aged 36 to 40 years old; and 261 (24.4%) aged over 41 years old. From a regional perspective, 915 cases were collected in the eastern region, covering the seven provinces of Shanghai, Zhejiang, Hainan, Jiangsu, Fujian, Guangdong, and Shandong, with 341 hospitals. Subsequently, we collected 91 cases from the central region, and the survey subjects were from five hospitals in the two provinces of Anhui and Jiangxi. A total of 61 cases were collected in the western region; specifically, the data came from nine hospitals in the five provinces of Gansu, Guangxi, Sichuan, Yunnan, and Chongqing. Notably, one copy from Northeast China was collected from Jilin Province. According to the classification of China’s tertiary diagnosis and treatment system, 190 were collected from first-level hospitals such as community health service centres and township health centres; 165 were collected from second-level county hospitals; and 713 were collected from third-level general hospitals. The need indicators were scored using the five-point Likert scale and assigned 1 to 5 points with the following choices: ‘really not needed’, ‘not needed’, ‘fair’, ‘more needed’, and ‘really needed’, respectively. The higher scores indicated that clinical posts had a stronger need for this knowledge. SPSS 26.0 and Amos 24.0 software were used for the statistical analysis of the data.

Results

Project analysis

The item analysis of the questionnaire was conducted using the critical ratio (CR) method and the homogeneity test method. The CR method was implemented as follows: the top 27% of the total score of the surveyed subjects were set as the high group, and the bottom 27% as the low group. Two independent samples t-tests were used for the two groups. The items whose critical ratio between the two groups did not reach a significant level (t < 3 or p > 0.05, at this time, the t value is the CR value) were deleted. The homogeneity test method was implemented as follows: Pearson’s product-moment correlation method was used to calculate the correlation between the total score of the scale and each item; furthermore, the items with a correlation coefficient r < 0.4 were deleted, indicating that those items had a low correlation to the scale theme. Table 2 shows the results.

Table 2 Project analysis results
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As can be seen from Table 2, all the t values of the 67 items exhibited positive and significant relationships (t > 3 and p < 0.001); moreover, the correlation coefficient r values between each item and the total score ranged between 0.492 and 0.848 (p < 0.001). Therefore, all 67 items were retained.

Construct validity

Exploratory factor analysis

The Kaiser–Meyer–Olkin (KMO) test for sampling adequacy and Bartlett’s Sphericity Test (BST) to measure the homogeneity of variance were assessed on 67 items. The BST was significant (p < 0.001) and the KMO value was 0.979, which was above the commonly recommended value of 0.6, indicating that the data were suitable for factor analysis. We conducted a principal components analysis (PCA) with a varimax orthogonal rotation. Based on the existing research [42], items with a lower load factor than 0.4 and a cross load in each dimension were excluded. Specifically, these items were B6, B7, B8, B9, E3, G3, G4, G5, G6, G7, and others in Table 1, and the factor loadings of the remaining 57 entries were all between 0.423 and 1.043. The final PCA analysis revealed the presence of eight PCs with eigenvalues of > 1, thereby explaining 78.542% of the variance (Table 3). In addition, examining the scree plot showed an inflection, which justifies the retention of the eight factors (Fig. 1). The medical theoretical knowledge in Table 1 was divided into two factor models, namely ‘PC 5 interdisciplinary knowledge’ and ‘PC 8 basic clinical knowledge’, according to the factor contribution. Thinking and judgement ability and medical humanistic literacy were combined into one factor model, which integrated thinking and judgement ability into medical humanistic literacy. Moreover, PC 6 was renamed ‘clinical skill operation’ because of its content.

Table 3 Construct validity by principal component analysis using varimax rotation
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Fig.1
figure 1

Screen plot

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Confirmatory factor analysis

The fitting degree of the above model was verified in Table 3 according to the following eight latent variables: medical humanistic literacy, technological innovation capability, international exchange vision, lifelong learning needs, interdisciplinary knowledge, clinical skill operation, public health knowledge, and basic clinical knowledge. The results showed that the five indicators of Chi-squared degrees of freedom ratio (χ2/df), comparative fit index (CFI), Tucker-Lewis index (TLI), normative fit index (NFI) and incremental fit index (IFI) did not meet the reference value requirements.

The initial model was revised according to the modification indices (MI). The entries C1, D9, E6, G8, G9 and H4 that were strongly correlated with multiple dimensions were eliminated, and the residual items e58 and e59, e61 and e62, e29 and e31, e33 and e34, e39 and e63, e49 and e50, and e52 and e53 were established. After the correction, the fitting indices all reached the model fitting standard [42]. The fit of the revised model was better. Table 4 presents the revised culture element model, Table 5 shows the specific indicators of model fitting, and Fig. 2 illustrates the revised fitting path diagram.

Table 4 A revised model of clinician training elements in the new era
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Table 5 Confirmatory factor analysis fitting results
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Fig. 2
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Fitted path diagram after correction

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Convergent validity

Table 6 shows that the average variance extraction (AVE) of each dimension was greater than 0.5. Furthermore, the combined reliability was greater than 0.6, indicating that the convergent validity of the entire scale was obvious.

Table 6 AVE and combined reliability values of each dimension of the scale
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Discriminant validity

As shown in Table 7, there was a significant correlation between basic clinical knowledge, interdisciplinary knowledge, clinical skill operation, public health knowledge, technological innovation capability, lifelong learning needs, medical humanistic literacy, and international exchange vision (p < 0.001). Most of the correlation coefficients between variables were in the range of 0.1 to 0.7, and all were less than the square root of AVE, suggesting good discriminant validity.

Table 7 Discriminant validity of training elements scale
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Reliability

All measures of the two types of internal consistency reliability were satisfactory for each dimension of the revised Training Elements Scale (Table 8). The Cronbach’s alpha coefficient of the full scale was 0.981, and the split-half reliability was 0.903. The minimum value of the total reliability and the reliability indicators of each dimension were all greater than 0.8. These observations showed that the scale had good internal consistency, stability, and reliability.

Table 8 Reliability
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Discussion

Scale items reflect the requirements of the times

This research was conducted under the background of the new era and a new trend of demand for high-quality and diversified development of medical education in the post-pandemic period, characterised by the Chinese government attaching great importance to public health, as well as promoting the implementation of its ‘Healthy China’ strategy [43]. Reviewing the relevant literature, we found that researchers in the new era are behind in presenting research on constructing a model of training elements to guide medical education in colleges and universities based on the needs of clinicians. In contrast, the research on constructing a job competency model is relatively abundant. Presently, there are the Huang Qixiang’s clinical resident competency model, Zhang **ujun’s clinician’s post competency model, Huang **aoling’s excellent medical talent competency model, Professor Sun Baozhi’s general model of clinician job competence, Ronald M. Epstein’s competency model, and others [44]. Compared with the above studies, the model constructed in this study takes the job requirements of clinicians as the starting point, and establishes the internal linkage of doctors, colleges, and students, which helps to provide more specific target directions for medical education reform and student learning in colleges and universities. The preparation of the scale is guided by important documents such as the Chinese government’s ‘Opinions on Strengthening the Collaboration between Medicine and Education to Implement the Excellent Doctor Education and Training Program 2.0’ and ‘Guiding Opinions on Accelerating the Innovative Development of Medical Education’ [2, 7]. Among them, the dimension of medical humanistic literacy is a reflection on the current situation of ‘emphasising theory and ignoring humanities’ in medical education in China. It is also a manifestation of the lack of medical humanities in clinical cures exposed in the fight against the COVID-19 pandemic. The development of medicine contains the nourishment and cultivation of the humanistic spirit. Given this, strengthening humanistic medical education is the historical mission and important responsibility of contemporary medical educators [45]. Additionally, original clinical thinking in the dimension of medical humanistic literacy emphasises the integration of humanistic care into the whole process of clinical diagnosis and treatment, which contributes to improving the quality of medical services and highlights the humanistic characteristics of medicine, not just the treatment of the disease itself. There is an emergence of new specialties, such as materials medicine, smart medicine, and precision medicine, that exist within the framework of the intersection between medicine and big data, medicine and humanities and social sciences, and medicine and artificial intelligence [43]. This connection shows that the knowledge content of interdisciplinary knowledge in the new era needs to be strongly emphasised in the teaching of medical students. Therefore, the original theoretical medical knowledge dimension is divided into two dimensions: clinical basic knowledge and interdisciplinary knowledge.

The dimensions of the scale model are comprehensive and extensive

The scale builds a model of clinician training elements in the new era, covering the eight dimensions, including basic clinical knowledge, interdisciplinary knowledge, clinical skill operation, public health knowledge, technological innovation capability, lifelong learning needs, medical humanistic literacy, and international exchange vision. Basic clinical knowledge is the focus of the entire medical undergraduate education as well as the starting point for the cultivation of clinical thinking ability [22]. Interdisciplinary knowledge is the product of the era in which medical education actively adapts to the new scientific and technological revolution and the new industrial revolution, and is the basis for the application of cutting-edge clinical diagnosis and treatment technologies, diagnosis and treatment decisions, and health management [43]. Clinical medicine is characterised by strong practice and strong skills, which requires medical students to be proficient in clinical skills operation [46]. Public health knowledge is a weak link in the current ‘big health’ and ‘full cycle’ medical training system. Therefore, strengthening the integration and application of public health knowledge will help reconstruct the public health system and improve the structure of medical personnel training [47]. The strategic position of medical science and technology is becoming increasingly prominent in health maintenance, and cultivating medical students’ scientific and technological innovation abilities is the reserve force for the implementation of the ‘Healthy China’ strategy [48]. As a profession of continuous development, doctors should be committed to the concept of lifelong learning and propose requirements for the culture and curriculum of lifelong learning [49]. The combination of medical humanistic literacy and medical science practice is an urgent need to achieve the goal of humanised medical care [50]. Hence, improving medical students’ vision of international exchanges is of great benefit to promoting the common development of medicine worldwide, broadening the field of international exchanges, and enhancing the international competitiveness of China’s medical education system [51, 52]. The model constructed in this study, from college education to post-graduation education and continuing education, from the professional knowledge of the first classroom to the humanistic literacy of the second classroom, to the expansion of international vision, fully integrates all elements of a medical student’s growth, indicating that the scale can comprehensively reflect training elements of clinicians.

The research scope is representative of the population

The reform of tertiary medical institutions has been implemented in China to reasonably allocate medical resources and alleviate the difficulty of seeking medical treatment in large hospitals. The township health centres and community hospitals are classified as first-class hospitals, which are mainly responsible for the prevention, medical treatment, and health and rehabilitation services in certain areas. The county hospitals are classified as secondary hospitals, which mainly undertake multiple community comprehensive medical and health services and certain teaching and scientific research tasks. A general hospital with a tertiary class A designation is classified as a tertiary hospital, mainly providing high-level specialised medical and health services and higher education teaching and scientific research tasks [53]. In this way, a whole-process, seamless health management system has been constructed so patients can seek reasonable medical and health services at a proper medical level at a reasonable medical and health institution [54].

Based on China’s new reform background, we conducted surveys of clinicians in tertiary medical institutions, reflecting the comprehensiveness and representativeness of Chinese doctors’ job requirements. The goal of the training of medical skills in colleges and universities is to transport these abilities to the whole society, especially in the undergraduate stage of clinical medicine. Furthermore, it is particularly important to comprehensively investigate the needs of different medical institutions for the training of clinicians in order to conduct the establishment of a solid foundation, wide calibre, and strong practice.

Practical application analysis of scale model

The scale model can be used in various ways. First, in the educational stage of colleges and universities. In revising the training program for clinical medicine professionals, medical colleges and universities can refer to the capacity training needs of clinical doctors in the new era and integrate the eight dimensions into the training programmes. For example, in earning content for new medical fields such as artificial intelligence, precision medicine and other interdisciplinary knowledge, it can guide colleges and universities to set up "Introduction to Artificial Intelligence and Big Data", "Intelligent Analysis of Medical image" and similar courses. To cultivate scientific and technological innovation ability, it can guide colleges and universities to use the second classroom to carry out students' scientific research design and project application training and other content. Since college education offers comprehensive cultivation of students' knowledge and ability, the content of the scale needs to run through the whole process of undergraduate clinical medicine education. Secondly, it is useful in the post-graduation education stage. Doctors at this stage have been engaged in clinical work, and the training content required by doctors at different levels of medical institutions has different emphases. Therefore, doctors in clinical institutions can score the needs of the scale of training factors according to their own needs. For example, we can set 1–5 points for each option of the scale or set "Yes or No" options. 1–5 points indicate the intensity of the training demand content intention, and the training content can be set according to the intensity of the demand of each dimension. We can also directly choose "Yes or No" options. Training content is also set according to the needs of doctors at different levels of medical and health institutions. Finally, after doctors are trained, they can also self-test and score the the eight dimensions, and conduct self-assessment according to their mastery of the training content. For those who think that the training content has not reached the desired level of training, they can arrange further training. Such demand-oriented training education can also stimulate the doctors’ learning autonomy. You can examine your lack of knowledge in clinical work on the content of the training scale, and regularly participate in all kinds of relevant knowledge training.

Conclusion

The Scale of Factors for Training Clinicians in the New Era has good reliability and validity, and the survey results can be used as reference for the training of clinicians in China in the new era. The questionnaire is comprehensive and easy to understand. It can be widely used in medical colleges and universities as a reference for reforming medical training content. It has significance for the reconstruction of theoretical teaching content and the strengthening of practical teaching projects. In particular, it provides a new ddirection for medical students in terms of increasing the weight of humanistic spirit training and expanding their global vision. It can also be widely used in the continued education of clinicians after graduation. This could make up for the lack of knowledge of doctors in the process of clinical work, improve the content of continuing education of doctors, and provide a reference for doctors' lifelong learning content.