Compulsory rural service directed medical student free training program is a medical education policy oriented to the cultivation of high-quality general medical talents for primary care system in rural areas, and is an important initiative to deepen the reform of the pharmaceutical and health system and accelerate the construction of a "healthy China", which is an important foundation for implementing the "poverty removal" and promotion of sustainable development of "poverty alleviation by health". Policy of compulsory rural service directed medical students free training program was designed scientifically and rationally, effectively combining motivating mechanisms with compulsory mechanisms, and is continuously refined in the practice process. In the course of policy implementation, various regions of our country have developed their characteristic implementation strategies accordingly in the links of enrollment, training, employment, and contract performance. The program based on the policy educated a large number of qualified GPs for rural primary care system. The compulsory rural service directed medical students fulfilled the contract well, and the career development trend was positive, which contributed to strengthening the construction of the primary health workforce, enhancing the level of primary health service, and promoting the establishment of a hierarchical diagnosis and treatment system. However, during the implementation of the policy, many challenges have been encountered, such as some students' low learning enthusiasm during the training period, limited capacity of local authorities to implement the policy, the need for improvement of pay incentives for primary GPs and the short service cycle. In this paper, we conducted a systematic analysis of the design concept and execution process of the policy of free training for compulsory rural service directed medical students, and suggested that further expansion of scale of the compulsory rural service directed free training program should be conducted to improve the quality of cultivation, enhance the effective collaboration among multiple parties and the contract fulfillment, which will collectively promote the effective implementation of the policy, thereby providing talent support for the hierarchical diagnosis and treatment system and the "Health China" strategy.
Our state policy of free training of compulsory rural service oriented medical students (abbreviated as rural service orientation project) starts with the construction of a team of primary medical health talents and makes an excellent contribution to improve the accessibility and quality of medical services in rural areas of China. A comprehensive understanding of the current state of the rural service directed medical student team is important to evaluate the implementation effect of the free training policy, as well as the long-term development of the primary care health talent team.
To review the research progress of related studies on rural service orientation project in China and similar projects abroad, summarize the execution process and execution results of the projects inductively, and compare the similarities and differences between domestic and foreign studies.
The study was conducted from July to September 2021. A literature search for Chinese language was conducted in CNKI, Wanfang Data Knowledge Service Platform and VIP, and the search time was set from 2010-07-01 to 2021-07-01. A literature search in English was conducted in PubMed, web of science, Scopus, and the search time was set from 2000-01-01 to 2021-07-01. Literature screening was performed according to the inclusion and exclusion criteria, relevant information was extracted, and the literature was classified and analyzed according to the subjects and contents of the studies.
A total of 443 articles were finally included, with 427 of them on our rural service orientation project in China and the rest 16 on similar projects abroad. The research topics that were studied in the literature included four broad categories: cultivation mode, enrollment, training process, and employment development. In 427 related literatures of China's rural service orientation project: 102 (23.9%) discussed the training mode of rural service oriented project. Ten (2.3%) analyzed the admission status of rural service directed medical students and found that rural service directed medical students had higher awareness rate of the related policies (>75.0%-90.9%) and the proportion of rural students sources was higher (57.6%-84.2%). 270 (63.2%) literatures used the cultivation process of rural service directed medical students as a starting point and focused on their learning situation, professional identification and performance willingness, and found that rural service directed medical students had lower academic performance and professional recognition than general clinical medical students. The results of studies on the performance willingness of rural service directed medical students varied greatly (42.4%-98.4%), and the average performance willingness was 66.2% when weighted by sample size. Only 25 (5.9%) studied employment development in rural service orientated graduates and found an average performance rate of 93.6%. Rural service directed medical students had a faster rate of completing standardized residency training and passing practitioner examination than other five-year clinical graduates. Of the 16 foreign related literatures included, 11 (68.8%) examined the employment development of rural service directed medical graduates and obtained results similar to those of domestic studies.
A larger number of current studies focused on rural service oriented project and had rich topics. It was found that the rural service directed free medical student training policy was better implemented, leading to a large number of excellent primary health talents in the Midwest. However, most of the current research focuses on the cultivation stage of rural service oriented medical students, and there is insufficient understanding of medical students who have joined the primary care team at elementary level. Future research should focus on three aspects: performance status after rural service directed medical students having completed the contract period, career development process after employment and the actual role they play in primary health care institutions.
To strengthen the construction of health talents team in rural areas, a national compulsory services program (CSP) was started in 2010 in China. In 2015, the state required graduates of the CSP to participate in a 3-year standardized training for residents (residency) upon graduation.
To understand the participation of CSP graduates in residency, analyze the effect of residency on the pass rate of the practicing physician's examination for CSP graduates, and explore the significance of residency on the training of CSP graduates and the rural primary health workforce, so as to provide policy recommendations for the high-quality training of CSP graduates.
Starting in 2015, a cohort of CSP graduates was established from a total of 4 colleges undertaking CSP training programs in 3 provinces in the Midwest of China, and 1∶1 general clinical graduates who graduated the same year were selected as controls and followed up annually. Descriptive analysis was used to show the status of CSP graduates' participation in residency, the pass rate of the examination for practicing physicians, and to compare them with those of general clinical graduates. Stratified Cox regression was used to analyze the effect of attending residency on the pass rate of practicing physician exams.
86.69% (228/263), 86.78% (361/416), 87.79% (381/434), 91.08% (388/426), 94.43% (356/377) of the 2015—2019 CSP graduates stated that they were willing to participate in training after graduation, and 72.20% (200/277), 58.75% (151/257), 70.42% (169/240), 73.23% (145/198), 61.03% (83/136) of the same general clinical graduates stated that they were willing to participate in training after graduation. The actual participation proportions of CSP graduates in 2015—2019 in residency were 99.02% (202/204), 97.10% (301/310), 94.99% (322/339), 89.91% (285/317), 69.45% (241/347), 67.57% (100/148), 66.12% (80/121), 74.79% (89/119), 43.33% (39/90), 34.62% (27/78), respectively. The pass rate of practicing physician examination in 2015—2017 CSP graduates reached 99.23% (259/261), 94.86% (351/370), 91.74% (311/339), while the pass rate of same general clinical students was 97.74% (173/177), 95.87% (116/121), 88.24% (105/119), respectively. Cox regression results showed that after adjusting for demographic variables, family economic status, intention of studying medicine, medical education, and factors related to attending the residency, the probability of attending the residency group passing the practitioner's examination was 1.232 times higher than that of not attending the residency group 〔95%CI (1.02, 1.49), P=0.03〕.
CSP graduates' willingness to participate in residency training, the proportion of participation, and the pass rate of the qualifying examination for practicing physicians were all high. Participating in residency training can improve the ability of medical graduates and has a promoting effect on passing the qualifying examination of practicing physicians.
Compulsory rural service directed medical student free training program is an important initiative to ameliorate the shortage of health human resources in rural areas of China, and the first graduates of the policy have now completed the contract performance. Analysis of the performance situation and influencing factors of these students is needed to improve the policy of compulsory rural service directed medical student free training program in time and improve and stabilize the performance rate of the rural service directed medical students.
To analyze the employment and performance status of compulsory rural service directed medical graduates of 2015—2019 in four Midwestern medical schools, and to analyze the influencing factors on the performance of the rural service directed medical students, so as to make recommendations to further improve the training policy of the rural service directed medical students.
A cohort of rural service oriented medical students was established from four medical schools including Qinghai University, Guangxi Medical University, Jiujiang college, and Gannan Medical College, and other five-year graduates of clinical medicine from the same session were selected as controls. A baseline questionnaire was administered to graduates before graduation, which included the basic information, family information, job expectations, and so on. An online follow-up survey was conducted annually thereafter and included graduates' employment, performance status, and so on. This study was conducted in July 2021 using data from a baseline survey of graduates of 2015—2019 from four institutions and a follow-up survey from September 2020. A total of 2 041 rural service directed medical graduates and 1 579 other 5-year clinical students were enrolled. Compare the difference in employment between rural service oriented medical graduates and other five-year clinical students. Multivariate Logistic regression was used to analyze the influencing factors on the performance of rural service directed medical graduates.
In the baseline survey, 2.26% (46/2 038) of the rural service directed medical graduates were willing to work in township health institutes. In the 2020 follow-up survey, 86.04% (228/265) of the rural service directed medical graduates chose to work in township health institutes. In a 2018 follow-up survey of 2015 and 2016 rural service directed medical graduates, 43.67% (290/664) of graduates expressed reluctance to remain in township health institutes after the expiry of the contract. 97.48% (1 546/1 586) of rural service directed medical graduates were allocated as personnel in public institution, a higher proportion than other clinical 5-year graduates (P<0.05). The overall performance rate of 5-year rural service directed medical graduates was 97.84% (1 589/1 624), and the results of multivariate logistic regression analysis showed that male gender, desired job location as rural areas in the baseline survey, job having public institution quota, and contract location as home district (county) were the promoting factors for the performance of rural service directed medical graduates (P<0.05) .
Rural service directed medical students are more smoothly employed with high performance rates, and the recruitment of this type of medical students should focus on students who have willingness to work in rural areas and try to contract with the counties where the students are from.
