Introduction

Standardised Training for Resident Doctors (STRD) encompasses systematic and standardised training provided to medical graduates during their tenure as resident physicians at accredited training bases. This form of education plays a pivotal role in enhancing clinical abilities of healthcare professionals following the completion of medical college education.1 2 As a crucial component of postgraduate medical education, STRD fulfils the imperative need for physicians to gain comprehensive clinical experience. Over the course of several years, residents engage in continuous skill refinement and knowledge acquisition guided by experienced supervising physicians.3 4 This structured training framework serves as a cornerstone for shaping competent and adept healthcare professionals and ensuring a seamless transition from medical education to clinical practice.

In the late 19th century, the USA and other nations embarked on initiatives to develop standardised training for residents. Over time, these efforts have evolved into more comprehensive STRD systems, reflecting the country’s sustained commitment to improving and strengthening resident education.5 As a developing country with a population exceeding 1.4 billion, China has witnessed significant economic and societal advancements. As the economy progresses and living standards improve, there is a growing demand for elevated healthcare services, reflecting the heightened expectations of the population.6 7 The inception of residency programmes in China dates back to 1988, when the first programme was established in Shanghai, setting a pioneering precedent for other provinces and municipalities.8 Acting as a trailblasing city, Shanghai introduced the STRD programme in 2010 to establish quality benchmarks for residency training.8 9 A significant milestone occurred in December 2013 when seven departments, including the National Health and Wellness Commission, jointly issued the Guiding Opinions on the Establishment of a System of Standardised Training for Resident Physicians, marking the substantial launch of China’s residency training. The standardised training of resident physicians in China covers clinical medicine (27 majors, including General Medicine, Neurosurgery and Pathology) and stomatology (seven majors, including General Dentistry, Oral and Maxillofacial Surgery major and Orthodontics). Before entering the STRD programme, medical graduates must complete at least a 5 year undergraduate medical/dentistry education programme. Medical graduates must then enrol in a 3 year regular STRD programme.10 The Chinese Medical Doctor Association’s (CMDA) Graduate Medical Education Department has established unified training and evaluation systems and updated them. CMDA accredits training bases, conducts regular accreditations, adjustments, and supervision to align with latest standards. After completing the STRD programme, some physicians may pursue further sub-specialty fellowship training, which can stretch to an additional 3 years, depending on the field. Medical graduates can take medical license exams after the first year of the STRD, which assess their foundational knowledge and readiness for continued residency training. This early certification helps ensure that residents possess the competencies necessary to advance in their specialty. Obtaining a medical license is a prerequisite for participating in the STRD graduation examinations. Furthermore, both an STRD graduation certificate and a medical license are required for autonomous practice and career progression. After over nearly a decade of exploration and development, the residency training system has undergone considerable refinement; however, there remains a need to bolster the quality of residency training. Resident satisfaction is widely acknowledged as a crucial indicator of the overall quality of residency training,4 11 making it particularly important to improve resident satisfaction.12 13 Guizhou Province also implemented residency training base certifications and programmes in 2014 under CMDA’s guidance.

Situated in the western region of China,14 15 Guizhou Province grapples with imbalances in regional socioeconomic development and faces challenges related to a shortage of healthcare professionals.16 According to the 2022 China Health Statistical Yearbook,17 the number of health technicians per 1000 people in Guizhou Province is 8.03 (including doctors, nurses, pharmacists, and laboratory technicians), far lower than that in Beijing (13.20) and Shanghai (9.20). This underscores the pressing need to enhance the standardised residency training system in Guizhou Province, which is a crucial step towards nurturing a cadre of proficient healthcare professionals to address the region’s healthcare demands.

We hypothesise that the satisfaction levels of resident physicians with STRD in Guizhou Province, China, may be related to factors such as their age and income. Through a questionnaire survey of physicians who have completed residency training in Guizhou Province, we aim to analyse the determinants of satisfaction with residency training, validate the research hypotheses, gain a deeper understanding of the challenges faced in the standardisation of residency training in Guizhou, and provide information on policy measures to effectively intervene and improve the quality of residency training in Guizhou. Additionally, this study aims to provide a reference for other regions and countries to address similar issues in residency training programmes.

MethodStudy design and setting

This study employed the satisfaction survey from Guangxi Province, China.18 The survey had a p-value (84.66%). The reason for using this survey is that there is currently no research on the satisfaction survey of resident physicians in Guizhou Province, Since Guangxi Province in China is adjacent to Guizhou Province, with a similar population size, and also a multi-ethnic province,19 we selected Guangxi Province’s data to calculate the sample size.

The sample size was determined using the formula:

n=z²p(1−p)/d²,

where n=sample size, z=statistic for level of confidence, p=expected prevalence and d=precision. The minimum required sample size was calculated as 199 individuals. This study adopted simple random sampling, and the specific steps are as follows:

Determining the Overall Scope and Assign Numbers: A total of 11 916 resident physicians who completed STRD since 2017 were identified for the study. These individuals were assigned numbers ranging from 00 001 to 11 916 to facilitate the generation of a random number table.

Selecting Sampling Units: Starting from the first number in the random number table, we extracted one random number every 10 digits, resulting in the selection of 1192 random numbers. Due to various reasons, such as unwillingness to participate and loss to follow-up, 1126 participants agreed to participate in the survey.

Deleting Invalid Questionnaires: Invalid questionnaires included those with anomalies (eg, age listed as a single digit or three-digit number, or other clearly implausible values) and those with low completion rates (eg, missing basic information such as age and gender). After excluding 56 questionnaires, 1070 subjects were ultimately included in the study, meeting the minimum sample size requirement.

Thus, out of the 11 916 resident physicians initially identified, 1070 participants who completed all questions on the questionnaire and met the inclusion criteria were included in the final analysis. The data of all trainees are managed synchronously by the CMDA, which is equivalent to the Accreditation Council for Graduate Medical Education in the USA, and the Health Commission of each province. The data for trainees in Guizhou Province are also managed in the same manner. The data include basic information such as the trainees’ name, age, gender, ethnic group, alma mater, name of training bases and training major. When trainees apply for standardised training, they update the relevant registration information themselves. After passing the exam and obtaining the qualification for standardised training, each training base reports the information of the trainees admitted to the CMDA and Health Commission. This database ensures that the accurate time for students to participate in standardised training and the time to take the graduation examination on schedule are accurate. The issuance of the final graduation certificate for standardised training also requires verification through the database.

Participants’ inclusion and exclusion criteria

Residents who completed residency training between 2017 and 2023 were included, whereas those who were still in training and those who had not participated in the STRD programme were excluded.

The reasons for not completing the STRD were as follows: (1) standardised training for resident physicians in China was officially implemented in 2014, with a training period of 3 years. STRD can only be completed after passing the graduation assessment, and some students fail the assessment and are unable to complete STRD; (2) some resident physicians are unwilling to participate in STRD for personal reasons, such as changing careers or dropping out during training.

Informed consent

The participants were informed of the purpose of the study, the procedures involved, potential risks and benefits, the voluntary nature of their participation and signed a written informed consent form before participating in the study. The participants were guaranteed that their answers will be kept confidential and that they had the right to withdraw from the study at any time without any consequences.

Questionnaire design and validityDesign

The survey questionnaire used in this study is derived from a document titled ‘Letter of the Chinese Medical Doctor Association on the request for assistance in carrying out the questionnaire survey on the implementation effect of the National Standardized Residency Training system in 2022’.20 The content included resident demographic information (gender, ethnicity, age, education, place of origin, etc.), resident training base information (enrollment year, level of training base, type of identity, graduate assessment time, year of passing the medical licensing examination, etc.) and satisfaction surveys (teaching and learning activities, appraisal system, opportunities for clinical practice, teaching faculty, instructors, dormitories, cafeterias, treatment, etc.). Education is categorised as associate’s degree, bachelor’s degree, master’s degree and doctorate degree. The place of origin indicates whether the resident physician was from within Guizhou Province or outside Guizhou Province. The year of enrollment represents the year in which the resident physician joined the STRD programme, categorised from 2014 to 2019. The level of the training base includes provincial and municipal hospitals. The type of identity explains the status of residents prior to their enrollment in the residency training programme. This includes individuals who were unemployed social personnel, employees from hospitals and postgraduate students currently pursuing master’s degrees. This study categorises ‘type of identity’ into social recruiters, employees of the base hospital, employees of other hospitals and students in master’s programmes. Graduate assessment time represents the time taken by the resident doctors to complete the STRD programme. Normally, STRD is completed in the third year after enrolment, which we categorised as ‘in the year of STRD graduation’. Some resident physicians may not have completed the STRD on time for personal reasons. Based on the completion time, we categorised it as ‘in the year of STRD graduation’, ‘the second year after STRD graduation’, ‘the third year after STRD graduation’, and ‘the fourth year after STRD graduation’. The year of passing the medical licensing examination indicates when resident physicians pass the medical licensing examination. Resident physicians are generally expected to complete the medical licensing examination in the first year after entering the STRD programme; we categorised this as ‘first year’, “second year’, ‘third year’ and ‘fourth year’. These detailed descriptions should provide a clearer understanding of the significance of each variable and its specific categories. This study questionnaire adopts a Likert 5-point scoring system: very satisfied, 5; somewhat satisfied, 4; average, 3; somewhat dissatisfied, 2; and very dissatisfied, 1. In this study, we classified ‘very satisfied’ and ‘somewhat satisfied’ as satisfied, and ‘average’, ‘somewhat dissatisfied’, and ‘very dissatisfied’ as dissatisfied.18

Validity

The questionnaire used in this study was validated using reliability and validity tests. The reliability of the questionnaire was tested using Cronbach’s alpha, which overcomes some shortcomings of the split-half method and is the most commonly used reliability analysis method in social science research. It is often used to determine whether the design of a survey questionnaire is reasonable and whether it can accurately reflect the actual situation of the respondents. The questionnaire in this study was divided into five dimensions: job satisfaction, teaching satisfaction, training assessment satisfaction, mentoring satisfaction and training opportunity satisfaction. The Cronbach’s alpha for the questionnaire was 0.978, indicating high reliability. The validity of the questionnaire was tested by an exploratory factor analysis. The Kaiser-Meyer-Olkin (KMO) test was used to check the partial correlation among the variables, and the KMO value was 0.977, indicating high suitability for factor analysis. Bartlett’s test was used to determine whether there was a strong correlation among the variables, with a p value of less than 0.001 indicating a strong correlation and suitability for factor analysis. The cumulative variance contribution rate of the factor analysis was 67.751%, which is greater than 60%, indicating good validity.

Quality control

Before the survey, the Science and Education Department of the Health Commission of Guizhou Province sent letters requesting their cooperation to all STRD training bases in Guizhou Province. Training was provided to the management personnel of each STRD training base to ensure that they could explain in detail the purpose and significance of the survey, specific requirements and precautions for filling out the questionnaire. It was emphasised that the questionnaire was anonymous and would not disclose the respondents’ privacy. The experts invited to participate in the questionnaire design modification held titles of associate chief physician, associate professor or higher or were experienced teaching instructors with over 5 years of experience teaching resident physicians.

Statistical methods

Statistical descriptions were performed using component ratios. Binomial distribution tests were used for specific satisfaction situations, X2 tests were used for between-group comparisons, and binary logistic regression analyses were used to analyse the associations between residency satisfaction and related factors by calculating odds ratio stats (ORs) and 95% Confidence Interval stats (CIs) . Questionnaire database creation to minimise potential bias was done using double-entry methods. Questionnaires with missing data were excluded from analysis. The test level α=0.05; all analyses were completed using SPSS 29.0 (IBM Corp., Armonk, NY, USA, Version 29.0) software.

Patient and public involvement

The design of this study referred to the ‘Letter of the Chinese Medical Doctor Association on the request for assistance in carrying out the questionnaire survey on the implementation effect of the National Standardized Residency Training system in 2022’ and consulted epidemiological experts. The subjects did not participate in the design, implementation and analysis of this study, nor did they participate in the writing or interpretation of the research results.

Discussion

Since the initiation of STRD in Guizhou Province, China, in 2014, there have been 24 national residency training bases. The growing emphasis on STRD in recent years underscores the need to enhance the quality of residency training in Guizhou Province. Conducting resident satisfaction surveys has been proven to be an effective and efficient means of comprehending the challenges within the realm of resident training. This approach facilitates the identification of specific issues, allowing for the formulation of targeted improvement measures to enhance the overall quality of resident training.

This study conducted a satisfaction questionnaire survey targeting all graduate residents who completed residency training in Guizhou Province from 2017 to 2023. The residents in this survey were mainly residents of Guizhou Province (90.9%), with slightly fewer trainees from provincial residency training bases (49.3%) than those from municipal residency training bases (50.7%), and mostly from ethnic minority backgrounds (66.1%),21 22 in line with the characteristics of the multi-ethnic province of Guizhou.14 The male-to-female ratio was 1:1.14, which is in line with the trend of the proportion of female physicians being higher than that of males in China.21 22 The average age was generally above 25–26 years (99.2%), which is in line with the current situation where the majority of Chinese medical graduates need to complete 5 years of medical undergraduate education8 before entering the STRD. Among the residents who participated in the survey, the majority were recruited from the society (32.1%) and assigned by outside hospitals (40.1%), indicating that the standardised training system of resident doctors in Guizhou Province has been widely recognised and positively responded to by society; notably, it was not just master’s students who participated in the STRD.

The results of this survey showed that the level of residents’ satisfaction ranged from 2.1% dissatisfied, 2.3% somewhat dissatisfied, 26.4% average, 45.4% somewhat satisfied and 23.8% very satisfied, and the overall satisfaction was 69.2%, indicating that there is still room for the improvement in the residency training work in Guizhou Province, China. It is worth noting that, except for the residents dissatisfied with income (63%), the number of satisfied residents in all other residency training-related systems reached more than 60%. Thus, we can conclude that, except for income, the residency training system in Guizhou Province was satisfactory for most residents.

Among them, the probability of women being dissatisfied with the residency training system was 1.509 times higher than that of men, which may be because female residents have fewer hands-on opportunities during clinical practice than male residents23 or perhaps because female resident physicians are more likely to face gender discrimination.24 The probability of being dissatisfied with the residency training system for residents aged 27–28 and aged 29 years and above is 2.719 and 1.524 times higher than that of those aged 23–24 years, respectively, which reflects that the satisfaction level of older residents is lower due to the pressures of life and the imperfections of the STRD system at that time. Imperfections in the residency training system led to lower satisfaction, and with increasing attention from both the national government and Guizhou Province, along with the promotion and continuous improvement of the residency training system, management personnel at all levels have come to a deeper understanding of the importance of the residency training system. Consequently, this has contributed to an enhancement in the satisfaction levels of resident doctors.2 25 The probability of trainees being dissatisfied with the residency training system in Guizhou Province who participated from 2016 to 2019 was 4.159, 2.034, 1.959 and 1.696 times higher than in 2014. We noticed a progressive decline in dissatisfaction levels among resident physicians with the residency training system in Guizhou Province over time. This decline, when compared with the initial stages of the programme’s implementation, indicates that the enhancements made to the residency training system in Guizhou yielded positive outcomes.

Income was one of the most critical factors influencing resident physicians’ satisfaction levels. This indicates that the average monthly income is the residency training system’s protective factor. This is because most of the residents are freshly graduated medical undergraduates, facing greater economic pressure (such as renting costs, marriage expenses, etc.), and the higher the demand for income and the higher the income, the more stable the future of the resident physician during their training period, which is conducive to the residents’ peace of mind regarding their training and learning. This in turn will lead to higher levels of satisfaction with the residency training.26 Some studies show that the satisfaction rate of residency training among radiology residents in Germany is 78%,27 the satisfaction rate of residency training among obstetrics and gynaecology residents in the USA is 94%28 and the satisfaction rate reported in a residency standardisation satisfaction survey from Mexico is 82.5%.29 However, direct comparisons are challenging due to significant differences in training models. For example, the US medical education and residency training are considered successful models of Western education but differ significantly from China’s STRD. In the USA, applicants must complete a 4 year undergraduate degree in science, clear the Medical College Admission Test (MCAT) and undergo 4 years of medical school, whereas in China, applicants must complete a 5 year undergraduate medical education before applying for residency training.30 Additionally, the training duration in the USA is more flexible, whereas in China, it is fixed at 3 years.31 32 The US residency training system is also more standardised, with senior teaching physicians dedicating more time to mentoring.33 34 Because of these differences, we compared satisfaction rates within China, focusing on provinces with economic conditions similar to those in Guizhou. For instance, the satisfaction rate in Guangdong Province was 60.3%35 and 84.66% in Guangxi Province,18 and in Gansu Province, 68.44% of residents believed that STRD was necessary.6 Our study found a satisfaction rate of 69.2% in Guizhou Province, indicating some recognition of the programme’s value, but also highlighting considerable room for improvement.

This implies that, compared with other developed countries and economically better-off provinces in China, Guizhou Province still has deficiencies in the standardisation of residency training for physicians. Residency training must be continued and improved for a long period of time and involves many aspects, such as teaching/instructors, training bases and financial investment.

This study reveals that training bases in Guizhou Province should integrate residency training into the key function of hospitals, continually improve the residency training system, innovate methods and approaches and enhance training quality. The following are some suggestions of this study: first, it is crucial to improve the income of resident doctors. Training bases should increase the income of resident physicians, which will help improve their overall satisfaction and focus more on training, thus enhancing the quality of training. This requires increased financial investment in resident doctors by all training bases and not just relying on national or local government subsidies. Second, it is recommended that medical undergraduates enter the STRD immediately on graduation, rather than after a period of work. This will help maintain the continuity of learning for medical graduates. Finally, improving the teaching quality of STRD is an effective measure that can help resident physicians efficiently acquire professional knowledge and skills. Enhancing the quality of teaching will contribute to higher satisfaction and better training outcomes for resident physicians. Although the relative shortage of health technicians in the region could be attributed to the quality of the STRD, it may also be related to the economic development level, educational level and basic medical and healthcare facilities in the area. This indicates limited medical education resources in the region, which cannot be ignored and has guiding significance for future research.

Strengths and limitations

The strengths of this study are as follows: first, it comprehensively covers the perspectives of graduates from a wide range of hospitals across Guizhou Province, providing a broad view of the standardised training programme’s effectiveness. Second, this study initiates a preliminary satisfaction survey among the graduates of the standardised training programme for resident doctors across Guizhou Province. As an initial effort, it addresses a notable gap in the literature by offering foundational data and insights that were not previously accessible.

This study also has some limitations. First, although all survey respondents were from various residency training bases in Guizhou Province, the data collected could not satisfy the need for a detailed analysis and discussion of resident satisfaction in each specialty. Second, the questionnaires were anonymous and voluntary, resulting in the uncoupling of the participants’ identities from their responses.36 Third, this study used a cross-sectional survey, which did not allow for the inference of causality; the next step in the study could be a cohort study with longitudinal comparisons to determine factors influencing resident satisfaction. Finally, although the quality of STRD is an important factor leading to a shortage of regional health technicians, the impact of other factors such as the economic development level, educational level, and basic medical and health facilities in the region cannot be ignored.

Conclusion

Based on this study, we validated our hypothesis that the satisfaction of resident physicians with STRD in Guizhou Province is related to their age and income. At the same time, the results also revealed that gender, level of the training base and years of training are all correlated with satisfaction with the STRD. Therefore, Guizhou Province should adopt adequate measures to improve the satisfaction of resident physicians with regard to their training, such as by enabling them to participate in the STRD as early as possible, increasing their income and improving the quality of training, thereby promoting the enhancement of the quality of resident physician training in Guizhou Province.