The issue of the professional commitment of clinical medicine students has long been ignored. Many studies haved explored nursing students’ sense of professionalism due to concerns about the loss of nurses [18, 19]. However, studies on doctors’ sense of professionalism rare. There is a huge shortage of doctors in China. For example, the shortage of anesthesiologists has become a concern for surgeons and is now considered as a social problem. The number of anesthesiologists per 100,000 people in China is only 6.7, compared to 13.8 in the United States and 17 in the European Union. Similarly, according to the Child Welfare Stocktaking Report 2016, there is a serious shortage of pediatricians in China, with only five pediatricians for every 10,000 children. A survey that investigated 54,214 hospitals from all 31 provinces in mainland China showed that the dropout rate of pediatricians has increased to 12.6% [20]. Our previous survey found that about 20% of students majoring in clinical medicine changed careers. Medical students, teachers, schools, and the government all incur huge costs during the long medical study period. However these “dropout” students did not continue to pursue a career as doctors. The following questions remain to be answered: (1) What has led to a change in these students’ initial career plans? (2) Can educators identify this change early and intervene effectively?
Professional commitment can provide insights that help to answer the above questions. The professional commitment in college can reflect the students’ recognition of their major. On the other hand, professional commitment can affect permanence, rotation, and/or abandonment at work [21]. We investigated students in the eight-year clinical medicine program for two main reasons. First, the duration of the eight-year program is quite long, and some studies have shown that anxiety and depression of students are more prominent among these students [22]. Second, these students have very high scores in the college entrance examination and strong professional intentions at the time of admission. The presnt study sought to explore whether these students who enjoy the highest standard of medical training pursue their career as originally planned, and arrived at the following five findings.
First, professional commitment, self-efficacy, and learning engagement were positively correlated with each other. The finding is consistent with those by Kung PC [23] who found a positive relationship between professional commitment and self-efficacy in clinical students. Walter, Juliette K et.al. [24] reviewed the factors influencing nurses engagement and found that professional motivation and organizational commitment are critical factors influencing engagement. Professional commitment, self-efficacy, and learning engagement evaluated the students’ cognition from different observational perspectives. The results showed that students with high professional commitment also had a high sense of self-efficacy and were more enthusiastic about learning.
Second, professional commitment exerts a mediating effect between self-efficacy and learning engagement. Professional commitment, an indicator of students’ subjective feelings about their major, has been shown to have a mediating effect among multiple psychological characteristics. Ying W revealed that professional commitment plays a mediating role between the clinical learning environment and learning engagement in nursing students [25]. Yu Hsingyi found that nursing professional commitment mediated on the relationship between social support, resilience, and intention to stay among newly graduated male nurses [26].
Third, our results found that both professional commitment and self-efficacy could influence academic performance through learning engagement. The impact of professional commitment and self-efficacy were indirect, not direct. Similar to the results of our study, Edlira Muca’s study among veterinary students also found that learning engagement has a positive and direct effect on academic performance, while self-efficacy and academic fit have an indirect effect on academic performance [27]. Academic performance is more directly and closely related to learning engagement, and a change in learning engagement can be directly reflected in academic performance. Learning engagement is a direct predictor of academic performance. Despite the positive indirect effect on academic achievement, there was minimal variation in self-efficacy among students of different regional origin, learning stages, and family income. Self-efficacy changed little during the students’ school years and differed among the students only between gender. This suggests self-efficacy is a relatively stable psychological trait. Liu’s study found that about 88.9% of the students’ self-efficacy was moderate and stable during their college years [28]. There was also an indirect effect on academic performance, and unlike self-efficacy, professional commitment was significantly different among students at different stages of learning. Professional commitment is more sensitive to changes in the learning phase. While considering the predictive role in students’ future career success [29], professional commitment is a good mediating variable for predicting academic performance and career success.
Fourth, students in the clinical practice stage had significantly lower professional commitment and learning engagement (P < 0.001). The clinical practice stage is significantly different from the pre-medical or medical course education stages in China. The methods of acquiring knowledge have changed from books to practice. Some studies have shown that when entering the clinical practice stage, students feel that there is a huge gap between medical theory and practical work, making it difficult for students to control their emotions. On the other hand, the pressure exerted on students is increasing. After entry into clinical practice stage, students are faced with many challenges, such as the medical practitioner examination, increased clinical work load, and scientific research required for graduation.In recent years, the job market has become increasingly demanding of students’ scientific research output, and students’ concerns about their future career have become more prominent. All these changes may contribute to the decline in the professional commitment of students in the clinical practice stage of the eight-year medical program. Similar results were obtained in another study of eight-year programme students from Fudan University of China [30]. They reported that eight-year programme students in clinical training (sixth/seventh year) had lower empathy than students in premedical study (first/second year), basic medicine (third/fourth year), and clinical medicine (fifth year). Eight-year program students in China lack effective career guidance and psychological counseling when entering the clinical practice stage, and the connection needs to be strengthened during this important period.
Finally, the professional commitment of students decreased along with the decrease of household income (F = 4.063, P = 0.018). Further pairwise comparison found that the professional commitment of students from low-income families (< 3000 yuan per month) was significantly lower than that of students from high-income families (> 5000 yuan per month) (P = 0.005). This study was conducted in Guangzhou, where the minimum living allowance for one resident is 1,125 yuan per month. For a family of three people, the economic status of low-income families in this study is equivalent to the income status of low-income families in China. According to the 2021 China Statistical Bulletin on Civil Affairs Development, China currently has 42,123 million people living on subsistence allowances. Although students from low-income families did not show significant differences in academic performance from other students, attention needs to be given to the decrease in professional commitment. This suggests that family income is negatively associated with student professional commitment. Additionally, due to the long training time of doctors and the low income in the early stage of career development, students generate very little income for their families. Low-income families usually have insufficient understanding of doctors’ career development, which makes it difficult for students to gain professional identity in the family.
Limitations
A number of limitations need to be considered when interpreting the findings of this study. Our sample was not representative of professional commitment levels among medical students in eight-year program countrywide. We also employed a self-reported scale of self-efficacy, professional commitment, and learning engagement and, although these scales have been reported to be reliable and valid, there may be discrepancies between self-report and actual behavior, and the self-reports might have been subject to bias. Furthermore, our findings were based on a cross-sectional design, and the possibility of cohort effects could not be dismissed in our study. Thus, a longitudinal study is recommended to verify the findings. Finally, since the medical students came from across the country, their family backgrounds may have differed significantly, such as living with a joint family or nuclear family, and parents’ education levels, which may have influenced their self-efficacy, professional commitment, learning engagement, and academic performance.