Perceptions and vocational tendency of undergraduate clinical medical students in China to general practiceA cross-sectional study

Background Undergraduate education determines the overall quality of general practitioners in the future, however, there were lack of standard objectives and teaching content of general practice in the academic sessions in China. This paper explore on the perception of general practice and vocational tendency of undergraduate clinical medical students. Methods A questionnaire was sent to clinical medical students from those 5 universities at the first semester by Wenjuanxing software. 30 valid questionnaires in each grade of each university were selected. Main outcome included the general information, cognizance of general medicine and attitude to be general practitioners. Results Among the 750 medical students, 87.9% thought it was necessary to developing this course and 54.5% thought it should be a required subject in the undergraduate years. Multimode teaching (74.1%) was the favorite teaching mode. The percentage of clinical medical students willing to be general practitioners was only 34.9%, the most important reason for medical students willing or unwilling to be general practitioners was both career prospect. In those who eager to be general practitioners 63.2% were unwilling to work in the community health service center. In logistic regression analysis, the grade (Odds Ratio OR = 1.55, 95% Confidence Interval CI: 1.20-2.0), the place of birth (OR = 0.82; 95% CI: 0.72-0.94), and the universities (OR = 1.24, 95% CI: 1.10-1.41) were significantly associated with the willingness of becoming general practitioners (P<0.05). The students who thought it was worth to developing general practice course were more prefer to be general practitioner, and students from schools who had made it a compulsory course. Conclusions In order to improve the perceptibility about general practice and attract


Abstract
Background Undergraduate education determines the overall quality of general practitioners in the future, however, there were lack of standard objectives and teaching content of general practice in the academic sessions in China. This paper explore on the perception of general practice and vocational tendency of undergraduate clinical medical students. Methods A questionnaire was sent to clinical medical students from those 5 universities at the first semester by Wenjuanxing software. 30 valid questionnaires in each grade of each university were selected. Main outcome included the general information, cognizance of general medicine and attitude to be general practitioners. Results Among the 750 medical students, 87.9% thought it was necessary to developing this course and 54.5% thought it should be a required subject in the undergraduate years.
Multimode teaching (74.1%) was the favorite teaching mode. The percentage of clinical medical students willing to be general practitioners was only 34.9%, the most important reason for medical students willing or unwilling to be general practitioners was both career prospect. In those who eager to be general practitioners 63.2% were unwilling to work in the community health service center.
In logistic regression analysis, the grade (Odds Ratio OR = 1.55, 95% Confidence Interval CI: 1.20-2.0), the place of birth (OR = 0.82; 95% CI: 0.72-0.94), and the universities (OR = 1.24, 95% CI: 1.10-1.41) were significantly associated with the willingness of becoming general practitioners (P<0.05). The students who thought it was worth to developing general practice course were more prefer to be general practitioner, and students from schools who had made it a compulsory course.
Conclusions In order to improve the perceptibility about general practice and attract more medical students to be general practitioners, the government should establish a perfect educational system, explore new teaching patterns and offer a bright career future.

Background
General practice is a discipline that has largely evolved over the past 30 years in the field of primary healthcare. It originated in the 18th century in Europe. General practice education abroad includes undergraduate education, graduate education and continued education, the undergraduate education was the base for promoting the rapid development of general practice. In Europe and America countries, more than 90 percent of medical schools had set up the department, teaching and research offices of general practice. At US medical schools Departments of family medicine-including departments of family and community medicine, departments of family and preventive medicine, and departments of family practice 1  Over the last two decades, the number of medical schools with family medicine teaching has significantly increased. Indeed, only undergraduate teaching may provide more competent general practitioners in China, so contact the general practice at the beginning of the university period may make more medical students knowing of general practice and willing to become general practitioners. A general description of undergraduate general practice teaching in the last two decades is lacking, a survey of 128 Chinese medical school points out that only 55 medical schools began to include general practice as part of the undergraduate curriculum until 2008 9 . Furthermore, there were lack of standard objectives and teaching content of general practice in the academic sessions and the monitoring system on the teaching quality and feedback evaluation.
This research intends to investigate the perception of general practice and vocational tendency of undergraduate clinical medical students. Also, most importantly, we attempted to identify some factors, which may affect the vocational tendency of undergraduate clinical medical students.

Selection of participants
The study was a cross-sectional survey from September 1st to October 30th in 2017.
The questionnaire was self-designed on the basis of references and opinions of GP The questionnaire covered the general information, cognizance of general medicine and attitude to be general practitioners. Requested general information included the medical students' age, gender, grade, university, source of students, the place of birth study general practice or not? The perceptions of general medicine included 'How much do you know about the general practice?', 'whether it was worth to developing this course?', 'Is general practice required or elective in your university?', 'Which way do you like? ', 'What kind of teaching methods do you like?
' and 'What have you gained from the course of general practice? '. The vocational tendency included whether the students willing or unwilling to pursue their master's degree of general practice, to attend the standardized training of general practitioners, to be general practitioners after graduation and to work in the community health center?

Statistical analysis
All statistical analyses were performed using SPSS 19.0 (SPSS Inc., IL, USA).
Continuous variables were expressed as mean ± standard deviation. Categorical variables were expressed as absolute values and percentages. Differences in continuous variables were tested using the F or t test, and differences in categorical variables were assessed using the Pearson χ2 test. We ran simple logistic regression and multiple logistic regression analyses to determine the factors (ie , sex, source of students, the place of birth university grade and knowledge about the general practice ) which may influence the vocational tendency of undergraduate clinical medical students. The minimum statistical significance level for all analyses was P <0.05.

Results
General characteristics of medical students A total of 750 clinical medical students from 5 different medical schools participated in the survey. The mean age of clinical medical students was 20.47±1.85 years, and 36.9% were male. The mean age of the male was 20.66±1.89 years old, while that of the female was 20.36±1.81 years old; there was no significant difference between the two groups (t = 2.19 P > 0.05). Among the 750 medical students, 35.7% (268/750) were out-of-province students.33.2% (249/750) were from countylevel city. Table 1 shows the general characteristic of medical students.
The perceptions of medical students to general practice Perceptions of medical students to general practice were given in Table 2. In all, 34.2% of the clinical medical students have no idea of the general practice, 49.5% without ever having taken a single course in general practice of any kind. However, 87.9% thought it was necessary to developing this course and 54.5% thought it should be a required subject in the undergraduate years. Multimode teaching (74.1%) was the favorite teaching mode. The greatest gain of learning general medicine was changing idea among those who have learned.

Vocational tendency of clinical medical students
The study showed that a total of 52.5% clinical medical students will consider to attending the standardized training of general practitioners (see Table 3). However, the percentage of clinical medical students willing to be general practitioners was only 34.9%, 20% did not care and 45.1% were reluctant to be General practitioners.
The majority of respondents strongly agreed that their motivation for becoming a Explore new teaching patterns Conventional general practice teaching was based mainly on theory lecture, and some universities have made it an optional course. In our study, changing idea was the greatest gain of learning general practice, and multimode teaching (74.1%) was the favorite teaching mode. A case-centered problem-based and communityoriented teaching model (CPC) was established in the First Affiliated Hospital of China Medical University. The investigation showed that 83.7% of the students believed that this mode was more helpful in deepening the understanding of general practice and community health services 11 . The faculty at Baylor University College of Medicine also used standardized patients in teaching prevention principles during the clerkship. At the University of Colorado, a case-based approach was also used.
Louisiana State University required each clerkship student to maintain logbook data about patients the student sees. Using these data and other resources, the student describes the patient population served, identifies their most common health problems, and develops an intervention plan for one of the most common health problem 1 . General practice is a discipline with strong practicality, thus we should be active in exploring and practicing the diversity teaching models for general practice education to better the present situation and to improve the perceptibility about general practice.
Offer a bright career future Significant progress had been made in the development of general practice in China, but the social status and salary of general practitioners were greatly inferior to that of the developed countries. Thus that's one factor why general practitioner was unattractive to medical students in China. Our survey showed that 34.9% of medical students were willing to be general practitioners. Interestingly enough, our research found that the most important reason for medical students willing or unwilling to be general practitioners was both career prospect. Some other studies found that the willing proportion of Qiqihar University of Medicine was 64.4% and the most important reason was with more development space 12 . 66.3% of the students of Shanghai Jiaotong University School of Medicine were willing to become general practitioners and the main reason was employment pressure (31.1%) Students who were unwilling to be general practitioners due to small room for potential development 35.0% and lower social status 30.0% 10 In those who eager to be general practitioners 63.2% were unwilling to work in the community health service center. In March of 2010, 'Planning for the construction of primary medical and health services team with the focus of general practitioners' was issued and encourage to set up the department of general practice in comprehensive hospitals. Most medical students tend to work in the comprehensive hospitals.
Tedious work, poor treatment and low social status prevent many undergraduate students from choosing a career in general practice. So in order to attract more medical students, the government should expand general practitioners career path and improve position promotion measures 13 .
There were several limitations of this study. Five universities may not sufficient to represent the undergraduate education of China and the perceptions of all medical students. And these five schools all had taken general practice as a necessary course, which may have some effect on the results.

Conclusions
China requires a continuous growth of general practice education in medical schools to provide more general practitioners serving the primary care needs of the community. Undergraduate education determines the overall quality of general practitioners in the future. In order to improve the perceptibility about general practice and attract more medical students to be general practitioners, the government should establish a perfect educational system, explore new teaching patterns and offer a bright career future.

Availability of data and material
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests.