ORIGINAL RESEARCH

published: 25 March 2022

doi: 10.3389/fpubh.2022.868914

Professional Identity of 0.24 Million

Medical Students in China Before
and During the COVID-19 Pandemic:
Three Waves of National
Cross-Sectional Studies
Chen Yu 1,2† , Qiao Liu 3† , Weimin Wang 1,2,4 , Ana Xie 1,2 and Jue Liu 3,5*
1
National Center for Health Professions Education Development, Peking University, Beijing, China, 2 Department of Medical
Education, Peking University, Beijing, China, 3 Department of Epidemiology and Biostatistics, School of Public Health, Peking
University, Beijing, China, 4 Peking University Health Science Center, Beijing, China, 5 Department of Global Health and
Development, Peking University, Beijing, China

Background: Professional identity (PI) influences the doctor’s thoughts and behaviors.
Thus, PI formation (PIF) plays an important role in medical students’ education. Major
Edited by: changes to the learning environment could impact PIF, but the influence of the novel
Bijaya Kumar Padhi, coronavirus disease 2019 (COVID-19) pandemic on medical students’ PI had confusing
Post Graduate Institute of Medical
Education and Research
conclusions in previous studies. We aimed to compare PI of medical students by using
(PGIMER), India the data from three waves of national cross-sectional surveys conducted in China in
Reviewed by: 2019, 2020, and 2021, and to examine factors that influence PIF.
Gete Berihun,
Wollo University, Ethiopia Method: We used data from the China Medical Student Survey (CMSS) which
Obasanjo Afolabi Bolarinwa, has conducted three national cross-sectional surveys. From 2019 to 2021, CMCC
University of KwaZulu Natal,
South Africa
retrieved data on PI from a nationally representative sample of medical students
*Correspondence:
from 33, 121, and 123 colleges, respectively. We analyzed the data using
Jue Liu Chi-square test, analysis of variance, and multivariable logistic regression according
jueliu@bjmu.edu.cn to sociodemographic characteristics, pre-university experience, college characteristics,
† These authors share first authorship and college experience.
Results: A total of 244,040 medical students in China participated in the surveys. The
Specialty section:
This article was submitted to overall score of PI increased from 3.80 in 2019 to 3.85 in 2021. Medical students with
Public Health Education and family medical background, high intrinsic and extrinsic motivation of major selection,
Promotion,
a section of the journal
teachers’ positive role model, and high personal comprehensive quality ranking were
Frontiers in Public Health more likely to have higher PI (all p < 0.05). The more attention students paid to the
Received: 03 February 2022 COVID-19 pandemic, the higher PI they would have (aOR 1.93, 95% CI 1.67–2.24 for
Accepted: 28 February 2022
more attention; aOR 2.31, 95% CI 2.00–2.68 for the most attention). However, parents’
Published: 25 March 2022
participation on the front lines of COVID-19 pandemic negatively influenced the PI of
Citation:
Yu C, Liu Q, Wang W, Xie A and Liu J medical students (aOR 0.72, 95% CI 0.57–0.93).
(2022) Professional Identity of 0.24
Million Medical Students in China
Conclusions: PI of medical students increased during the COVID-19 pandemic. The
Before and During the COVID-19 impact of the pandemic on PI was complex. To improve the PI of medical students, the
Pandemic: Three Waves of National education sector, health sector and the society need to make concerted efforts.
Cross-Sectional Studies.
Front. Public Health 10:868914. Keywords: professional identity, professional identity formation, medical students, COVID-19, national cross-
doi: 10.3389/fpubh.2022.868914 sectional survey

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Yu et al. PI of Medical Students in China

INTRODUCTION METHODS
Professional identity (PI) refers to people’s professional Study Design, Participants, and Sampling
perception of themselves based on their beliefs and values. It Our data was collected by the China Medical Student Survey
leads the way they think, behave, and interact with professional (CMSS). CMSS is a nationwide large-scale survey project
and social norms (1). PIs influence the doctor’s thoughts for medical undergraduates in China which was jointly
and behaviors, hence, PI formation (PIF)was suggested to initiated by the Peking University National Center for Health
be a major focus of medical education (2, 3). PIF is now Professions Education Development and the Association for
recognized as crucial to developing doctors who can deliver Health Professions Education Research in China (AHPERC).
high-quality care (4). Those who constructed a PI that aligns CMSS aims to understand the training process and growth
with the needs and values of the general practice environment experience of medical students from the perspective of students
have shown more satisfaction and emotional well-being in themselves, echoing the medical education certification concept
their roles (5). Newly graduated doctors are required to of “student-centered” and “result-oriented” learning and further
perform professionally, while there is little time for medical improve the quality assurance system of medical education. It
students to transit from student to doctor. Therefore, a well- then provides data support of policy advice and decision-making
formed PI during medical education and clinical practice for the reform and development of medical education in China.
is of vital importance for medical students to quickly adapt The China Medical Student Survey was officially launched in
to professional status and to better deal with practical 2019 and has conducted three national cross-sectional surveys
challenges. Those doctors with a strong PI could not only so far via Wen Juan Xing (Changsha Ranxing Information
benefit themselves, but also positively impact their patients and Technology Co., Ltd, Hunan, China), an online survey company.
coworkers (1). In 2019, stratified sampling was used, and medical students were
Personal identity formation could be impacted by major separately sampled from “Double First-Class” universities and
changes to the learning environment, and medical education is non- “Double First-Class” universities with a total of 10,031
now in the midst of a radical change with the novel coronavirus medical students from 33 colleges involved. In 2020 and 2021, all
disease 2019 (COVID-19) pandemic (6). The pandemic could colleges offering medical majors in China were investigated, and
alter, impede, or accelerate the process of PIF of medical students 30,395 medical students from 121 colleges and 219, 396 medical
by creating additional concerns about doctors’ role in providing students from 123 colleges were, respectively, involved in each
healthcare, the functions and limitations of medical care, and year of investigation.
individuals’ vulnerability to infection and asymptomatic disease
spread (7). Educators should seize the opportunity to understand Measures
the changes of medical students’ PI under the pandemic and A structured self-administered online questionnaire was
formulate targeted measures to help medical students form a designed based on the Student Development Theory and College
better PI. Impact Theory (11). The questionnaire included the following
We searched PubMed to identify full-text reports that parts: (1) sociodemographic characteristics, (2) pre-university
were relevant to our study aims and found that several experience, (3) college characteristics, (4) college experience,
studies had examined the influence of COVID-19 pandemic and (5) PI. Sociodemographic characteristics included sex,
on medical students’ PI, but with contrary conclusions. A nationality, family location, and parents’ educational years.
cross-sectional study conducted in Zhengzhou, China that Pre-university experience included types of high school, ideal
included 474 nursing students found that anxiety during the profession, and motivation of major selection scale. College
COVID-19 pandemic gave an adverse effect on the PI of characteristics included the college location and college types,
nursing students (8). Another nation-wide cross-sectional study while college experience included doctors’ role model scale,
identified an increased level of PI among Chinese nursing clinical practice events scale, and personal comprehensive
students during the COVID-19 pandemic (9). Ardi et al. quality ranking during college studies. PI included a PI scale
found that the socialization processes that promotes PIF might with 12 questions. In the survey in 2020, there were additional
change due to the tremendous disruption brought by the questions related to the COVID-19 pandemic. Variable selections
pandemic (10). Notably, this study was a qualitative research, were shown in Table 1.
particularly because of how they assessed undergraduate Each scale contained several questions, and each question
medical students’ adaptations and PIF during the pandemic by was answered on a five-point Likert scale (“strongly disagree,”
exploring their written reflections. These studies showed that “disagree,” “neither agree nor disagree,” “agree,” and “strongly
reliable and accurate information on the PI level of medical agree”) and were assigned scores of 1, 2, 3, 4, and 5, respectively.
students and its change during the COVID-19 pandemic is The motivation of the major selection scale included nine
urgently needed. questions, with five representing the intrinsic motivation and
In the present study, we aimed to compare PI of medical four representing the extrinsic motivation. The doctors’ role
students by using the data from three waves of national cross- model scale contained six questions, with two representing
sectional surveys in China conducted in 2019, 2020 and 2021, doctors’ positive medical behaviors, one representing doctors’
which represent students’ PI before and during the COVID-19 negative medical behaviors, two representing doctors’ positive
pandemic (based on the COVID-19 prevalence in China). teaching behaviors, and one representing doctors’ negative

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Yu et al. PI of Medical Students in China

TABLE 1 | Variable selections. representing personal events. PI consisted of four dimensions

(professional cognition, professional emotion, professional
Variables Description
behavior, and professional expectation) which were measured by
Independent variables three, four, three, and two questions, respectively. The content of
Professional identity score Continuous 1–5 these scales is shown in Supplementary Table 1.
Categorical 0: ≤3 The primary outcome was PI scores. The higher score refers
1: >3 to higher PI, and in this study, if the average scores of the 12
Dependent variables questions in the PI scale were more than 3, participants were then
Survey year Categorical 0: 2019 defined as having a high PI (12).
1: 2020
2: 2021 Statistical Analysis
Sex Categorical 0: male Descriptive statistics were performed to describe the
1: female
sociodemographic characteristics and the rates of having a
Family medical background Categorical 0: no high PI score (>3). Analysis of variance (ANOVA) was used to
1: yes
compare the PI scores based on years of this study. Chi-square
Type of high school Categorical 0: key high school
1: ordinary high school
test was used to compare the rates of hiving a high PI score by
2: secondary vocational colleges sociodemographic characteristics, pre-university experience,
3: private school college characteristics, and college experience. In each scale of the
Years of education of father Continuous 0–22 questionnaire, each variable was calculated by the average score
Family region Categorical 0: Municipality directly under of questions it contained. For example, the intrinsic motivation
the Central Government/special score was calculated by the scores of the five questions which
administrative region represented the intrinsic motivation. If the scores of variables
1: Eastern
2: Central
were over 3, participants were defined as having an agreement
3: Western with the situation.
College location Categorical 0: Wuhan The multivariable logistic regression model was used to assess
1: Hubei except Wuhan the adjusted associations of factors related to the PI which were
2: China except Hubei adjusted by the survey time, sex, family location and region,
Ideal profession related to Categorical 0: no family medical background, types of high school, education year
medicine in high school 1: yes of father, college type and its location, ideal profession in high
Intrinsic motivation score of Categorical 0: ≤3 school, motivation scores of major selection, doctors’ medical
major selection 1: >3
and teaching behavior scores, personal events score during
Extrinsic motivation score of Categorical 0: ≤3
clinical practice higher, personal comprehensive quality ranking
major selection 1: >3
during college studies, attention to the COVID-19 pandemic, and
Positive medical behavior Categorical 0: ≤3
scores 1: >3 parents’ or teachers’ participation on the front lines of COVID-
Negative medical behavior Categorical 0: ≤3
19 pandemic. We established three logistic regression models
scores 1: >3 containing different numbers of medical students with different
Positive teaching behavior Categorical 0: ≤3 factors according to the characteristics of participants (Figure 1).
scores 1: >3 Model 1 contained all the 244,040 participants but lack the factors
Negative teaching behavior Categorical 0: ≤3 related to clinical practice and personal comprehensive quality
scores 1: >3 rankings due to some participants have not experienced the
Personal events score Categorical 0: ≤3 clinical practice. On the other hand, model 2 included the factors
during clinical practice 1: >3 related to clinical practice and contained 68,872 participants.
Personal comprehensive Categorical 0: <10% Model 3 only included participants in the 2020 survey and
quality ranking 1: 11–25%
2: 26–50%
added factors related to the COVID-19 pandemic. Adjusted odds
3: 51–75% ratios (OR) with 95% confident interval (CI) for each variable
4: >75% were calculated.
Attention to the COVID-19 Categorical 0: general
pandemic 1: more Ethical Approval
2: most The study was approved by the Institutional Review Boards at
Participation of parents or Categorical 0: neither parent nor teacher Peking University (IRB00001052-20069).
teachers on the front lines of 1: only parent
COVID-19 pandemic 2: only teacher
3: Both parent and teacher RESULTS
Characteristics of Participants
A total of 259,795 medical students were involved in the
teaching behaviors. The clinical practice events scale included three national cross-sectional surveys, with 244,040 valid
six questions, with two representing medical events and four questionnaires (Figure 1). Characteristics of participants were

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Yu et al. PI of Medical Students in China

FIGURE 1 | Flowchart of participants selection.

shown in Table 2. Independent medical college accounted for had more than 20 years of education (0.65% for fathers and 0.33%
67.60%. Males accounted for 53.30% of all the students involved, for mothers). Students who had a career related to medicine in
and the Han nationality accounted for the vast majority (88.69%). high school accounted for 52.89%. The majority of students had
Students from urban areas were more than those from rural areas the intrinsic (82.61%) and extrinsic (68.24%) motivation scores of
(58.16%), while only 2.94% of the students were from Hubei over 3 in the 3 years. During clinical practice, most of the teachers
province. Most parents had <10 years of education and 10–20 also showed to be positive role models. Medical events (2.03%)
years of education, which were relatively average, while very few and personal events (2.44%) accounted for a small proportion in

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Yu et al. PI of Medical Students in China

the 3 years. Differences among different PI and different years PI score as evidenced by the following: aOR of more attention
of the CMSS were in Table 2. Lastly, except for college location was 1.93 (95% CI, 1.67, 2.24), and aOR of most attention was 2.31
(p = 0.126), sex (p = 0.284), and nationality (p = 0.985), the (95% CI, 2.00, 2.68). However, medical students whose parents
differences were all statistically significant (p < 0.001, Table 2). participated on the front lines of COVID-19 pandemic had lower
In 2020, only 5.04% (1,520/30,147) of the students had a PI scores (aOR = 0.72, 95% CI, 0.57, 0.93).
general involvement and attention to the COVID-19 pandemic,
while 42.03% (12,670/30,147) were more involved and therefore
had more attention, and 52.93% (15,957/30,147) had the DISCUSSION
most involvement and attention to the COVID-19 pandemic
compared to other participants. Fifty-two-point-thirty-four To the best of our knowledge, this is the first comprehensive
percent (15,780/30,147) of students’ parents and teachers did not effort to assess the PI of medical students in China using the
participate on the front lines of COVID-19 pandemic (Figure 2). data from the three national cross-sectional surveys of CMSS in
2019, 2020, and 2021. We additionally conducted a multivariable
Professional Identity of Medical Students logistic regression to find out what factors could influence the
Professional identity score slightly increased from 2019 (3.80) PI of medical students in China. The overall PI increased from
to 2021 (3.85). ANOVA of the 3 years overall PI scores showed 2019 (3.80) to 2021 (3.85), and students had the highest identity
that the differences were significant (F = 58.69, p < 0.001). As to professional behaviors and the lowest identity to professional
shown in Figure 1, in 2019, 2020, and 2021, medical students cognition. All the three logistic regression models showed that
had the identified the highest with professional behaviors (4.04, family located in rural areas and low educational years of father
4.04, and 4.02, respectively) (ANOVA: F = 15.69, p < 0.001), had positive impact on PI. Professional ideal career in high school
followed by professional emotion (3.84, 3.86, and 3.92) (ANOVA: and the motivation of major selection could also influence the PI.
F = 111.07, p < 0.001), professional expectation (3.69, 3.79, and Students’ experience during clinical practice impacted the PI in
3.79) (ANOVA: F = 56.41, p < 0.001), and professional cognition many ways. The more attention students paid to the COVID-19
(3.61, 3.58, and 3.68) (ANOVA: F = 363.76, p < 0.001). PI pandemic, the higher PI they would have. Parents’ participation
was the highest among all four dimensions in 2021. Specifically, on the front lines of COVID-19 pandemic negatively impacted
identity to professional cognition was highest in Q1 in all three the PI of medical students.
years (4.37, 4.22, and 4.19); identity to professional emotion was Our results showed that the overall PI increased from 2019
highest in Q4 in all three years (3.95, 3.97, and 4.00); identity to 2021. However, the logistic regression results showed that, in
to professional behavior was highest in Q8 in 2019 (4.08) and all the participants, PI in 2020 (OR = 0.75, 95% CI, 0.70–0.81)
2020 (4.06), and Q9 in 2021 (4.11); and identity to professional and 2021 (OR = 0.89, 95% CI, 0.83–0.96) was lower than in
expectation was highest in Q11 in all three years (4.01, 4.00, 2019. Meanwhile, in those having experienced clinical practice,
and 3.97) (Figure 3). PI was also lower in 2020 (OR = 0.88, 95% CI, 0.81–0.96) but
higher in 2021 (OR = 1.15, 95% CI, 1.05–1.25) than in 2019.
Logistic Regression for the Influencing CMSS in 2020 was conducted in June and July, when medical
Factors of the Professional Cognition students had been retracted from offline education and clinical
Table 3 showed the logistic regression results of the three models. practice for over 6 months due to the COVID-19 pandemic. Due
In all the three models, medical students living in rural areas to absence of peer interactions and omission of direct patient
were found to have a higher possibility of having their PI scores care involvement, there was increasing barriers in PIF as medical
higher than 3 [aOR and 95% CI of model 1, 2, and 3: 1.14 students struggled with finding their worth in healthcare (13).
(1.10, 1.17), 1.22 (1.15, 1.29), and 1.23 (1.12, 1.34), respectively]. Study had shown that the lockdown and the school closure
Education years of father was a negative influencing factor of could have negative consequences on students, affecting their
medical students’ PI scores in the three models, and the aOR and education, social life, and mental health (14). Nevertheless,
its 95% CI were 0.99 (0.99, 0.99), 0.98 (0.97, 0.99), and 0.98 (0.97, online education did ensure that students get uninterrupted
0.99) per year, respectively. As shown in the three models, ideal learning during the COVID-19 pandemic. Thus, the curriculum
profession before college and motivation of major selection could and clinical practice could be carried out effectively with the
also positively influence medical students’ PI scores. re-opening of universities in China, which might explain the
Model 2 and 3 examined the influence of clinical practice on PI increased PI in students who had clinical practice experiences
scores. Both medical behavior and teaching behavior (regardless in the 2021 survey. Additionally, the promotion of medical
of positive or negative) had positive influence on medical students’ PI may also be related to the important role played
students’ PI scores. However, Model 2 showed that personal by health workers in the COVID-19 pandemic and the timely
events during clinical practice could negatively influence medical and effective prevention and control of COVID-19 in China,
students’ PI scores (aOR = 0.83, 95% CI, 0.75, 0.92). Model 2 which imperceptibly improves the professional pride of medical
and 3 also showed that the higher medical students’ personal students in China.
comprehensive quality ranking, the higher their PI scores. Family influence is an important factor of PIF. Our results
Model 3 further examined the influence of factors related to showed that medical students from rural areas had higher PI than
the COVID-19 pandemic on medical students’ PI scores. The those from cities. Low educational years of fathers had a small
attention to the COVID-19 pandemic could positively influence but statistically significant positive effect on medical students’

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Yu et al. PI of Medical Students in China

TABLE 2 | Rates of professional identity score over 3 in medical students in China by demographic characteristics, and characteristics of participants in the 2019, 2020,
and 2021 waves.

Total Professional identity scores Year of surveys

(N = 244,040)
(%)

>3 (n = 212,016) P value 2019 n = 8,032 2020 n = 30,147 2021 n = 205,861

(%) (%) (%) (%)

College location
Wuhan 2,877 (1.18) 2,473 (85.96) 0.13 355 (4.42) 585 (1.94) 1,937 (0.94)
Hubei except Wuhan 6,074 (2.49) 5,241 (86.29) 0 (0.00) 679 (2.25) 5,395 (2.62)
China except Hubei 235,089 (96.33) 204,302 (86.90) 7,677 (95.58) 28,883 (95.81) 198,529 (96.44)
College type
Independent medical college 164,976 (67.60) 142,957 (86.65) <0.001 3,709 (46.18) 17,525 (58.13) 143,742 (69.82)
Medical College of comprehensive 79,064 (32.40) 69,059 (87.35) 4,323 (53.82) 12,622 (41.87) 62,119 (30.18)
university
Sex
Male 130,065 (53.30) 113,087 (86.95) 0.28 3,590 (44.70) 12,222 (40.54) 114,253 (55.50)
Female 113,975 (46.70) 98,929 (86.80) 4,442 (55.30) 17,925 (59.46) 91,608 (44.50)
Nationality
Han 216,450 (88.69) 188,045 (86.88) 0.99 7,184 (89.44) 26,939 (89.36) 182,327 (88.57)
Others 27,590 (11.31) 23,971 (86.88) 848 (10.56) 3,208 (10.64) 23,534 (11.43)
Family location
Urban 141,936 (58.16) 122,848 (86.55) <0.001 5,323 (66.27) 15,496 (51.40) 121,117 (58.83)
Rural 102,104 (41.84) 89,168 (87.33) 2,709 (33.73) 14,651 (48.60) 84,744 (41.17)
Hubei 229 (0.09) 189 (82.53) <0.001 229 (2.85)
Wuhan 821 (0.34) 697 (84.90) 158 (0.52) 663 (0.32)
Hubei except Wuhan 6,132 (2.51) 5,239 (85.44) 863 (2.86) 5,269 (2.56)
China except Hubei 236,858 (97.06) 205,891 (86.93) 7,803 (97.15) 29,126 (96.61) 199,929 (97.12)
Family region
municipality directly under the Central 13,250 (5.43) 11,498 (86.78) <0.001 675 (8.40) 1,358 (4.50) 11,217 (5.45)
Government /special administrative
region
Eastern 80,018 (32.79) 69,853 (87.30) 2,794 (34.79) 8,064 (26.75) 69,160 (33.60)
Central 66,990 (27.45) 58,201 (86.88) 2,255 (28.08) 10,249 (34.00) 54,486 (26.47)
Western 83,782 (34.33) 72,464 (86.49) 2,308 (28.74) 10,476 (34.75) 70,998 (34.49)
Family medical background
Yes 71,128 (29.15) 62,660 (88.09) <0.001 2,373 (29.54) 3,205 (10.63) 65,550 (31.84)
No 172,912 (70.85) 149,356 (86.38) 5,659 (70.46) 26,942 (89.37) 140,311 (68.16)
Years of education of father/mother
∼10 years 122,867 106,940 <0.001/ 3,520 17,253 102,094
(50.35)/142,015 (87.04)/123,649 <0.001 (43.82)/4,180 (57.23)/20,062 (49.59)/117,773
(58.19) (87.07) (52.04) (66.55) (57.21)
10–20 years 119,648 103,799 4,417 12,766 102,465
(49.03)/101,217 (86.75)/87,696 (54.99)/3,796 (42.35)/10,009 (49.77)/87,412
(41.48) (86.64) (47.26) (33.20) (42.46)
20–years 1,525 (0.62)/808 1,277 95 (1.18)/56 128 (0.42)/76 1,302 (0.63)/676
(0.33) (83.74)/671 (0.70) (0.25) (0.33)
(83.04)
Types of high school
Key high school 118,630 (48.61) 103,809 (87.51) <0.001 5,297 (65.95) 14,262 (47.31) 99,071 (48.13)
Ordinary high school 113,998 (46.71) 98,379 (86.30) 2,711 (33.75) 15,795 (52.39) 95,492 (46.39)
Secondary Vocational Colleges 481 (0.20) 353 (73.39) 24 (0.30) 90 (0.30) 367 (0.18)
Private school 10,931 (4.48) 9,475 (86.68) 0 (0.00) 0 (0.00) 10,931 (5.31)
Was the ideal profession related to medicine in high school
Yes 129,080 (52.89) 117,638 (91.14) <0.001 3,426 (42.65) 15,688 (52.04) 109,966 (53.42)
No 114,960 (47.11) 94,378 (82.10) 4,606 (57.35) 14,459 (47.96) 95,895 (46.58)

(Continued)

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Yu et al. PI of Medical Students in China

TABLE 2 | Continued

Total Professional identity scores Year of surveys

(N = 244,040)
(%)

>3 (n = 212,016) P value 2019 n = 8,032 2020 n = 30,147 2021 n = 205,861

(%) (%) (%) (%)

Intrinsic motivation score of major selection

>3 201,611 (82.61) 187,655 (93.08) <0.001 5,772 (71.86) 23,975 (79.53) 171,864 (83.49)
≤3 42,429 (17.39) 24,361 (57.42) 2,260 (28.14) 6,172 (20.47) 33,997 (16.51)
Extrinsic motivation score of major selection
>3 166,526 (68.24) 153,268 (92.04) <0.001 6,113 (76.11) 21,778 (72.24) 138,635 (67.34)
≤3 77,514 (31.76) 58,748 (75.79) 1,919 (23.89) 8,369 (27.76) 67,226 (32.66)
Positive medical behavior score
>3 93,539 (38.33) 87,802 (93.87) <0.001 6,460 (80.43) 23,396 (77.61) 63,683 (30.93)
≤3 30,418 (12.46) 17,465 (57.39) 1,572 (19.57) 6,751 (22.39) 22,095 (10.73)
Negative medical behavior score
>3 14,803 (6.07) 13,526 (91.37) <0.001 1,365 (16.99) 6,892 (22.86) 6,546 (3.18)
≤3 109,154 (44.73) 91,741 (85.05) 6,667 (83.01) 23,255 (77.14) 79,232 (38.49)
Positive teaching behavior score
>3 88,899 (36.43) 83,459 (93.88) <0.001 6,217 (77.40%) 22,487 (74.59%) 60,195 (29.24%)
≤3 35,058 (14.37) 21,808 (62.21) 1,815 (22.60%) 7,660 (25.41%) 25,583 (12.43%)
Negative teaching behavior score
>3 18,054 (7.40) 15,970 (88.46) <0.001 1,934 (24.08) 7,323 (24.29) 8,797 (4.27)
≤3 105,903 (43.40) 89,297 (84.32) 6,098 (75.92) 22,824 (75.71) 76,981 (37.39)
Medical events score during clinical practice
>3 4,948 (2.03) 4,253 (85.95) 0.040 847 (10.55) 1,884 (6.25) 2,217 (1.08)
≤3 119,009 (48.77) 101,014 (84.88) 7,185 (89.45) 28,263 (93.75) 83,561 (40.59)
Personal events score during clinical practice
>3 5,948 (2.44) 4,700 (79.02) <0.001 831 (10.35) 2,404 (7.97) 2,713 (1.32)
≤3 118,009 (48.36) 100,567 (85.22) 7,201 (89.65) 27,743 (92.03) 83,065 (40.35)
Personal comprehensive quality ranking
<10% 9,654 (3.96) 8,581 (88.89) <0.001 1,153 (14.36) 4,432 (14.70) 4,069 (1.98)
11–25% 16,824 (6.89) 14,720 (87.49) 1,619 (20.16) 8,250 (27.37) 6,955 (3.38)
26–50% 21,968 (9.00) 18,699 (85.12) 2,525 (31.44) 9,862 (32.71) 9,581 (4.65)
51–75% 14,319 (5.87) 12,101 (84.51) 1,878 (23.38) 5,515 (18.29) 6,926 (3.36)
> 75% 6,097 (2.50) 4,648 (76.23) 857 (10.67) 2,088 (6.93) 3,152 (1.53)

PI. Notably, students whose parents participated on the front During medical education and clinical practice, teachers’ role
lines of COVID-19 pandemic had relatively low PI (OR = 0.72, model (regardless of positiveness or negatives) could all positively
95% CI, 0.57–0.93). For these students, the fact that their parents influence medical students’ PI. Despite this, personal events
were under the high risk of infection and kept away from their during clinical practice can also negatively influence the PI (OR
families might affect the PIF despite their heroic contributions = 0.83, 95% CI, 0.75–0.92). Meanwhile, students with higher
for fighting against the pandemic. In addition, a qualitative study personal comprehensive quality ranking had higher PI. During
found that healthcare workers on the front lines might also had clinical practice, medical students reported that clinical teachers
their PI affected by factors such as the “impression of exhaustion exert an important influence on their PIF through role modeling,
and fear,” “feeling the unfairness,” “perceiving incompetence in formal and informal teaching, mentoring, assessment, feedback,
rescue task,” and “unexpected professional benefits.” (15). We and interpersonal interactions (17–20). Sternszus et al. explored
also found that students studying outside of Wuhan province the PIF from the perspective of clinical teachers and found that
had higher PI than those study in Wuhan. The COVID- participating teachers identified explicit role modeling, engaging
19 pandemic let medical students and professions discover a in difficult conversations, and providing graded autonomy as
“hidden corner” in themselves. Some had managed to overcome ways in which they could influence the identity development of
these emotional struggles to fulfill their responsibilities, but some medical students (21). These findings emphasized the importance
had not (16). of teachers’ role in medical students’ PIF. A previous study also

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Yu et al. PI of Medical Students in China

FIGURE 2 | Proportion of variables related to the coronavirus disease 2019 (COVID-19) pandemic in the CMSS of 2020. COVID-19, Corona Virus Disease 2019;
CMSS, China Medical Student Survey.

FIGURE 3 | Results of professional identity scale. Professional Cognition is represented by Q1 to Q3; Professional Emotion is represented by Q4 to Q7; Professional
Behavior is represented by Q8 to Q10; and Professional Expectation is represented by Q11 and Q12.

showed that social interactions with others in the clinical practice (7). The pandemic not only brought pain or death, but
could help medical students to construct their PI (22). Therefore, also brought attention to medical humanity education,
experiencing personal events (such as being publicly humiliated making more medical students realize that the core of
or being asked to deal with the personal affairs of others) in the medicine is humanity (16). The COVID-19 pandemic has
clinical practice had a negative impact on the PI. also motivated many high-school students in China to
Our results also showed that the more attention students choose medical schools in the National College Entrance
paid to the COVID-19 pandemic, the higher PI they would Examination (23). Therefore, the pandemic is a crisis and
have. During the COVID-19 pandemic, medical students an opportunity, and educators can harness this chance
were uncertain about their roles but were eager to contribute for growth.

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Yu et al. PI of Medical Students in China

TABLE 3 | Factors influenced professional identity of medical students in China by multivariate logistic regression models.

Factors 2019–2021 2019–2021 2020 (30,147 individuals

(244,040 individuals) (68,872 individuals) with variables related to
COVID-19 pandemic)

aOR (95% CI) P-value aOR (95% CI) P-value aOR (95% CI) P-value

Survey year
2019 1.00 1.00
2020 0.75 (0.70, 0.81) <0.001 0.88 (0.81, 0.96) 0.003
2021 0.89 (0.83, 0.96) 0.002 1.15 (1.05, 1.25) 0.002
Sex
Male 1.00 Excluded Excluded
Female 1.35 (1.31, 1.38) <0.001
Family location
Urban 1.00 1.00 1.00
Rural 1.14 (1.10, 1.17) <0.001 1.22 (1.15, 1.29) <0.001 1.23 (1.12, 1.34) <0.001
Family medical background
No 1.00 Excluded Excluded
Yes 1.06 (1.03, 1.10) <0.001
Type of high school
Key high school 1.00 Excluded 1.00
Ordinary high school 0.97 (0.94, 0.99) 0.04 1.01 (0.93, 1.10) 0.81
Secondary vocational colleges 0.94 (0.88, 1.00) 0.05 0.42 (0.23, 0.76) 0.004
private school 0.57 (0.43, 0.74) <0.001
Years of education of father
0 1.00 1.00 1.00
Per year 0.99 (0.99, 0.99) <0.001 0.98 (0.97, 0.99) <0.001 0.98 (0.97, 0.99) 0.007
Family region
Municipality directly under the Central 1.00 1.00 1.00
Government/special administrative
region
Eastern 0.96 (0.91, 1.02) 0.24 1.02 (0.91, 1.14) 0.75 0.96 (0.79, 1.17) 0.69
Central 0.95 (0.89, 1.01) 0.09 1.13 (1.01, 1.27) 0.03 1.11 (0.91, 1.35) 0.30
Western 0.93 (0.87, 0.98) 0.01 1.04 (0.93, 1.16) 0.54 0.97 (0.80, 1.18) 0.74
College location
Wuhan Excluded 1.00 1.00
Hubei except Wuhan 1.37 (1.06, 1.79) 0.02 1.97 (1.28, 3.04) 0.002
China except Hubei 1.41 (1.17, 1.70) <0.001 1.45 (1.10, 1.92) 0.008
College type
Medical school of comprehensive 1.00 Excluded Excluded
university
Independent medical college 0.93 (0.90, 0.96) <0.001
Ideal profession was related to medicine in high school
No 1.00 1.00 1.00
Yes 1.69 (1.65, 1.74) <0.001 1.58 (1.49, 1.66) <0.001 1.46 (1.34, 1.59) <0.001
Intrinsic motivation score of major selection
≤3 1.00 1.00 1.00
>3 6.63 (6.44, 6.82) <0.001 3.51 (3.32, 3.71) <0.001 3.33 (3.04, 3.64) <0.001
Extrinsic motivation score of major selection
≤3 1.00 1.00 1.00
>3 2.16 (2.10, 2.22) <0.001 1.53 (1.45, 1.62) <0.001 1.42 (1.30, 1.56) <0.001
Positive medical behavior scores
≤3 1.00 1.00
>3 4.44 (4.14, 4.77) <0.001 5.52 (4.91, 6.21) <0.001

(Continued)

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Yu et al. PI of Medical Students in China

TABLE 3 | Continued

Factors 2019–2021 2019–2021 2020 (30,147 individuals

(244,040 individuals) (68,872 individuals) with variables related to
COVID-19 pandemic)

aOR (95% CI) P-value aOR (95% CI) P-value aOR (95% CI) P-value

Negative medical behavior scores

≤3 1.00 1.00
>3 1.26 (1.14, 1.39) <0.001 1.38 (1.22, 1.56) <0.001
Positive teaching behavior scores
≤3 1.00 1.00
>3 2.47 (2.30, 2.65) <0.001 2.35 (2.09, 2.64) <0.001
Negative teaching behavior scores
≤3 1.00 Excluded
>3 1.17 (1.08, 1.27) <0.001
Personal events score during clinical practice
≤3 1.00 Excluded
>3 0.83 (0.75, 0.92) <0.001
Personal comprehensive quality ranking
<10% 1.00 1.00
11–25% 0.83 (0.76, 0.92) <0.001 0.83 (0.73, 0.95) 0.007
26–50% 0.74 (0.68, 0.81) <0.001 0.80 (0.70, 0.91) 0.001
51–75% 0.69 (0.63, 0.76) <0.001 0.72 (0.63, 0.83) <0.001
>75% 0.46 (0.41, 0.51) <0.001 0.47 (0.40, 0.56) <0.001
Attention to the COVID-19 pandemic
General 1.00
More 1.93 (1.67, 2.24) <0.001
Most 2.31 (2.00, 2.68) <0.001
Participation of parents or teachers on the front lines of COVID-19 pandemic
Neither parent or teacher 1.00
Only parents 0.72 (0.57, 0.93) 0.01
Only teachers 1.09 (1.00, 1.18) 0.07
Both parents and teachers 1.01 (0.87, 1.17) 0.87
Hosmer and lemeshow test χ 2 = 51.101, f=8, P < 0.001 χ 2 = 198.884, f=8, P < 0.001 χ 2 = 75.450, f=8, P < 0.001

aOR, adjusted odds ratio; CI, confident interval; COVID-19, novel coronavirus disease 2019.

Limitations and Strengths and 2021. We quantified medical students’ PI and additionally
This study has several limitations. First, the first 2 years’ survey conducted multivariable logistic regression to find out what
were anonymous. Hence, we could not track the change of factors influenced the PI of medical students in China.
personal PI by a cohort study. Second, these surveys were
conducted in China, and due to the differences in disease control CONCLUSIONS
policies, the results have limited generalizability. However, our
findings may be useful in undergraduate medical education The PI of medical students in China increased during
settings, because the COVID-19 pandemic and its consequences the COVID-19 pandemic compared with before. Timely
on medical education have been global. Third, the three surveys and effective prevention and control of COVID-19
were all conducted at a time when the pandemic situation was could improve PI of medical students. Sociodemographic
relatively stable (the peak of the COVID-19 pandemic in China characteristics, medical education, and clinical practice
was from January to March in 2020 (24)), and the results of experience can influence medical students’ PI. The association
our study may be overestimated or underestimated due to the of the pandemic and medical students’ PI was complex. The PI
difference of PI between peak and off peak of the pandemic. was positively influenced by students’ attention to the pandemic,
Nevertheless, our study also had strengths. To the best of but negatively influenced by participation of parents on the front
our knowledge, this is the first comprehensive effort to assess lines. A well-formed PI during medical education and clinical
the PI of medical students in China using the data from the practice is of vital importance for medical students to quickly
three national cross-sectional surveys of CMSS in 2019, 2020, adapt to professional status and to better deal with practical

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Yu et al. PI of Medical Students in China

challenges. Concerted efforts should be made by the education drafted the manuscript. JL, CY, QL, WW, and AX revised the
sector, health sector, and the society to improve the PI of medical manuscript. All authors contributed to the article and approved
students and health care workers. the submitted version.

DATA AVAILABILITY STATEMENT FUNDING

The raw data supporting the conclusions of this article will be This study was funded by the Major Project of the National Social
made available by the authors, without undue reservation. Science Foundation of China (AIA210011). The funders had no
role in study design, data collection and analysis, decision to
ETHICS STATEMENT publish, or preparation of the paper.

The studies involving human participants were reviewed and

approved by Institutional Review Boards at Peking University. ACKNOWLEDGMENTS
The patients/participants provided their written informed
The authors appreciate the works by the China Medical Student
consent to participate in this study.
Survey (CMSS) collaborators.

AUTHOR CONTRIBUTIONS
SUPPLEMENTARY MATERIAL
JL and CY conceived and designed the study. CY, WW,
and AX did the questionnaire design, colleges connection, The Supplementary Material for this article can be found
data collection, and cleaning. QL did a literature search, online at: https://www.frontiersin.org/articles/10.3389/fpubh.
analysis and interpretation, compiled tables and figures, and 2022.868914/full#supplementary-material

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