Background: China started a national program in 2010 to train qualified general practitioners with compulsory services (CSP) in rural and remote areas. While the program has shown positive effects on staffing primary health care in rural areas, very little is known about how well they perform. This study aims to evaluate the job performance of medical graduates from this program and the influence of program design on job performance. Methods: A cohort study was conducted with graduates from CSP and non-CSP (NCSP) from four medical universities in central and western China. Baseline and three waves of follow-up surveys were conducted from 2015-2020. The pass rate of China National Medical Licensing Examinations (NMLE) and self-reported job performance were used as measurements. Multivariable regressions were used to identify factors affecting job performance. Results: 2154 medical graduates were included, with 1586 CSP and 568 NCSP graduates. CSP (90.6%) and NCSP (87.5%) graduates showed no difference in passing the NMLE (P=0.153). CSP graduates reported similar job performance with NCSP graduates (CSP, 63.7; NCSP, 64.2); in the multivariable regression, CSP graduates scored 0.32 and 1.36 points lower in the total sample and graduates of 2015-2017, respectively, but not significantly. Having formally funded positions improved the job performance of CSP (β coefficient=4.87, P<0.05). After controlling for Qinghai which adopted a different contracting strategy, "working in hometown" showed significant influence on job performance (β coefficient=1.48, P<0.05). Conclusion: CSP graduates have demonstrated as good job performance as NCSP, proving the competency to provide high-quality care for remote and rural areas. The contracted township health centers should provide guidance for CSP graduates, especially in the first few years after graduation. The local government should provide formally funded positions on time and prioritize signing contracts with hometowns or places nearby.

Background A major challenge of prospective cohort studies is attrition in follow-up surveys. This study investigated attrition in a prospective cohort comprised of medical graduates in China. We described status of attrition, identified participants with higher possibility of attrition, and examined if attrition affect the estimation of the key outcome measures. Methods The cohort study recruited 3,620 new medical graduates from four medical universities in central and western China between 2015 and 2019. Online follow-up surveys were conducted on an annual basis. Follow-up status was defined as complete (meaning that the participant completed all the follow-up surveys) and incomplete, while incomplete follow-up was further divided into ‘always-out’, ‘rejoin’ and ‘other’. Multivariable logistic and linear regressions were used to examine factors predicting attrition and the influence on the outcome measures of career development. Results 2364 (65.3%) participants completed all follow-up surveys. For those with incomplete follow-up, 520 (14.4%) were ‘always-out’, 276 (7.6%) rejoined in the 2020 survey. Willingness to participate in residency training (OR=0.80, 95%CI[0.66 - 0.98]) and willingness to provide sensitive information in the baseline survey predicted a lower rate of attrition (providing scores for university entrance exam OR=0.82, 95%CI[0.69 - 0.97]]; providing contact information (OR=0.46, 95%CI[0.32 - 0.66]); providing household income (OR=0.60, 95%CI[0.43 - 0.84]). Participants with compulsory rural service (OR=1.52, 95%CI[1.05 - 2.19]) and those providing university entrance scores (OR=1.64, 95%CI[1.15-2.33)) were more likely to rejoin in the follow-up survey. These factors associated with follow-up status did not have significant impact on key outcome measures of career development. Conclusions Graduates who were unwilling to participate in residency training or not providing sensitive information should be targeted early in the cohort study to reduce attrition. More information about the study should be provided to those graduates early to facilitate their understanding of the meaning in participation. On the contrary, medical graduates with compulsory rural service and those who provided university entrance scores were more likely to rejoin in the cohort. The research team should invest more effort in contacting those graduates and returned them to the cohort.

Background: A major challenge of prospective cohort studies is attrition in follow-up surveys. This study investigated attrition in a prospective cohort comprised of medical graduates in China. We described patterns of attrition, identified participants with higher possibility of attrition, and examined if attrition affect the estimation of the key outcome measures. Methods: The cohort study recruited 3,620 new medical graduates from four medical universities in central and western China between 2015-2019. Online follow-up surveys were conducted on an annual basis. Follow-up status was defined as complete (meaning that the participant completed all the follow-up surveys) and incomplete, while incomplete follow-up was further divided into ‘always-out’, ‘rejoin’ and ‘other’. Multivariable logistic and linear regressions were used to examine factors predicting attrition and the influence on the outcome measures of career development. Results: 2364 (65.3%) participants completed all follow-up surveys. For those with incomplete data, 520 (14.4%) were ‘always-out’, 276 (7.6%) rejoined in the 2020 survey. Unwillingness to participate in residency training (OR=1.311, 95%CI[1.028-1.672]) and unwillingness to provide sensitive information in the baseline survey predicted a higher rate of attrition (providing scores for university entrance exam (OR=1.313, 95%CI[1.064-1.620]; providing contact information (OR=2.762, 95%CI[1.660 - 4.593]; providing household income (OR=1.679, 95%CI[1.122-2.512]). Participants with compulsory rural service (OR=1.516, 95%CI[1.050-2.190]) and those providing university entrance scores (OR=1.639, 95%CI[1.152-2.334)) were more likely to rejoin the follow-up survey. These factors associated with follow-up status did not have significant impact on key outcome measures of career development. Conclusion: Graduates who were unwilling to participate in residency training or not providing sensitive information were associated with higher attrition and should be targeted early in the cohort study to reduce attrition. On the contrary, medical graduates with compulsory rural service and those who provided university entrance scores were more likely to rejoin in the cohort. The overall attrition is unlikely to affect the estimates of outcome measures.

Objective China started a national program in 2010 to train qualified general practitioners with compulsory services in rural and remote areas. While this compulsory services program (CSP) has shown positive effects on staffing primary health care in rural areas, very little is known about how well they perform in the rural service. This study aims to evaluate the job performance of those medical graduates from this program and how the program design has influenced their job performance. Methods A cohort study was conducted with medical graduates from CSP and non-CSP (NCSP) in four medical universities in central and western China. Baseline survey and three waves of follow-up surveys were conducted from 2015-2020. The pass rate of China National Medical Licensing Examinations (NMLE) and self-reported job performance were used as measurements of job performance. Comparisons were made between CSP and NCSP graduates. Multivariable regressions were used to identify factors affecting job performance. Results 2154 medical graduates were included in the sample, with 1586 CSP graduates and 568 NCSP graduates. CSP (90.6%) and NCSP (87.5%) graduates showed no difference in passing the NMLE (P=0.153). CSP graduates reported high job performance, similar to those NCSP graduates (CSP, 63.7; NCSP, 64.2). In the design of CSP, having officially budget posts improved job performance of CSP (β coefficient=4.87, P＜0.05). Working in hometown was also a significant factor that increase job performance when controlling the differences in contracting strategy (β coefficient=1.48, P＜0.05). Conclusion Medical students trained by CSP have demonstrated good job performance in primary healthcare systems in China. Compared to NCSP peers who work in urban areas in majority, CSP graduates’ high job performance could increase the accessibility of equal- or high-quality services in rural areas, which contributes to qualified workforce supply and health equity. Providing officially budgeted posts and working in hometowns can affect job performance and future retention. Early career support can have critical importance for CSP graduates.