Based on the BEI method, this study identified six core competencies that pediatric residents should have: professional spirit, clinical skills, communication ability, learning ability, mental capacity and research ability. csQCA was conducted, and a truth table algorithm was used to identify sufficient solutions. The results in Fig. 1 confirm our hypothesis that the core competency of pediatric residents cannot be achieved through a single factor but can be achieved through multiple and equivalent configurations of these causal condition variables. Excellent pediatric residents were mainly the "clinical type", "scientific research type", "all-around development type" and "high emotional intelligence type", while general pediatric residents generally lacked mental capacity.
Competency index and comparison with existing research
The six competencies identified by this study were consistent with international mature competency models.
Professional spirit
With the development of medicine, medical education has gradually changed from a focus on natural science knowledge and clinical skills to a focus on patients’ needs [43]. With the proposal of residents’ post competency, residents’ professionalism and humanistic quality are among the six core competencies necessary for resident doctors [44]. Foreign scholars studied occupational spirit in the medical field relatively early, and the United States formed a relatively complete system of physicians’ occupational spirit education and evaluation [45]. The competency model developed by the Accreditation Council for Graduate Medical Education (ACGME) and the American Academy of Medical Sciences after years of research and practice also indicates that residents must possess professional spirit after participating in residential training [46]. The 'Global Standards in Basic Medical Education' created by the World Federation of Medical Education (WFME) state that residents should be able to handle health issues with appropriate and effective empathy and have strong professional ethics [47]. Many studies have shown that professional spirit is an important lever to improve the quality of medical services, so it is important to cultivate doctors’ professional spirit [48]. Many scholars put clinical skills and medical services in first place among the core competencies of clinicians, but the coding results of this study showed that the most frequent occurrence was professional spirit [15]. The results of this study indicate that in their particular specialty, pediatricians are faced with double pressure from children and their families and need to have more empathy and responsibility than clinical skills.
Clinical skills
Pediatric residents should have a certain type of thinking regarding clinical diagnosis and treatment and should be able to systematically connect the knowledge they have learned to make reasonable diagnosis and treatment plans. They should master basic clinical operations together with the entire medical team to provide patients with comprehensive, high-quality medical services. In the “Administrative Measures for Standardized Training of Resident Doctors (Trial)”, China clearly stated that STFR should train clinicians in solid medical theoretical knowledge and clinical skills for medical institutions at all levels so that they can independently and normatively undertake the diagnosis and treatment of common and multiple diseases in their specialty [49]. The General Medical Council of Britain (GMC) completed a new round of revision of Good Medical Practice in 2013, which has been revised into four core aspects: knowledge, skills and performance; safety and quality; communication, partnership and teamwork; and maintaining trust. The first section states that clinicians should provide a good standard of practice and care. The primary responsibility of physicians is to clearly diagnose patients and effectively treat and relieve pain, which is the most important manifestation of the social value of physicians [50].
Communication ability
It is necessary to pay attention not only to the improvement of clinical skills but also to the cultivation of residents’ communication ability and consciousness [51]. The communication section of the Good Medical Practice implemented by the GMC states that clinicians should listen and respond to patients’ concerns and preferences, give patients the information they want or need in a way they can understand, respect patients’ right to make decisions about their treatment and care, and support patients in caring for themselves to improve and maintain their health. CanMEDS divides the competence of a good clinician into seven roles, including the role of communicator [15]. In 2014, the “Contents and Standards of Standardized Training for Residents (Trial)” released by the former National Health and Family Planning Commission also included professional interpersonal communication and teamwork in the training objectives of resident doctors [52]. Studies have shown that the most important reason for medical complaints or disputes is poor communication between doctors and patients [53]. Therefore, strengthening doctor‒patient communication can prevent and solve some doctor‒patient disputes [54].
Learning ability
Self-learning ability is one of the core educational objectives of STFR [55]. The ACGME made this clear when designing core competencies for residency training: "Residents must demonstrate the ability to explore patient care processes, evaluate and integrate scientific evidence, and improve patient care based on continuous self-reflection and lifelong learning", namely, practice-based learning and improvement ability [16]. The medical and health industry requires lifelong learning, practice and continuous education [56]. In particular, the medical knowledge system is rapidly updated with changes in the social economy and technology, so lifelong learning ability is crucial to the cultivation of qualified residents [57].
Mental capacity
Mental capacity means having good psychological quality, being able to make timely adjustments to one’s mentality under great work pressure in the medical industry, and having good adaptability and coordination ability when dealing with emergency situations. Due to the serious shortage of pediatricians, their work tasks are more onerous than those of other clinicians. At the same time, the onset of pediatric diseases is faster and more urgent than that of other diseases, which makes pediatrics more prone to dangerous situations, leading to high risk and high stress [58]. This requires pediatric residents to have the ability to resist pressure and strain on the basis of sufficient medical knowledge and clinical skills. Doctors’ good mental health status is conducive not only to the improvement of their overall health but also to the diagnosis, treatment and rehabilitation of patients [59]. Therefore, it is necessary to cultivate good psychological qualities in residents and reduce the gap between them and clinical experts [14]. However, there are few relevant studies and evaluation methods in China, and the international model for mature resident competency does not cover this dimension.
Research ability
The development of medicine depends on innovation in medical knowledge and the deepening of medical research. Clinical practice is the foundation of clinical medicine, but scientific research is the future strength. Without scientific research, clinical medicine will stop moving forward [60]. With only experience and no scientific research to guide clinical practice, the development of medical education will involve the traditional teaching of traditional artisans [61]. Pediatric residents should have the ability to retrieve and read a large number of studies, pursue certain innovation abilities, and independently write various materials, such as research papers, scientific and technological reports, and project applications [62]. Some studies have noted that residents' lack of independent time, uncertain course arrangements, heavy clinical workload and lack of financial support limit the development of their scientific research ability, especially in the aspects of paper writing and statistical analysis [63, 64]. Although there is no rigid requirement for the completion of the residency program, pediatric residents should adjust their degree of mastery according to their own energy, independently pursue certain innovation abilities, and be able to find problems and questions from actual cases to enrich the pediatric care system [65].
Competency configuration analysis of two groups
Excellent performance configurations
Each pediatric resident has a different combination of competencies, and the competencies of excellent pediatricians differ from those of general pediatricians. In this study, there were four types of excellent pediatricians: the clinical type, scientific research type, all-around development type and high emotional intelligence type.
The path of the clinical type is as follows: PS*CS* ~ CA* ~ LA* ~ MC* ~ RA. The interviews also indicated that professional spirit and clinical skills often come together, and pediatric residents with these skills feel a strong sense of achievement when they use their medical skills to provide patients with necessary medical services and achieve good outcomes. At the same time, pediatric residents who focus on clinical services tend to invest time and energy in daily medical activities, so the corresponding work pressure is also greater [66]: "It was the most painful day at work I have ever worked, but I felt a sense of accomplishment to have saved a child."
The scientific research path is as follows: ~ PS* ~ CS*CA*LA* ~ MC*RA. Pediatric residents of this type are often able to determine doubtful or difficult points of a disease through communication with patients and their parents in daily medical activities and consult literature and books independently after work, so their scientific research achievements are relatively fruitful. With the implementation of the dual track of the training of medical graduate students and resident doctors, the requirements for the clinical ability of pediatric residents are increasing, but scientific research training is still in a relatively weak position [67]. An interviewee for this study said, "I think both the Department of Infection and the Department of Neurology are very fond of learning. After finding a suitable case, they will look through the literature or summarize by themselves".
The path of the all-around development type is as follows: PS*CS*CA*LA* ~ MC*RA. The interviews indicated that most of the pediatric residents believed that too little time was allocated to research during the training period, and they had to sacrifice their rest time to balance clinical and scientific research: "Basically, I spent the day in the department and the night in the lab, doing some experiments in my rest time." In this regard, many all-around development pediatricians often feel excessive work pressure and have difficulty regulating their emotions: "In addition to clinical work to do well, the department will also divide some tasks to write articles. I often feel powerless and want to resign.” Approximately 18.18% of the excellent pediatric residents were explained by this approach. A comparison of path 1 and path 3 reveals that if a clinical resident can improve his or her communication ability, learning ability and research ability, he or she can transform into the all-around development type. Similarly, a comparison of path 2 and path 3 reveals that if a resident of the scientific research type can improve his or her professional spirit and clinical skills, he or she can transform into an all-around development type.
The path of the high emotional intelligence type is as follows: PS*CS*LA*MC* ~ RA. The interviews indicated that this type often has a high degree of professional spirit. They believe that pediatrics is a sacred profession, and they are willing to deal with children. Therefore, they can relieve their stress even if work pressure is high. This is the only one of the four paths in which mental capacity exists. This path explained approximately 27.27% of the cases, and the proportion was relatively high.
General performance configurations
A comparison of paths 2a' and 2b' revealed that although communication ability and clinical skills exist as core conditions, when professional spirit and mental capacity do not exist, excellence cannot be achieved. The interviews indicated that this type of pediatric resident was relatively less empathetic and more self-centered. Therefore, they tended to become bored and lose their work enthusiasm when faced with high work pressure: "The Children's Hospital was too busy; most of the time was spent doing mechanical work. In addition, the relationship between doctors and patients in pediatrics was also very tense, so there was the idea of giving up" and "Especially when I just moved to a new department, I basically had to work overtime until 10 o'clock at night every day, which made me feel tired physically and mentally anxious.” The two paths each explained approximately 9% of the cases.
Path 3' was the type with poor communication skills. The interviews indicated that many of these pediatric residents had poor communication skills although they were skilled in operation, leading to many conflicts with patients’ parents. Pediatrics is one of the clinical departments where disagreements and conflicts are most likely to arise between doctors and patients [68]. Thus, young pediatricians need to strengthen their doctor‒patient communication ability. Many young pediatricians cannot effectively communicate with children and their parents when faced with the diversity of children and their families and cannot participate in the diagnosis and treatment of clinical diseases [69]. Because children are too young to accurately describe their condition, in most cases, doctors need to rely on their own experience for diagnosis. To enhance family members’ trust, doctors need to understand their anxiety, explain patiently, and inform them about situations that may occur so that family members can anticipate them [70]. Poor communication between doctors and patients is one of the main reasons for violent medical injuries. Only when doctors and patients understand and trust each other can disputes between them be reduced [71]. At the same time, active and effective doctor‒patient communication can enable patients to more comprehensively obtain information related to the disease so that a diagnosis and treatment plan can be developed more quickly and accurately, the medical compliance of the families of sick children can be strengthened, and the medical effect can be improved. Therefore, medical colleges and universities should strengthen residents’ training in communication [72].
The current resident competency model does not involve the dimension of mental capacity alone, but the necessity analysis of the causal conditional variables shows that poor mental capacity is a necessary condition for the general performance of pediatric residents, indicating that mental capacity is also crucial to the career development of resident doctors [73]. In recent years, given the tension in doctor‒patient relationships, the improvement of medical work quality and workload demand, the psychological pressure borne by physicians has increased significantly. In particular, the high work intensity, high medical risk and low remuneration in pediatrics not only affect the quality of doctors’ lives as well as the level of clinical diagnosis and treatment but also cause a variety of psychological illnesses [74]. Positive psychological intervention has significant value in the psychological regulation of physicians, as confirmed by clinical studies [75]. However, the popularization and application of such interventions require research data support. In the future, mental capacity education training for pediatric residents should be strengthened.
