In order to address the challenges to medical fairness, Chinese government initiated a comprehensive healthcare reform in 2019 [1], and medical education became the key to the success of this healthcare reform [2]. As a crucial component of the medical education system, continuing medical education (CME) offers lifelong learning opportunities to medical workers who enters healthcare practice positions after graduating from medical colleges. This is an important approach to assure medical quality [3].

Public hospitals in China provides about 90% of medical services [4]. Currently, a three-level healthcare system is being implemented. To be specific, hospitals are classified into three levels based on indexes [5], such as hospital scale, scientific and research direction, talent and technology strength, and medical hardware, in accordance with Hospital Classified Management Standards. Primary hospitals refer to primary healthcare institutions, i.e., basic-level hospitals directly providing communities with comprehensive medical services, including medical treatment, disease prevention, recovery, and healthcare. Secondary hospitals refer to regional technical centers for medical treatment and disease prevention, i.e., regional healthcare facilities which provides health services for several communities. Secondary hospitals primarily focus on the guidance of monitoring of high-risk groups. Moreover, they accept referrals from primary hospitals, and offer professional and technical guidance for primary hospitals. Additionally, secondary hospitals are capable of performing teaching and scientific research to a certain extent. Tertiary hospitals refer to healthcare facilities that provide services across cities, provinces, regions and even the whole country. Furthermore, they are medical treatment and disease prevention technical centers with comprehensive capabilities for medical treatment, teaching, and scientific research. Tertiary hospitals mainly provide specialized medical services, diagnose, treat critical, difficult and complicated diseases, accept referrals from secondary hospitals, and offer professional and technical guidance, and train talents for hospitals at lower levels. Additionally, tertiary hospitals are in charge of cultivation and the teaching of various senior medical professionals, undertaking scientific research projects at provincial level and above, and attending and guiding the disease prevention work of primary and secondary hospitals.

The current three-level healthcare system in China may influence doctors’ diagnosis and treatment skills, especially doctors from primary and secondary hospitals. This can result in patients’ distrust due to the perceived limitations in their current professional skills. As a consequence, a large number of urban and rural patients intend to seek medical consultation in tertiary hospitals. The improvement of the professional level of basic-level medical institutions is the key to assuring the balanced development of China’s three-level healthcare system. This research executed, for the first time, a large-sample investigation on the degree of mastery of common diseases by doctors from hospitals at different levels in China. The needs for contents and methods of CME were evaluated through the distribution of network questionnaires. These efforts aim to provide scientific basis for the improvement of the continuing education in medical institutions at each level.

The demographic data in our investigation have revealed that doctors from secondary hospitals have the highest need for continuing education and learning among the main groups participating in continuing education and learning. The current three-level healthcare system in China provides doctors from secondary hospitals with more opportunities than those from primary hospitals to diagnose and treat relatively complicated diseases compared to those from primary hospitals. However, they face limitations in patient resources, unlike doctors from tertiary hospitals, which restrains the improvement of their professional skills. As a result, this group of doctors exhibits the greatest need for continuing education.

In our investigation, according to the results of both single-factor analysis and regression analysis after correction of multiple factors, the degree of doctors’ mastery of diseases herein presented significant positive correlation with the hospital level. In most high-income countries, doctors are a homogeneous group, receiving the same level of education and training. However, in order to quickly increase the number of doctors, multilevel medical education system has been adopted in China in order to train physicians since the 1950s. While some doctors have undergone comprehensive education and training, others have only received short-term or incomplete training, thus resulting in the heterogeneity of Chinese doctors [8]. This education system has benefited the increase of healthcare professionals in China at a lower cost. On the other hand, it has also resulted in the inequality and efficiency loss of medical treatment and healthcare, thus paying the price for the multilevel medical education. The three-level medical system of China has further resulted in the inequality of talent distribution, and doctors who have received higher learning are more likely to be hired by high-level hospitals [9]. Since a hospital-centered healthcare system is adopted in China, patients would thus chase good doctors by visiting high-level hospitals. This status quo has created a situation where doctors in high-level hospitals have more opportunities to diagnose and treat various diseases, allowing them to master their understanding of said diseases. Currently, China is trying to change the gap existing in the medical education. According to the national statistical data, the number of five-year medical students as increased from 320,000 to 3,050,000, and the number of three-year medical students in the same period as also increased from 530,000 to 1,210,000, from 1999 to 2018. According to the forecast of distribution of physicians’ education degrees from 2015 to 2035, the ratio of physicians with education background of undergraduate and above will grow from 47% in 2015, to 54% in 2035 [10]. The already practicing doctors mainly improve their treatment level through CME. Therefore, another concern for our research is how to launch CME to provide the most efficient services to the doctor group.

The professional direction expected by doctors from hospitals at each level for strengthening of training, favorable training contents, and the degree of mastery of 19 diseases by doctors from hospitals at each level supplement each other. Doctors from hospitals at each level had relatively weak mastery of related gynecological endocrine diseases. In regard to professional direction expected for strengthening of training, doctors from hospitals at each level selected gynecological endocrine diseases as their first choice. Moreover, more than half of doctors from secondary and tertiary hospitals were familiar with, and even comprehensively mastered common gynecological and obstetric diseases. Since surgeries are the daily work of doctors from secondary and tertiary hospitals, needs for surgical skills ranked the second place. Doctors from primary and other hospitals seldom have the opportunity to engage in surgeries in their daily work due to the restriction of hospital levels, and therefore they have greater needs for the training of diagnosis and treatment of common gynecological diseases.

All doctors from hospitals at each level mainly chose online training forms and expected method to acquire professional resources and support. Meeting report and periodic WeChat push were the two training forms least chosen. With the development of network technology and the pandemic of coronavirus disease 2019 (COVID-19), online learning and medical education have been gradually integrated, and remote learning has become the norm [11]. According to some research findings, online learning has a certain impact on the learning effect due to its flexibility and convenience [12]. Furthermore, the quality of online learning is also a research focus. A meta-analysis indicated that the improvement of internet-based learning forms was seemingly related to learning achievements in terms of interaction, exercise, feedback, and repetition [13]. Other studies indicated that certain factors might influence the effect of online learning, such as interaction and communication between lecturers and trainees, centering on learners or not, and teaching based on learners’ purposes and expectations [14, 15]. However, an investigation targeted at senior doctors in Australia, with more than half of them being general practitioners, indicated that CME in traditional forms was much more popular than online learning [16]. The possible reason for this difference was analyzed as related to whether the contents of online learning complied with the educator’s actual work needs and preferences.

The low response rate to the online questionnaire makes it possible that our findings are not representative of a larger group of physicians, potentially skewing our results in favor of physicians who have more time, or who are more willing to take the survey. The online questionnaire model may favor those who prefer to interact online. On the other hand, deviation may occur due to participants choosing to take online courses.

Our investigation results indicated that the degree of doctors’ mastery of diseases presented positive correlation with different hospital levels, and gynecological endocrine diseases were not effectively mastered by doctors from hospitals at the different levels. Doctors from hospitals at each level failed to effectively master gynecological endocrine diseases, and AUB, menopausal syndrome, and PCOS were confirmed as diseases for which the doctors had the greatest need of continuing education. China’s three-level medical system results in differential distribution of medical resources, and CME might be one of the methods to narrow this gap. Network teaching is a popular teaching method, and further researches shall be conducted as how to improve teaching quality by optimizing teaching methods.

All data points generated or analyzed during this study are included in this article and there are no further underlying data necessary to reproduce the results.

AS conceived and designed the study. HW, HD, YZou, WW, QZ, YF, ZT, XZ and YZhao performed the research. HW, JC, ZZ and YW extracted the data. HW analyzed the data and wrote the manuscript. AS, JC and ZZ revised the manuscript and supervised the study. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

All subjects gave their informed consent for inclusion before they participated in the study. This nationwide online survey was approved by the Ethics Review Committee of the Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, on June 8, 2020 (No. S-K 1206).

We would like to express our gratitude to all those who helped us during the writing of this manuscript. We thank Xiaoping Xiao for help in extracting the data. Thanks to all the peer reviewers for their opinions and suggestions.

This study was supported by the Capital’s Funds for Health Improvement and Research (CFH:2020-2-40113).

The authors declare no conflict of interest.