订单定向和普通临床毕业生收入纵向比较研究

Income of Order-oriented Medical Graduates and General Clinical Graduates:a Longitudinal Comparative Study

背景农村订单定向医学生免费培养政策的实施为我国中西部地区培养了大量基层卫生人才。到2021年夏季,首届订单定向毕业生已完成服务期面临留任和离开的选择,收入情况是影响其选择的重要影响因素,而现有关于订单定向毕业生收入情况研究仍较少。目的应用订单定向医学生队列研究的面板数据,比较分析订单定向毕业生和普通临床毕业生的收入在职业生涯早期的变化趋势,分析影响收入变化的因素。方法选取青海大学、广西医科大学、九江学院和赣南医学院4所医学院校,2015—2019年每年建立订单定向毕业生队列,并匹配选取同届的普通临床毕业生作为对照,进行基线调查,内容包括基本信息、家庭信息等。于2016、2017、2018和2020年共进行4次随访调查,内容包括住院医师规范化培训(简称规培)情况、通过执业医师考试情况、工作情况等信息。应用固定效应模型探究订单定向毕业生和普通临床毕业生收入的影响因素,并通过倾向评分匹配(PSM)对结果进行稳定性检验。结果毕业后前两年,订单定向毕业生的收入高于普通临床毕业生,差异有统计学意义(P<0.05);毕业两年后,订单定向毕业生的收入低于普通临床毕业生,差异有统计学意义(P<0.05)。固定效应模型结果显示,完成规培情况、通过执业医师考试情况、有无职务晋升、毕业年限是订单定向毕业生收入的影响因素(P<0.05);完成规培会使订单定向毕业生收入降低47%,通过执业医师考试和职务晋升分别使其收入增加16%、10%,在毕业后第3、4、5年订单定向毕业生的收入较毕业第1年时的增幅分别为7%、16%和34%。换工作情况、毕业年限是普通临床毕业生收入的影响因素(P<0.05);换工作使普通临床毕业生收入增加15%,在毕业后第3、4、5年普通临床毕业生的收入较第1年收入的增幅分别为27%、83%和101%。双向固定效应模型回归结果显示,完成规培情况、通过执业医师考试情况、换工作情况、有无编制、毕业年限对订单定向毕业生和普通临床毕业生收入的影响不同(P<0.05)。利用PSM后的数据进行双向固定效应模型回归分析,得到的结果与基于原始样本得出的结果相似,一致性较好。结论订单定向毕业生的收入起点较高,但增速明显低于普通临床毕业生,两者收入差距逐年拉大,主要原因为订单定向毕业生规培结束后失去规培补助及工作机构的不同带来的收入差异。同时订单定向毕业生出现毕业时长增加收入反而降低的现象,将严重影响其基层服务的绩效和意愿。

Background The free training for rural order-oriented medical students has trained a large number of primary health personnel for the central and western regions of China.By the summer of 2021,the first order-oriented medical graduates had completed their compulsory service and face the choice of staying or leaving.The income is an important influencing factor of their choices,however,there are still few studies on the income of order-oriented medical graduates.Objective The panel data of order-oriented medical graduate cohort study was used to compare and analyze the change trend of the income of order-oriented medical graduates and general clinical graduates in the early career,and to explore the influencing factors of the change of income.Methods Qinghai University,Guangxi Medical University,Jiujiang Medical University and Gannan Medical University were selected to establish the order-oriented medical graduate cohort every year from 2015 to 2019,matching the general clinical graduates of the same grade as controls.The baseline survey was conducted,including basic information and family information.A total of four follow-up surveys were conducted in 2016,2017,2018 and 2020,including the status of standardized resident training(hereinafter referred to as"standardized training"),passing of medical licensing examination,working conditions and other information.Fixed effects model was used to explore the factors influencing the income of orderoriented medical graduates and general clinical graduates,and propensity score matching(PSM)was used to test the stability of the results.Results In the first two years after graduation,the income of order-oriented medical graduates was higher than general clinical graduates,and the difference was statistically significant(P<0.05).Two years after graduation,the income of order-oriented graduates was lower than general clinical graduates,and the difference was statistically significant(P<0.05).The results of the fixed effects model showed that completion of standardized training,passing of the medical licensing examination,working position,and year of graduation were factors influencing the income of order-oriented graduates(P<0.05).The income of order-oriented graduates who completed the standardized training decreased by 47%,and the income of the graduates who passed the medical licensing examination and promoted increased by 16%and 10%,respectively;the income of the graduates in the third,fourth and fifth years after graduation increased by 7%,16%and 34%,respectively,compared with the first year of graduation.Job change and graduation years were the factors influencing the income of general clinical graduates(P<0.05);Job change increased the income of general clinical graduates by 15%,and the income of graduates in the third,fourth and fifth year after graduation increased by 27%,83%and 101%,respectively,compared with the first year.The regression results of two-way fixed effects model showed that the completion of standardized training,passing of the medical licensing examination,job change,staffing and graduation years had different effects on the income of order-oriented graduates and general clinical graduates(P<0.05).The regression results of two-way fixed effects model using the data after PSM showed similar to the results of the original sample with good consistency.Conclusion The starting point of income of order-oriented graduates is higher,but the growth rate is significantly lower than general clinical graduates,the income gap between them has been increasing year by year.The main reasons include the loss of training allowance after the standardized training of order-oriented graduates and the income difference caused by different working institutions.At the same time,the income of order-oriented graduates decreases with the increase of graduation time,which will seriously affect their performance and willingness of primary care.