Global higher medical education has undergone three transformations: from being discipline - knowledge - centered, to problem - solving - oriented, and now to the third - generation reform, namely competency - oriented medical education^[1].The third - generation medical education, with competency as the orientation, aims to cultivate professional practitioners who can address the challenges faced by the current healthcare system. China has established a multi - level medical education system, but the traditional training model lags behind the development of modern medicine and the demand for high - quality services^[2,3].Both "Healthy China 2030" and the 20th National Congress of the Communist Party of China have emphasized deepening the reform of medical education, accelerating the construction of a high - quality education system and a professional team^[4,5].Currently, there is an urgent need to optimize the structure of talent cultivation and improve its quality to break the bottleneck of the shortage of high - level medical talents^[6].However, studies have shown that although domestic research on competency is relatively mature, there is a lack of research specifically focusing on the competency evaluation index system for clinical teachers^[7].Clinical teachers refer to clinical physicians who engage in the clinical practical teaching of medical students in clinical practical teaching bases (including internship, teaching, and affiliated hospitals). They are not only the main force of the clinical practical teaching team in medical colleges and universities but also the key resource for promoting the development of medical education^[8].Therefore, the construction of the competency evaluation index system for clinical teachers needs in - depth exploration. As the main force of the clinical practical teaching team in medical colleges and universities, clinical teachers are not only the core resource for promoting the progress of medical education but also the key factor determining the quality of clinical practical teaching^[9].Moreover, the quality of practical teaching directly affects the quality of medical talent cultivation. ^[10].Therefore, based on McClelland's Iceberg Model^[11]this study constructs the competency evaluation index system for clinical teachers, so as to help clinical teachers enhance their understanding of job competency and provide a basis for the selection, training, assessment, and evaluation of clinical teachers in the future.

methods

The research team utilised MacLeod's iceberg model as a foundational framework, meticulously collecting literature based on the principles of purposefulness, holism, and scientific rigour. Following the conduction of interviews with five representative clinical instructors and the analysis of the interview data, an initial competency indicator pool was established.Expert consultation was conducted via email correspondence until consensus was reached. Only indicators with an average importance value exceeding 3.5 and a coefficient of variation below 0.2 were retained. The Analytic Hierarchy Process was employed to determine the weights for each indicator within the evaluation framework, followed by consistency testing to establish the final assessment model.

Research team establishment

For the purpose of this research project, a research team was established, comprising one senior medical education administrator cum medical education expert and four postgraduates majoring in medical education. The primary responsibilities of the team encompassed the following aspects:(1) Conducting a comprehensive literature review to develop an initial pool of competency items for clinical teachers;(2) Designing the expert consultation questionnaire;(3) Recruiting consulting experts and establishing communication with them;(4) Gathering and synthesizing expert feedback, followed by data analysis and organization;(5) Participating in multiple thematic group discussions tailored to the specific focus of this research project.

Evaluation system construction

Initial draft

This study first conducted a literature review spanning nearly two decades using Chinese and foreign databases including CNKI(China National Knowledge Infrastructure), Wanfang Data, PubMed, and Web of Science. Search terms included ‘competency’, ‘job competency’, ‘clinical teaching’, ‘clinical instructor’, “competency”, and ‘mode’. Concurrently, established clinical physician competency assessment models from both domestic and international sources were referenced to inform the construction of an indicator pool. Although literature review enabled preliminary screening of competency terms, their suitability for clinical teaching positions remained unclear. Therefore, building upon the preliminary literature analysis, an interview panel was established with a self-designed outline. Semi-structured interviews were conducted with five clinical practice teaching secretaries from five representative clinical departments (Internal Medicine, Surgery, Gynaecology, Paediatrics, and Emergency Medicine) at the First Affiliated Hospital of Anhui Medical University. This group holds dual roles as both clinical practice teaching staff and administrators, possessing both authority and representativeness within the field. Ultimately, grounded in literature analysis and expert interviews, the study established an initial indicator pool adhering to indicator construction principles. This pool comprises four primary indicators—‘Professional Competence, Teaching Competence, Professional Ethics, and Personal Traits’—along with nine secondary indicators and 48 tertiary indicators.

Advisory questionnaire

This study independently designed an expert questionnaire comprising four main sections: (1) Expert background details, including age, gender, highest academic qualification, years of professional experience, position, and professional title; (2) Assessment of the indicator system, wherein experts rated indicators across different levels based on their theoretical knowledge and professional experience. Each indicator was scored for importance using a 5-point Likert scale, accompanied by specific comments; (4) Experts' familiarity with the consultation content and the basis for their judgements. Expert selection constitutes a decisive factor in Delphi studies, as the authority, representativeness, and specialisation of experts determine consultation outcomes. Literature indicates that Delphi expert panels should comprise 15–50 members. Considering this study's scope and to enhance panel diversity, 20 experts were consulted. These individuals, drawn from tertiary hospitals and higher education institutions, specialise in medical education, hospital management, and clinical teaching practice. Expert inclusion criteria were: (1) holding a bachelor's degree or higher; (2) possessing over 10 years' experience in clinical teaching practice; (3) holding an associate senior or higher professional title; (4) providing informed consent to participate in this study and voluntarily committing to complete both rounds of consultation within the research timeframe; (5) being able to offer targeted recommendations from a professional perspective relevant to this study^[12].

Implementation

First round

The research team recruited consulting experts and, upon obtaining their consent, distributed consultation questionnaires via email. These were collected within 15 days. Following the collection of the questionnaires, the experts evaluated certain secondary and tertiary indicators and provided suggestions for modifications or deletions. The research team then collated and analysed the feedback, subsequently revising the consultation questionnaires accordingly.

Second round

The research team first submitted the experts' proposed amendments to the thematic group for in-depth discussion. Based on the conclusions reached, targeted adjustments were made to the questionnaire's indicator system — specifically including refining ambiguously worded indicators, supplementing omitted core items, and removing redundant content or elements deemed poorly aligned with clinical teaching roles. Subsequently, the team resubmitted the revised questionnaire to the experts via email.

Weight assignment of indices

The Analytic Hierarchy Process (AHP) is employed to determine the weights of individual indicators. AHP constitutes a systematic, hierarchical multi-criteria decision-making methodology, suitable for the quantitative and qualitative synthesis analysis of complex problems. Its core principle involves constructing a hierarchical structural model to decompose decision-making problems into objective, criterion, and alternative layers. By integrating expert judgement with mathematical logic, it quantifies the relative importance of elements across these hierarchical levels^[13].

General characteristics of experts

Experts selected in this study were predominantly male, accounting for 70% of the total number. In terms of age distribution, most experts were aged over 50 years (50%), followed by those aged 40–49 years, which accounted for 40%. Regarding the highest educational attainment, the majority of experts held doctoral or master’s degrees, representing 95% of the total; among these, doctoral degrees were the most common (65%). For professional titles, the largest proportion of experts held senior professional titles (80%), while the remaining held associate senior professional titles—no experts held titles below the associate senior level. In terms of professional fields, the distribution of experts was relatively concentrated: administrative personnel constituted the largest group (40%), followed by medical professionals (35%) and teaching professionals (25%). The participants' information is summarised in Table 1.

The expert's positive coefficient, authority coefficient and coordination coefficient

The expert engagement coefficient is typically represented by questionnaire response rates. This study conducted two rounds of expert consultation, both achieving a 100% response rate (20 questionnaires distributed, 20 returned). This indicates high levels of interest and excellent cooperation among experts. The rate of expert feedback was 50% in the first round and 10% in the second, demonstrating that experts were more proactive in proposing revisions during the initial round, with the second round tending towards consensus. The expert authority coefficient (Cr) was calculated jointly from familiarity level (Cs) and basis of judgement (Ca). Familiarity level (Cs) was categorised into five grades: highly familiar, relatively familiar, moderately familiar, somewhat unfamiliar, and unfamiliar. An authority coefficient Cr ≥ 0.7 was deemed indicative of high authority. Calculations reveal that the 20 experts' average basis for judgement (Ca) was 0.965, average familiarity (Cs) was 0.910, and average authority (Cr = (Ca + Cs)/2) was 0.938. This indicates exceptionally high expert authority, lending the research findings considerable credibility.

This study employs Kendall's coefficient of concordance (W) to reflect the consistency of expert opinions, with values ranging from 0 to 1, where higher values indicate greater consistency^[14].The W-value for the first round of expert consultation was 0.191, while that for the second round was 0.158. Although these values are relatively low, both yielded p-values below 0.05, indicating statistical significance. This confirms the scientific reliability of the results^[15].Although the correlation coefficient was not high, the differences were statistically significant, indicating that while expert opinions were dispersed, they were not random. After multiple rounds of feedback, an effective consensus was reached.

Indices modification

The criteria for indicator screening require that the average importance score be > 3.5 and the coefficient of variation < 0.2. Both conditions must be met; otherwise, the indicator will be removed.

During the first round of expert consultation, two experts noted potential redundancy or overlap within the secondary indicator ‘Professional Attributes’ under the primary indicator ‘Professional Competence’, recommending its renaming to ‘Professional Awareness’. Three experts suggested modifying ‘Interpersonal Communication’ to ‘Communication Skills’ and ‘Self-Characteristics’ to ‘Personality Traits’. Regarding tertiary indicator revisions: - ‘Mastery of the progression patterns and prevention principles of common infectious diseases’ was amended to ‘Possession of emergency response capabilities for public health incidents’; - ‘Possession of diagnostic and management capabilities for common and prevalent diseases in internal medicine, surgery, gynaecology, and paediatrics’ was amended to ‘Possession of diagnostic and management capabilities for common and prevalent diseases relevant to the discipline’; ‘Possess diagnostic, emergency treatment, and management capabilities for general emergencies’ was revised to ‘Possess fundamental emergency treatment and management capabilities’; ‘Possess the ability to prepare teaching designs in advance’ was revised to ‘Possess innovative teaching design capabilities’; ‘Be adept at stimulating classroom atmosphere’ was revised to ‘Be adept at creating a conducive teaching environment’; ‘Be adept at posing heuristic questions’ was revised to ‘Be adept at guiding students' critical thinking’. Under the secondary indicator ‘Clinical Practice Capabilities’, ‘Practical capabilities in intelligent medical development’ was added; Under ‘Teaching Design and Methods,’ add ‘Possess the ability to organically integrate information technology, teaching models, and the teaching process’; under ‘Teaching Guidance Capabilities,’ add ‘Possess the ability to cultivate students' autonomous learning and lifelong clinical skills’; under ‘Professional Ethics,’ add ‘Uphold the Chinese Physician's Code of Ethics’; under ‘Professional Awareness,’ add ‘Possess teamwork awareness’; under ‘Personal Characteristics,’ add ‘Possess resilience under pressure’; Relocate ‘Empathy’ and ‘Innovative Capacity’ to the secondary indicator ‘Personality Traits’ with specific interpretative explanations. Consolidate and restructure all tertiary indicators under the secondary indicator ‘Communication Skills’ into four categories: ‘Interpersonal Relationships,’ ‘Teacher-Student Relationships,’ ‘Doctor-Patient Relationships,’ and ‘Superior-Subordinate Relationships.’

The second round of expert consultation saw a reduction in the number of indicators proposed, with assigned values stabilising and coefficients of variation consistently below 0.2, indicating converging expert opinions and strong consensus. Two experts provided supplementary suggestions for two tertiary indicators: ‘Possesses the ability to integrate practical operations with case-based theoretical instruction’ was revised to ‘Possesses the practical educational capability to integrate practical operations with case-based theoretical instruction’; ‘Possesses critical thinking (applying logical reasoning and data analysis to resolve workplace issues)’ was amended to ‘Possesses critical thinking and evidence-based principles (applying logical reasoning and data analysis to resolve workplace issues)’. The final clinical teaching position competency evaluation framework comprises 4 primary indicators, 9 secondary indicators, and 53 tertiary indicators. See Table 2 for details.

Weighting of the Evaluation Indicator System

This study employed the YAAHP 10.1 software to calculate the weights of each indicator in the second round of expert consultation, subsequently conducting consistency tests on the results. All judgement matrices from the 20 experts satisfied a consistency ratio (CR) < 0.1, indicating acceptable indicator weighting outcomes. The composite weight coefficients for each indicator are presented in Table 2. The primary indicators were ranked by weight as follows:‘Professional Competence’(0.3722), ‘Professional Ethos’(0.2918),‘Teaching Proficiency’(0.2463), and ‘Personal Attributes’ (0.0897). Among the secondary indicators, ‘Professional Awareness’ carries the highest weight (0.2189), followed by ‘Professional Knowledge’ (0.1861), ‘Clinical Practice Skills’(0.1861), ‘Teaching Guidance Ability’(0.1292), ‘Teaching Design and Methods’(0.0822), ‘Professional Ethics’(0.0730), ‘Communication Skills’(0.0718),‘Teaching Evaluation and Feedback’(0.0349), and ‘Personality Traits’(0.0179).

Clinical educators play a pivotal role throughout the entire clinical teaching process. Their ethical standards, professional competence, and personal attributes are intrinsically linked to teaching outcomes, constituting key factors influencing the quality of clinical education^[8].Through systematic and in-depth research into the job competencies of clinical teaching staff, this study not only provides theoretical underpinnings for enhancing their professional capabilities and broadens the practical application of competency-based methodologies and theories, but also pioneers new avenues for theoretical research on job competencies, thereby fostering the ongoing development of competency theory. This study employs the Delphi method to construct an evaluation framework for clinical teaching competencies, clarifying the competencies required for educators to deliver high-quality teaching. This framework not only provides quantifiable metrics for teacher selection, training, and assessment but also offers a reference for conducting competency evaluations and tailoring teaching and training programmes. Consequently, it advances the professional development and overall quality of the clinical teaching faculty.Moreover, the professional skills and teaching competencies of clinical faculty directly influence the quality of medical student training. Establishing a competency assessment framework for clinical teaching positions is crucial for enhancing clinical teaching standards, thereby facilitating the cultivation of high-calibre, standardised medical professionals^[16].

This study established an evaluation framework for clinical teaching competencies comprising four primary indicators, nine secondary indicators, and fifty-three tertiary indicators. Among these, the primary indicator ‘Professional Competence’ exhibited the highest significance and lowest coefficient of variation at 0.063. This indicates that the core competency of clinical teaching staff relies upon robust medical knowledge and skills. As individuals fulfilling dual roles as both clinicians and educators, their professional competence directly influences teaching quality. Scores for professional competence were concentrated with minimal divergence, indicating broad expert consensus on its foundational role within the competency framework. Professional conduct ranked second in weighting, as educators' rigorous work ethic and enthusiastic teaching approach exert direct or indirect influence on students through osmosis and instruction^[17].The weighting for teaching ability is slightly lower, though within the sub-indicators, “teaching guidance ability” carries a higher weighting (0.5247). This indicates that teaching ability places greater emphasis on interactive and guiding capabilities within practical teaching contexts, rather than solely on instructional design. Personal characteristics have the lowest weighting (0.0897), as these constitute implicit traits—such as resilience under pressure and empathy—which, while exerting a subtle influence on teaching outcomes, are difficult to quantify. Following two rounds of expert consultation, the weighting coefficients for secondary indicators ranged from 0.1416 to 0.7500, with ‘Professional Consciousness’ holding the highest coefficient at 0.7500. This indicator emphasises professional values such as accountability and ethical integrity, reflecting healthcare's stringent ethical standards and aligning with current anti-corruption policies in the medical sector. ‘Teaching Evaluation and Feedback’ carries the lowest weighting, potentially due to its relatively standardised assessment methods offering limited scope for improvement, coupled with experts deeming its importance subordinate to other teaching components. The weighting coefficients for tertiary indicators range from 0.0009 to 0.0638. Among the top ten weighted tertiary indicators, nine pertain to professional competence, underscoring the critical role of the physician's professional standing in clinical teaching. Educators must establish authority through robust professional expertise to ensure the scientific reliability of teaching content. The highest-weighted tertiary indicator is ‘Mastery of fundamental pharmacology knowledge and rational medication principles (0.0638)’. Pharmacological competence serves as a key differentiator between competent and outstanding clinical educators. Particularly against the backdrop of antibiotic misuse and frequent adverse drug reactions, reinforcing pharmacology education carries pressing practical urgency. Clinical educators must cultivate students' scientific and rigorous approach to medication through demonstrating standardised prescribing practices, thereby preventing medical errors.

This study employed the Delphi method and the Analytic Hierarchy Process to construct a competency model for clinical teaching positions. Guided by the competency iceberg model, this framework comprehensively identifies the requisite competencies for clinical teaching roles, providing novel evidence for clinical faculty development and advancing research on positional competencies within this field. However, owing to constraints on human, material, and financial resources, the experts selected for this study were predominantly concentrated within Anhui Province, resulting in limitations to the representativeness of the sample. Furthermore, the clinical teaching position competency model has yet to undergo practical validation. Subsequent empirical research should be conducted with clinical teaching staff as subjects to further refine and improve this model.