Embedding career development into clinical clerkships: an action research project with a cross-sectional mixed-methods evaluation among Chinese medical students

Abstract Background: In China, three-year vocational medical programmes supply much of the grassroots health workforce, yet career support is confined to classrooms and absent from clinical clerkships—a "functional isolation" contributing to indecisive career choices and workforce mismatch. We report the implementation of a career-embedded clerkship support system and a descriptive evaluation of students' career development after a 16-week clerkship. Methods: Using action research (four 4-week plan–act–observe–reflect cycles), we implemented a structured Career Development Log (task record, career reflection, competency evidence, mentor feedback) and a tri-mentor mechanism (clinical preceptor, career mentor, industry role model) in three tertiary hospitals and five community health centres. A cross-sectional mixed-methods evaluation comprised a survey of 1,000 final-year students (12 Likert items in three dimensions; two open-ended questions), 37 student interviews, and process records. Non-parametric tests with effect sizes were primary; open responses were LLM-assisted coded; interviews were thematically analysed. No causal inference was attempted. Results: Internal consistency was excellent (α=0.950). Self-perceived competence (3.92) and professional identity (3.83) exceeded career decision-making readiness (3.58); plan formulation had the lowest agreement (46.6%). Rural-origin students and women reported lower career decision-making readiness (p=0.013, p=0.007; |r|≈0.10), scores rose with parental education; self-perceived competence showed no subgroup differences—all effects were small. Tertiary hospitals were the most frequently selected employer (61.8%); primary care was selected by 54.1% but ranked first by only 15.8%. In open-ended responses (n=909), 18.0% reported a specific direction and 59.6% no obvious change. Of students naming one most influential element (n=558), career mentors (57.5%) far outweighed role models (28.1%) and the log (14.3%). Process indicators improved across cycles (log submission 52%→71%; preceptor comment participation 21%→46%). Interviews revealed shifts from idealised to realistic views, technique-first to whole-person care, and conformity to active planning. Conclusions: Embedding structured career development support in vocational medical clerkships is feasible and acceptable, and iterative refinement was essential. Students valued human guidance—especially career mentors—over the reflective tool itself, suggesting that reflective instruments work best within responsive interpersonal feedback loops. Given the cross-sectional design, findings are descriptive; controlled, longitudinal studies are needed.