Introduction

Since the beginning of the 21st century, with the rapid progress of China’s socioeconomic development, significant changes have occurred in the lifestyles of Chinese people. Moreover, accelerated urbanization and population aging have led to a marked increase in the risk of cardiovascular diseases (CVD) among the Chinese people1,2. Currently, CVD has become the leading cause of death in China3. To address the challenges posed by CVD, it is essential to establish a high-quality cardiovascular workforce. McClelland proposed the concept of competence, suggesting that competence is a deep-seated characteristic that distinguishes individuals with outstanding achievements from ordinary ones4. This concept of competence is crucial for accurately and rapidly selecting, appointing, and training high-quality personnel in the cardiovascular workforce5.

Internationally, research on the competence model of cardiologists has already begun. Since the release of the first Core Cardiovascular Training Statement (COCATS) in 1995, the American College of Cardiology (ACC) has defined the knowledge, experience, skills, and behaviors required for clinical cardiologists6. Subsequent revisions have shifted towards competency-based training, guided by the six domains of competence established by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties, as well as the American Board of Internal Medicine (ABIM)7. The ACC has adopted a similar approach to emphasize the consistent lifelong learning abilities that practicing cardiologists should maintain8. Additionally, the Royal College of Physicians and Surgeons of Canada’s CanMEDS framework outlines seven roles for physicians to fulfill their professional duties9. The European Society of Cardiology (ESC) has also developed a comprehensive series of core curricula in areas such as general cardiology10 cardio-oncology11 percutaneous valvular and structural heart disease interventions12 preventive cardiology13 and cardiovascular nursing14 facilitating the standardization and coordination of training and assessment within the field. Furthermore, countries and regions such as the United Kingdom, Japan, and Singapore have respectively integrated Western research findings with their own traditional culture and social background to conduct relevant studies on the competence composition of physicians15.

Chinese CVD has its own characteristics, including changes in the epidemiology of CVD due to the interrelated changes in population, environment, lifestyle, and healthcare. These changes include an increase in the burden of atherosclerotic CVD (ischemic heart disease and ischemic stroke), a decrease in the mortality rate of hemorrhagic stroke, various epidemiological trends of CVD subtypes in different regions, an increase in the number of patients with moderate ischemic heart disease and ischemic stroke, and the exacerbation of the aging of CVD patients. Other characteristics also highlight issues that need special attention, such as the high proportion of out-of-hospital deaths among ischemic heart disease patients due to insufficient pre-hospital care, a significant gap between guideline-recommended targets and levels of lifestyle indicators, and a large number of patients with undiagnosed, untreated, or uncontrolled hypertension, hypercholesterolemia, or diabetes16,17,18,19,20,21,22,23,24.

Currently, many scholars have conducted research on the competence model of clinical physicians in China. For example, in 2015, Professor Baozhi Sun’s team proposed a general competence model for clinical physicians in China25,26. Additionally, some scholars have proposed competence models for general practitioners, department heads, emergency physicians, clinical medical teachers, and traditional Chinese medicine physicians. However, a competence model specifically tailored to cardiovascular physicians with Chinese characteristics has not yet been established27,28,29,30. This context is shaped by several unique factors, including distinct epidemiological trends in cardiovascular diseases31sociocultural values32healthcare delivery systems33medical education structures34and patient expectations35. These factors collectively influence the competency requirements of cardiovascular physicians and differentiate them from those in other countries or regions. Therefore, constructing a competency model that reflects these contextual realities is essential. This model can also serve as a reference for public health departments in the recruitment, assessment, and residency training of cardiovascular physicians, laying the foundation for further realizing the objectives of the “Healthy China 2030” plan.

Materials and methods

Ethics statement

This study was conducted in accordance with the Declaration of Helsinki. Ethics approval was obtained from the Research and Ethics Committee of the Second Affiliated Hospital of Guangzhou Medical University. The study design and information sheets were reviewed and deemed appropriate by the committee. All 20 experts provided written informed consent and voluntarily participated in the study. Participant information was kept confidential, and participants had the right to withdraw from the study at any time.

Modified Delphi method

This study employed the modified Delphi method to develop a competency model for cardiovascular physicians tailored to the Chinese context. The Delphi method, developed by the RAND Corporation, is a consensus-building approach that gathers a panel of experts to systematically obtain structured feedback through questionnaire surveys based on consensus opinions36,37. Widely used in medical research, it remains one of the most common methods for selecting quality indicators in healthcare. The process involves multiple rounds of questionnaire responses from experts, with anonymity maintained within the expert panel. Experts receive feedback on aggregated responses after each round and have the opportunity to revise their answers38,39. To meet the study’s objectives, various adaptations of the Delphi method, collectively referred to as “modified Delphi method,” were employed while adhering to its fundamental principles40,41,42. The study conducted two rounds of questionnaire surveys with an expert panel via email or mail from April to June 2024. Throughout the application of the modified Delphi method, the study followed established research and Delphi survey technical guidelines43,44,45,46.

The establishment of the initial competency model

The modified Delphi method used in this study consisted of two stages: (1) conducting a literature review, behavioral event interviews, and expert consultations to compile an initial set of competencies and develop the Delphi questionnaire; (2) conducting two rounds of Delphi surveys with cardiovascular internal medicine experts to achieve consensus on competencies tailored to the Chinese context and construct the competency model. The research process is illustrated in Fig. 1.

Fig. 1
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Research process diagram.

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Selection of study participants and experts

This study selected cardiovascular physicians and experts from Guangdong Province as representatives for the research. This decision was primarily based on Guangdong’s significance as a major economic and cultural hub in southern China, characterized by its typical geographical location, economic status, and population composition. Firstly, Guangdong’s status as a port city facilitates frequent international exchanges, allowing doctors in this region easier access to advanced international medical technologies and concepts47,48. Secondly, as a pioneering region in China’s reform and opening-up policies, Guangdong boasts abundant medical resources and advanced medical equipment, conducive to establishing a high-level competency model49,50. Additionally, the diverse population composition in Guangdong, consisting of residents from various regions and cultural backgrounds, ensures the representativeness of the research data51,52. Importantly, the prevalence of cardiovascular diseases in Guangdong aligns with the typical characteristics of CVD in China, making it an ideal location to study and address the challenges posed by CVD in China and provide robust support for the construction of a competency model tailored to the Chinese context3,16,53.

It is acknowledged that this sample may not fully represent physicians in rural or resource-limited areas, where cardiovascular diagnosis and treatment is typically provided by general internal medicine departments in primary or lower-tier secondary hospitals54,55. According to China’s Hospital Classification Management Measures, only secondary and tertiary hospitals are required to establish independent cardiovascular departments56. In rural areas, patients with complex or severe cardiovascular conditions are typically referred to higher-level hospitals via China’s hierarchical diagnosis and treatment system, which is supported by a cross-regional and multi-tiered health insurance reimbursement framework57,58. Despite these regional differences, the study adopts a competency-based framework grounded in the understanding that core competencies—defined as the deep, underlying attributes distinguishing superior from average clinical performance—are consistent across practice settings59,60. The model developed in this study reflects high-level competency expectations, which serve as benchmarks for excellence rather than basic entry-level standards. Furthermore, the study recognizes the importance of competency stratification, as outlined in frameworks such as the ESC Core Curriculum and CanMEDS, where competency levels (e.g., 1–2 for generalists and 4–5 for subspecialists) vary by clinical role and context11,61. Future research is warranted to explore how such stratified models can be adapted to suit the needs of low-resource settings, thereby supporting more context-sensitive workforce development across China. Therefore, selecting physicians and experts from Guangdong Province for this study is particularly significant, given the province’s advanced medical infrastructure and diverse patient population, making it an appropriate setting for modeling high-level cardiovascular diagnosis and treatment competencies.

The physicians and experts participating in the behavioral event interviews and expert interviews all come from the Cardiovascular Disease Research Institute of Guangzhou Medical University.

The research team selected 20 experts from well-known hospitals in Guangdong Province, specializing in cardiology. This number aligns with the Delphi method’s requirement for the number of experts, which ranges from 15 to 5062. The participating experts were from the following hospitals: The Second Affiliated Hospital of Guangzhou Medical University, The First Affiliated Hospital of Guangzhou Medical University, The Third Affiliated Hospital of Guangzhou Medical University, The Affiliated Panyu Central Hospital of Guangzhou Medical University, Shenzhen Longcheng Hospital, Guangdong Provincial People’s Hospital, Guangzhou Red Cross Hospital, Zhujiang Hospital of Southern Medical University, Southern Medical University Hospital of Integrated Traditional Chinese and Western Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Armed Police Corps Hospital, Guangzhou Women and Children’s Medical Center, and The First Affiliated Hospital of Jinan University. The criteria for selecting the experts included: (1) possessing solid knowledge in general cardiology and internal medicine, along with recognized academic achievements and reputation in the field of cardiology; (2) holding a senior professional title; (3) having 10 or more years of clinical experience; and (4) being involved in the training, teaching, and practice of cardiology. Expert information is detailed in Table 1.

Table 1 Expert information.
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Preparation of the Delphi questionnaire

Literature review

First, the research group referenced the framework of the General Competency Model for Chinese Clinical Physicians from China Medical University and established eight primary indicators, including clinical skills and medical services, disease prevention and health promotion, information and management skills, medical knowledge and lifelong learning ability, interpersonal communication skills, teamwork skills, scientific research skills, and Core Values and Professionalism25,26. Then, in March 2024, a search was conducted in the WOS database for publications related to cardiovascular physicians. Specifically, we used the search strategy ((“Cardiovascular” AND (“Physicians” OR “doctor”) AND (“competency” OR “competencies” OR “core competencies” OR “evaluation” OR “measurement” OR “tool” OR “indicator”))) to retrieve 1951 publications. After excluding publications unrelated to cardiovascular internal medicine by filtering through Web of Science Categories, Citation Topics Meso, and Citation Topics Micro, 226 publications were retained. Subsequently, each publication’s content (including titles and abstracts) was manually reviewed to eliminate duplicates, literature reviews, and irrelevant publications, ensuring that the selected publications addressed the construction of competency models for cardiovascular physicians. Finally, 50 articles were retained for further analysis (Supplementary Table 1).

From these sources, secondary indicators were extracted, and a panel of two reviewers (ML and HL) was formed to screen them based on the following criteria: (1) indicators measuring physicians’ abilities; (2) indicators relevant to the work of cardiovascular physicians; (3) indicators relevant to the requirements of cardiovascular physicians in China. When there was uncertainty about whether to retain a particular indicator, the research team collectively discussed and made decisions. The screening process identified 52 secondary indicators (Supplementary Table 2).

Behavioral event interviews

The research team recruited 22% of cardiovascular physicians from the Guangzhou Cardiovascular Disease Research Institute as participants (half defined as “high achievers” and half considered “low achievers,” as shown in Supplementary Table 3) for behavioral event interviews. The classification was based on departmental recommendations and peer evaluations, which considered clinical performance, teamwork, communication skills, and professional development potential over the past two to three years. A total of 10 individuals were interviewed, resulting in 10 valid interview records. Subsequently, we supplemented the secondary indicators, resulting in the identification of 63 secondary indicators (Supplementary Table 2).

Expert interviews

The research team invited senior experts from the Guangzhou Institute of Cardiovascular Diseases for expert interviews. During these interviews, the entries obtained from literature analysis and behavioral event interviews were discussed to further refine or modify relevant items. Additionally, important abilities or qualities of cardiovascular physicians were supplemented, leading to the construction of an initial competency model. This model comprises 8 primary indicators and 76 secondary indicators (Supplementary Table 2).

Design of the Delphi questionnaire

The research team designed the Delphi questionnaire based on the initial competency model. The questionnaire comprises sections detailing the research background, objectives, expert demographics, criteria for indicator selection, a survey on the importance of primary indicators, and evaluation tables for the primary and secondary indicator systems. Assessment criteria include importance, feasibility, sensitivity, familiarity, criteria for judgment and impact level, and suggestions for modification. The scoring range and relevant guidelines for the assessment criteria are elaborately outlined (Supplementary Questionnaire 1).

Delphi questionnaire survey

The study employed two rounds of Delphi questionnaire surveys. Throughout the survey process, only the researchers knew the identities of the participants and could access each participant’s responses. Participants were unaware of each other’s names or responses. They could not view the replies of other participants or the round-by-round summary of results sent by the researchers, and they responded independently of other participants for each subsequent round.

First round

The first round of Delphi surveys was conducted from April to May 2024, lasting for 4 weeks. Experts were required to assess each indicator and provide feedback. After the completion of the first round of Delphi surveys, data were collated and analyzed, and adjustments to the indicators were made based on expert feedback.

Second round

The second round of Delphi surveys was conducted from May to June 2024, spanning 4 weeks. The survey was sent to the experts who participated in the first round. In the second round questionnaire, the competencies that had reached consensus or were modified based on expert feedback from the first round were retained. Additionally, statistical charts of the data from the first round survey were provided to the experts along with the second round questionnaire.

Consensus criteria

In Delphi studies, there are no exact consensus criteria63. In this study, the criteria for consensus are as follows: (1) At least two of the boundary values for importance, feasibility, and sensitivity meet the standard; (2) In the first round of surveys, modification of indicators requires suggestions from at least one expert, while in the second round, suggestions from at least two experts are necessary for modification; (3) The survey is terminated after two rounds, indicating consensus among the group members.

Statistical analysis

Positive coefficient of experts

The expert coefficient refers to the effective response rate of the expert consultation questionnaire, which can reflect the level of active participation by the experts. Generally, a 50% effective response rate is considered the minimum acceptable level, 60% is regarded as a good level, and 70% is considered to meet a very high standard64.

Coefficient of experts’ authority

The authority of experts (Cr) is determined by two factors: their professional knowledge in assessing the indicators (Ca) and their familiarity with the issue (Cs). The specific calculation method is as follows: (1) To evaluate Ca, experts are asked to assess the impact of their professional knowledge on judging the indicators from four aspects: “work experience”, “theoretical analysis”, “peer knowledge”, and “intuition”. When Ca = 1, the expert’s professional knowledge has the highest impact on their judgment, and when Ca = 0, the expert’s professional knowledge has no impact on their judgment, based on the valuation criteria outlined in Supplementary Table 4. (2) To evaluate Cs, experts are required to self-assess their familiarity with the issue using a Likert scale method divided into five levels. When Cs = 1, the expert’s familiarity with the issue is the highest (very familiar), and when Cs = 0, the expert’s familiarity with the issue is the lowest (not familiar), based on the valuation criteria outlined in Supplementary Table 5. (3) Cr=(Ca + Cs)/2; values greater than 0.7 are considered acceptable46.

Coefficient of experts’ coordination

The level of expert coordination serves as a crucial indicator for assessing the consistency of indicators among experts, encompassing both the Kendall W coordination coefficient and the coefficient of variation for each index. The coefficient of variation plays a pivotal role in determining which indices should be excluded65. A smaller coefficient of variation indicates a higher degree of expert coordination.

Calculation and standards for boundary values

Drawing on previous research that utilized the Delphi method for competency studies, this research establishes boundary values for importance, feasibility, and sensitivity in the questionnaire. These boundary values include the mean boundary value, the coefficient of variation boundary value, and the full score frequency boundary value46. For example, the boundary value for importance is calculated as follows: the mean boundary value is determined by subtracting the standard deviation of importance from the mean of importance (importance mean boundary value = importance mean - importance standard deviation). The coefficient of variation boundary value is computed by adding the standard deviation of the coefficient of variation of importance to its mean (importance coefficient of variation boundary value = importance coefficient of variation mean + importance coefficient of variation standard deviation). The full score frequency boundary value is found by subtracting the standard deviation of the full score frequency of importance from its mean (importance full score frequency boundary value = importance full score frequency mean - importance full score frequency standard deviation).

For the importance of a competency to be considered as meeting the standard, it must satisfy at least two of the following conditions: the mean exceeds the mean boundary value, the coefficient of variation is below the coefficient of variation boundary value, and the full score frequency surpasses the full score frequency boundary value. The same method applies to calculating boundary values for feasibility and sensitivity, and evaluating whether an individual’s feasibility or sensitivity meets the standard.

Calculation of weighted index

To determine the importance of each competency, in the second round of the survey, the research team employed the Scale Matrix Judgment Method. This involved having each expert compare the primary indicators in each row and column and then calculating the weights of the primary indicators using the Analytic Hierarchy Process (AHP). As for the weights of the secondary indicators, the team utilized the Percentage Weight Method for calculation.

Descriptive analysis was utilized to depict the characteristics of participants and outcomes. Mean (with standard deviation, SD) was used to report continuous variables, while frequency (%) was used for categorical variables. Data management and analysis were performed using SPSS 26.0 and YAAHP (Yet Another Analytical Hierarchy Process, https://www.metadecsn.com/yaahp/).

Results

Positive coefficient of experts

In the first round of the Delphi survey, 24 questionnaires were distributed, and 20 were successfully retrieved, resulting in a response rate of 83%. In the second round, 20 questionnaires were distributed, and all were successfully retrieved, achieving a 100% response rate. Both rounds met relatively high standards, indicating that the experts demonstrated significant interest and enthusiasm for this research.

Coefficient of experts’ authority

The authority coefficients of the experts in the two rounds of the Delphi survey ranged from 0.7 to 0.9, both exceeding 0.7. This indicates that the results of both rounds have high accuracy and reliability (Supplementary Table 6).

Coefficient of experts’ coordination

In the two rounds of the Delphi survey, the mean coefficient of variation (Mean CV) for both primary and secondary indicators gradually decreased, indicating that expert opinions became more convergent with each successive round. Additionally, the coordination coefficients for both primary and secondary indicators increased, suggesting an improvement in the degree of consensus among experts. After two rounds of surveys, the P-values corresponding to the coordination coefficients were all less than 0.05, demonstrating a good level of agreement among the experts and indicating that the results are reliable (Table 2).

Table 2 Coefficient of experts’ coordination.
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Consensus process

First round

Statistical analysis of the first round of Delphi questionnaire results showed that the boundary values for the primary indicators “Information and Management Skills” and “Core Values and Professionalism” did not meet the study’s predetermined thresholds. However, given the importance of Information and Management Skills in enhancing the efficiency of cardiovascular healthcare66,67 and the critical role of Core Values and Professionalism in physicians’ practice68,69expert consultation concluded that these competencies are essential for effective diagnosis and treatment. Therefore, despite not meeting the predefined thresholds, these indicators were retained (Supplementary Table 7).

Among the secondary indicators, 18 did not meet the study’s boundary value requirements. Following expert consultation, 12 indicators were excluded, while 6 were retained. These 6 indicators primarily cover areas such as interprofessional collaboration, understanding the healthcare system, utilizing information technology, promoting cardiovascular health, and fostering effective communication and critical thinking skills. Experts deemed these competencies essential for the effective practice of Chinese cardiovascular physicians and for improving clinical outcomes and patient satisfaction, thus they were retained (Supplementary Table 8).

Therefore, based on the consensus criteria, 8 primary indicators and 64 secondary indicators were included in the second round (Supplementary Questionnaire 2).

Second round

After conducting statistical analysis of the second round of Delphi questionnaire results, it was found that the boundary values for the two primary indicators, “Information and Management Skills” and ‘scientific Research Skills”, did not meet the study’s requirements. However, following expert consultation, both indicators were retained. In particular, Scientific Research Skills are increasingly recognized as crucial in the training of future cardiovascular professionals70,71,72 (Supplementary Table 9).

Among the secondary indicators, 10 did not meet the study’s boundary value requirements. Following expert consultation, 4 indicators were excluded, while 6 were retained. These 6 indicators, covering areas such as personalized cardiovascular disease prevention, interprofessional collaboration, understanding the healthcare system, effective communication, critical thinking, and maintaining personal health, were considered essential components of the competency framework for Chinese cardiovascular physicians and were thus retained (Supplementary Table 10).

The Delphi process concluded with consensus on 60 secondary indicators under 8 primary indicators. These are: Clinical Skills and Medical Services (17 competencies), Disease Prevention and Health Promotion (3 competencies), Information and Management Skills (6 competencies), Medical Knowledge and Lifelong Learning Ability (5 competencies), Interpersonal Communication Skills (9 competencies), Teamwork Skills (3 competencies), Scientific Research Skills (3 competencies), and Core Values and Professionalism (14 competencies) (Table 3).

Table 3 Competency model for cardiovascular physicians in accordance with the Chinese context.
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Indicator system and weighting results

After completing the two rounds of Delphi surveys, the research team employed the Analytic Hierarchy Process (AHP) and percentage weighting method to determine the weights for primary and secondary indicators, resulting in the assigned weights for each indicator. Additionally, in developing the competency scale, the team followed a hierarchical approach to ensure better alignment with clinical practicality, proposing an enhanced Likert scale method tailored for physician competency models. Finally, based on the Onion Model, a competency model for cardiovascular physicians suited to the Chinese context was established. (Table 3; Fig. 2)

Fig. 2
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Chinese cardiovascular physician competency model diagram. Codes represent the meanings of the items in Table 3.

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Discussion

Although research on cardiovascular physician competency models is already very systematic internationally, factors such as China’s unique geographic and cultural environment, healthcare industry, medical education system, and policies and regulations directly impact the actual work and competency requirements of physicians33,57,73,74,75,76. Therefore, directly adopting international cardiovascular competency models may not fully meet China’s practical needs. To address this issue, our research developed a customized competency model for cardiovascular physicians within the framework of the Chinese clinical physician competency model25,26. Using an improved Delphi method, we conducted literature reviews, behavioral event interviews, and expert consultations, followed by two rounds of Delphi surveys with 20 renowned cardiovascular experts from Guangdong Province. In both rounds of the Delphi surveys, the expert authority coefficients exceeded 0.7, and the p-values of the expert coordination coefficients were less than 0.01, indicating high accuracy and reliability of the results. Ultimately, this research developed a competency model tailored to the Chinese context for cardiovascular physicians, comprising 8 primary indicators and 60 secondary indicators, each with assigned weights.

In the meantime, this competency model is based on the onion model and is divided into three layers: knowledge, skills/abilities, and motivation/values. The outermost layer represents the professional knowledge required by Chinese cardiovascular physicians in their work, including “Clinical Skills and Medical Services” ,“Disease Prevention and Health Promotion” and “Information and Management Skills”. These are the basic competencies necessary to fulfill their duties. The middle layer comprises the skills and abilities that Chinese cardiovascular physicians must possess, such as “Medical Knowledge and Lifelong Learning Ability” ,“Interpersonal Communication Skills” ,“Teamwork Skills” and “scientific Research Skills”. These competencies are usually acquired through practical experience or systematic training. The innermost layer is “Core Values and Professionalism”, which reflects the motivational traits and values of Chinese cardiovascular physicians. This layer represents the driving force behind their commitment to their work.

Since the establishment of The American College of Cardiology/American Heart Association/American College of Physicians–American Society of Internal Medicine (ACC/AHA/ACP–ASIM) in 1998, the Core Cardiology Training Statement (COCATS) has been formulated6,77,78,79,80. COCATS primarily covers six dimensions: Medical Knowledge, Patient Care and Procedural Skills, Systems-Based Practice, Practice-Based Learning and Improvement, Professionalism, and Interpersonal and Communication Skills. In comparison, our research team developed a cardiovascular physician competency model tailored to the Chinese context, addressing specific needs within China’s medical environment. This model includes eight dimensions: Clinical Skills and Medical Services, Disease Prevention and Health Promotion, Information and Management Skills, Medical Knowledge and Lifelong Learning Ability, Interpersonal Communication Skills, Teamwork Skills, Scientific Research Skills, and Core Values and Professionalism. This model not only encompasses the dimensions emphasized by COCATS—such as medical knowledge, clinical skills, continuous learning, professionalism, and communication skills—but also adds a focus on teamwork, information management, scientific research abilities, and core values. These additions reflect the importance of team collaboration, information technology application, scientific research capabilities, and core values within the Chinese medical environment.

The cardiovascular education roadmap proposed by the European Society of Cardiology (ESC) emphasizes the humanistic aspects of medical training, including medical ethics, communication skills, and attention to patient-related outcomes. It also highlights the impact of new technologies on cardiology training and continued medical education. These recommendations support ESC’s goal of providing comprehensive and high-quality cardiovascular education for the next generation of specialists81. These aspects align well with our model’s emphasis on information management, core values, and physician professionalism. However, unlike the ESC’s broader recommendations, our model is specifically designed to address the unique characteristics of China’s healthcare system. In China, there is a significant focus on the efficient management of information due to the large population and the need for streamlined healthcare services. Additionally, there is an increasing emphasis on research innovation to tackle prevalent local health issues and to advance medical practices. Furthermore, the core values and professional standards for physicians in China are tailored to align with the cultural context and healthcare policies of the country. Therefore, our model more effectively meets the specific demands for information management, research innovation, and physician professionalism in the Chinese medical environment.

The Canadian Medical Education Directions for Specialists (CanMEDS) framework requires residents to achieve proficiency in seven roles: medical expert (central role), professional, health advocate, scholar, manager, collaborator, and communicator. This comprehensive description offers trainees guidance on the cognitive knowledge, technical skills, and personal qualities necessary for their profession9. In comparison, our model is specifically designed for the Chinese healthcare environment, utilizing two levels of indicators that provide more detailed descriptions of competencies. This approach offers a more concrete and practical framework for evaluating the capabilities of Chinese cardiovascular physicians, delivering a more targeted and operational tool.

In constructing the competency model for cardiovascular physicians, our research team has fully taken into account various factors unique to China, including its culture, distribution of medical resources, medical education system, policies and regulations, as well as patient needs. These considerations are reflected in the following aspects:

  1. (1)

    In terms of clinical skills and medical services, we focus on the characteristics of common cardiovascular diseases among the Chinese population. By integrating China’s unique cultural and social background, as well as considering the country’s medical resources and technological capabilities, we are committed to selecting appropriate medications tailored to the characteristics and needs of Chinese patients.

  2. (2)

    In terms of disease prevention and health promotion, we emphasize analyzing the epidemiological trends of cardiovascular diseases in China. By tailoring personalized prevention measures and health promotion programs for Chinese patients, we aim to optimize the utilization of cardiovascular medical resources in China. We actively promote cardiovascular health education initiatives and public awareness campaigns tailored to the Chinese context, aiming to implement infection control measures for cardiovascular diseases and advance the implementation of cardiovascular health policies and strategies in China.

  3. (3)

    In terms of information and management capabilities, we emphasize the utilization of professional databases and literature retrieval tools in the field of cardiovascular diseases to conduct cardiovascular health education and promotional activities tailored to the Chinese context. We advocate for effective communication with other healthcare professionals, considering the unique epidemiological characteristics and cultural background of cardiovascular diseases in China, to promote comprehensive patient management.

  4. (4)

    In terms of medical knowledge and lifelong learning abilities, we focus on cardiovascular biomedical fundamentals tailored to the characteristics of the Chinese population. We emphasize the importance of integrating Chinese cultural backgrounds and considering patients’ psychological, social, and legal factors to develop personalized diagnosis and treatment plans. Additionally, we advocate for staying updated on the latest advancements in the field of Chinese cardiovascular medicine to continuously enhance our professional expertise.

  5. (5)

    In terms of interpersonal communication skills, we particularly emphasize the Chinese cultural background. Integrating Chinese ethical traditions, values, and cultural atmosphere, we are committed to establishing trust with patients.

  6. (6)

    In terms of teamwork ability, we integrate the Chinese cultural atmosphere and emphasize the work and life of team members. We emphasize harmony and stability, timely resolution of internal conflicts and disputes within the team, to reflect the importance of teamwork cooperation in the Chinese medical context.

  7. (7)

    In terms of scientific research ability, we integrate the traditional Chinese values of seeking truth and cautious deliberation. Within the Chinese medical environment, we foster an atmosphere of innovation and exploration, nurturing creative thinking and innovative capabilities. Moreover, grounded in the Chinese emphasis on academic exchange and collaboration, we advocate active participation in academic exchanges and conferences.

  8. (8)

    In terms of core values and professional ethics, we prioritize patient health and uphold the original intention of being a doctor. We pay special attention to the issue of trust between Chinese doctors and patients, providing warmth and care to patients. Regarding the allocation of medical resources, we adhere to principles of fairness and reasonableness, promoting the sustainable development of healthcare services.

Furthermore, to better align with practical clinical application, our research team proposed an improved Likert scale method for the physician competency model based on a hierarchical approach. In this scale, the familiarity of physicians is subdivided into the following five levels:

  1. (1)

    Unable to perform at all (1 point): The physician has no understanding of the competency or is unable to complete related tasks.

  2. (2)

    Can perform under supervision (2 points): The physician requires guidance from a superior to complete the tasks.

  3. (3)

    Can perform independently (3 points): The physician can complete the tasks independently without additional guidance.

  4. (4)

    Can guide junior physicians (4 points): The physician can not only complete the tasks independently but can also guide junior physicians.

  5. (5)

    Deep understanding and personal insight (5 points): The physician has a profound understanding of the competency, can think independently, and can provide insightful evaluations and decisions based on personal insights.

Compared to the typical competency models that only categorize physicians’ familiarity levels using Likert scales as very familiar, quite familiar, moderately familiar, somewhat familiar, and unfamiliar, this improved approach is more aligned with real clinical application, exhibiting greater specificity and differentiation. It emphasizes physicians’ autonomy and reflective awareness and enhances the flexibility and adaptability of the scale. Consequently, it can more effectively assess physicians’ competency levels, provide more targeted guidance for their training and development and offer greater advantages.

Although we employed the modified Delphi method and integrated various approaches**—such as literature review, behavioral event interviews, and expert consultations—**in our study, including two rounds of Delphi surveys with experts in cardiovascular medicine to develop a competency model tailored to the Chinese context, we must acknowledge several limitations that may impact the interpretation and generalizability of our findings.Firstly, the Delphi method itself has inherent limitations. It relies on the subjective judgments and experiences of experts. Although we strengthened the rigor and scientific validity of our study through measures such as expert positive coefficients, authority coefficients, and coordination coefficients, the process may still be susceptible to biases stemming from expert selection and participation levels. Additionally, during the process of expert communication and consensus-building, there is a potential risk of information imbalance or opinion dominance. Secondly, the literature review component may have been affected by selection bias. Some relevant studies may not have been included in the analysis, which could compromise the comprehensiveness and accuracy of the resulting competency model. Thirdly, the behavioral event interviews and expert consultations may have been influenced by the respondents’ subjective memory and personal biases, potentially leading to incomplete or inaccurate data. Fourthly, our study focused on cardiovascular physicians and experts from Guangdong Province. While Guangdong exhibits typical geographical, economic, and demographic features and holds a leading role in China’s healthcare development, it may not fully represent the diversity of medical environments across the country—particularly in rural or economically underdeveloped regions. These areas may differ significantly in terms of healthcare resources, physician responsibilities, training access, and population health needs. As such, the competency requirements for cardiovascular physicians in these settings may differ from those in tertiary, high-resource centers. This could limit the generalizability of our model. In future work, we plan to expand the sampling scope to include experts from multiple regions and healthcare settings to further validate and refine the model. Moreover, considering the substantial variation in healthcare systems and physician roles across China, it may be necessary to develop a stratified competency framework—for example, a basic tier (e.g., level 1–2 in the ESC Core Curriculum or CanMEDS framework) for general cardiovascular care in primary or resource-limited settings, and an advanced tier (e.g., level 4–5) for subspecialist physicians in high-income or tertiary institutions. Finally, we also intend to disseminate the research findings through follow-up surveys aimed at assessing the actual competency levels of cardiovascular physicians in China. This will further enhance the model’s generalizability and provide more effective guidance for physician recruitment, evaluation, and training.

Conclusion

Based on the consensus process using the modified Delphi method, the research team has developed a competency model for cardiovascular physicians tailored to the Chinese context. This model consists of 8 primary indicators and 60 secondary indicators, covering various aspects of clinical performance and professional behaviors of cardiovascular physicians. This model can provide effective guidance for the recruitment, assessment, and training of cardiovascular physicians in China. However, further research validation is still needed before applying this competency model to general practice.