Introduction

Self-determination is a recognized critical personality trait. It is defined as an individual’s capacity to make autonomous choices informed by a holistic understanding of personal needs and environmental contexts, along with the ability to act upon reflective decision-making processes [1–3]. The concept of self- determination originally emerged within the realm of special education for individuals with disabilities, aiming to enhance the quality of life and lifelong well-being of this population [4,5]. With the advent of positive psychology, an increasing number of scholars have focused on the significance of self-determination in fostering positive youth development, thereby promoting equitable outcomes in self-determination for students [5]. For instance, research has investigated the impact of self-determination on the motivation of college students and the learning capabilities of high school students [6,7]. The exploration of learning motivation and self-efficacy is a prevalent theme among medical students [8–10], while there is a conspicuous absence of research focused on the self-determination within this population.

In China, the decision to pursue a medical degree after the National College Entrance Examination is an intricate process, confronting dual pressures stemming from the unique educational and socio-cultural context. The National College Entrance Examination, often metaphorically described as “thousands of troops and horses crossing a single-log bridge”, represents a highly competitive and unavoidable gateway to higher education. Moreover, high-achieving students, in particular, face substantial familial and societal expectations regarding their career choices. Professions such as medicine—viewed as offering high prestige, stability, and financial security—are frequently promoted as ideal pathways, often leading students to prioritize external expectations over their intrinsic interests or passions.

Under the influence of the aforementioned pressures, the self-determination of high school students plays a significant role in their ability to autonomously select medical careers. Self-determination not only influences students’ choice of major but also significantly impacts their future career trajectories within the medical industry [11]. Medical students are poised to become the backbone of the future medical system, providing essential medical services to society [12]. Studies have revealed that during critical developmental stages such as adolescence and undergraduate education, enhanced self-determination significantly improves academic self-reliance, academic performance, social skills, and overall well-being [6,13,14]. High levels of self-determination during these developmental stages could even yield benefits in the workplace [15,16], such as reducing job burnout and eliminating stigmatization [17,18]. Given the importance of assessing self-determination levels among medical students, a reliable assessment tool was essential. To address this gap, we have adopted the widely recognized self-determination scale [19], which enables effective measurement and exploration of medical students’ self-determination levels, thereby supporting our hypothesis.

Previous studies have demonstrated strong correlations between professional identity, self-determination, and role models. Additionally, these studies indicated that a stronger professional identity might assist adolescents in making decisions about their future careers and enhance their understanding of workplace and career options [20,21]. Professional identity is operationalized as an individual’s cognitive, affective, and behavioral commitment to their future profession, as measured by the Professional Identity Scale (PIS) [22]. Through professional education, university instructors could encourage students to inspire career self-determination [22]. In recent years, the cultivation of a robust professional identity among medical providers has increasingly been recognized by medical educators as a central mission of medical education [23,24]. Medical professionals widely acknowledged that a heightened professional identity not only promotes favorable perceptions of the medical profession but also strengthens occupational prestige and accountability, while encouraging the development of positive professional conduct [24]. Scholars have extensively studied professional identity, revealing that medical professionals in China exhibited an average level of professional identity in China [25–27]. These studies indicated that medical students with higher professional identity were more likely to plan their career paths stably, pursue medical careers more resolutely, and experience greater satisfaction in their work. This sense of identity also fulfilled their need to contribute to society through their work, while simultaneously gaining recognition and respect [22,28–30]. Individuals with a robust professional identity were more inclined to make career decisions that result in positive outcomes [31–34]. Scales measuring professional identity are widely utilized in research. For this study, we selected a broadly applicable scale specifically designed for medical students to accurately assess their levels of professional identity [35].

Moreover, role models, as pedagogical strategies, have been extensively employed to enhance career motivation and professional excellence among medical students [36,37]. As behavioral archetypes, role models exert substantial influence on cognitive frameworks and decision-making patterns [38,39]. However, individual differences might result in either positive or negative responses to role models [40,41]. Recent research on role models has primarily concentrated on medical educators and students [37,40], underscoring their established significance within medical education curricula. Undergraduate students in the pharmacy and dentistry disciplines exhibited particularly strong susceptibility to the effects of role models, with teachers serving as pivotal figures in helping students internalize positive behaviors [42,43]. We believed that cultivating students’ self-determination through the observation of role models constituted a unique educational initiative [44,45]. Notably, the perceptions of role models among medical students have seldom been quantified. A role model admiration scale was recently developed in China to measure individuals’ admiration for role models via standardized scaling methods [46]. We have adopted this scale to gain deeper insights into the implications of role models for medical students’ professional skill development, learning motivation, interpersonal competencies, and future patient‒care relationships [46,47]. Research has confirmed that self-determination could be enhanced through the influence of external role models and the processes of observational learning [47,48]. In medical education, role models serve as a prerequisite for increasing the autonomy of medical students [39,49,50]. Additionally, while professional identity played a significant role in self- determination, evidence indicated that role models also contributed to shaping the professional identity of medical students [51].

In summary, our study revealed that the enhancement of self-determination among medical students was influenced by role models, with professional identity serving as a mediating factor in this relationship. Consequently, the hypotheses for this study were articulated as follows:

1. Hypothesis 1 – Professional identity and role models can influence the self-determination of medical students.
2. Hypothesis 2 – Professional identity has a mediating effect on the relationship between role models and self-determination in medical students.

Methods

Results

Demographic characteristics

The demographic characteristics of the participants are summarized in Table 1. The participants had a mean age of 19.85 years (SD = 1.40). The majority of participants were female (n = 208, 71.9%) and in Grade 2 or below (n = 210, 72.6%).

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Table 1. Demographic characteristics and group differences in SDS, SAS, and PIS.

https://doi.org/10.1371/journal.pone.0337935.t001

SDS, PIS, and SAS scores of medical students

The average score on the SDS was 71.21 (SD = 11.72). Among the dimensions assessed, “What Happens at School” recorded the lowest score of 13.81 (SD = 2.81), while “What Happens at Home” exhibited the highest score of 21.15 (SD = 4.29). In terms of professional identity, the mean score for PIS was 69.49 (SD = 11.57), which included scores of 26.12 (SD = 4.83) for the “Occupational Exploration Behavior” dimension, 29.45 (SD = 6.17) for the “Professional Self-Awareness” dimension, and 13.91 (SD = 2.34) for the “Autonomy of Career Choices and Career Persistence” dimension. Additionally, the mean score for SAS was 61.48 (SD = 10.41), comprising scores of 24.77 (SD = 4.30) for the “Ability Admiration” dimension, 16.63 (SD = 2.89) for the “Virtue Admiration” dimension, and 20.06 (SD = 3.79) for the “Sense of Worship” dimension (Table 2).

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Table 2. Descriptive summary and correlation analysis of PIS, SAS, and SDS.

https://doi.org/10.1371/journal.pone.0337935.t002

Mediating effect of professional identity

Tables 3 and 4 present the results of the mediating analysis, where all covariates were controlled for, and bootstrapping methods were employed. First, the findings indicated that role models positively influenced professional identity (β = 0.590, P < 0.001). Second, role model had a positive predictive effect on self-determination (β = 0.591, P < 0.001). Finally, professional identity served as a partial mediator between role model and self-determination (Fig 1), with an indirect effect of 0.2777, which was statistically significant and accounted for 54.83% of the total effect (95% CI: 0.2078–0.3589, P < 0.001).

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Table 3. Mediating effects of PIS between SAS and SDS.

https://doi.org/10.1371/journal.pone.0337935.t003

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Table 4. Verifying the bootstrapping mediation effect.

https://doi.org/10.1371/journal.pone.0337935.t004

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Fig 1. The mediating role of professional identity between role models and self-determination.

https://doi.org/10.1371/journal.pone.0337935.g001

Discussion

The gender distribution of medical students in this study appeared imbalanced; however, it accurately reflected the current reality of higher education in China. According to the gender ratio of undergraduate students published by the Ministry of Education of China from 2013 to 2021, the proportion of female students has consistently exceeded that of male students, demonstrating a continuous upward trend [55]. Furthermore, essentialist views on gender suggested that males and females possess different interests and strengths across various fields of study; for instance, males were generally more adept at logical reasoning, while females excel in memorization [56]. Additionally, societal perceptions of gender roles imposed distinct demands for the social division of labor on both genders, resulting in males and females tending to select different majors. This contributed to a prevalent phenomenon of gender segregation in medical education in China, characterized by a high concentration of professionals of a particular gender within specific specialties [56,57]. For example, a study in China reported that the proportion of female students in nursing reached as high as 84.5% [58]. In this context, this study explored the effects of role models on self-determination among medical students. A path model was constructed to elucidate the direct and indirect effects between variable pairs, mediated by professional identity. The results showed that role models significantly influenced self-determination, with professional identity serving as a partial mediator in the relationship between role models and self-determination among medical students.

This study revealed an overall moderate level of self-determination among medical students, consistent with self-determination levels reported in previous studies on college students [16,17,19], but slightly higher than those observed in disabled adolescents [4,5]. Furthermore, medical students achieved the highest scores in the “What Happens at Home” dimension, suggesting a strong level of self-determination at home and robust support from family members. These findings might be attributed to the substantial family and social support that medical students received in China [59], as well as their heightened sense of self-efficacy and well-developed self-management skills [60].

Nevertheless, medical students performed the worst in the aspect of “What Happens at School”. This domain primarily measured students’ self-determination abilities within the educational setting. This phenomenon differed from the factors contributing to the lower self-determination levels observed among other college [19] and disabled students [4,5,61]. First, Upon entering university, medical students often encounter a more rigorous learning environment and heightened academic demands, making the transition particularly challenging as they confront complex content and elevated expectations [62,63]. Second, medical students, having recently transitioned from the high-pressure environment of high school, find themselves immersed in a demanding curriculum. They must navigate a wide array of subjects, ranging from basic medical sciences to clinical practice, while managing frequent exams and assessments [62]. Third, medical education typically adheres to a rigid curriculum with limited flexibility. Students often have minimal choices regarding course selection or the pacing of their learning, which can diminish their sense of autonomy and self-determination [64]. Finally, in China, the medical profession is perceived as both high-stakes and high-rewards. The significant expectations placed on these students can create substantial pressure, compelling them to excel academically. This pressure may lead to tension and discomfort within the school environment, ultimately impacting their performance and self-determination [65]. Hence, offering incoming medical students theoretical courses on emotional and stress management to equip them with the necessary skills to navigate their academic journeys is essential.

In this study, role models were identified as a significant factor influencing medical students’ self-determination. For the medical students in this sample, achieving a high level of self-determination through “Virtue Admiration” was deemed essential. This phenomenon is closely linked to China’s rich tradition of medical ethics education [46,47]and the moral expectations placed upon medical professionals. In China, society enforces nearly obligatory moral standards on medical workers, and this prevailing value system profoundly shapes medical students’ identification with these moral exemplars. Notably, role models for medical students should extend beyond on-campus learning to include clinical practice [42,43,47,66]. Establishing medical role models who are both virtuous and skilled within the complex clinical environment could profoundly influence medical students’ career planning and life choices [31,32], thereby reflecting an enhancement in their levels of self- determination.

This study revealed a positive correlation between medical students’ professional identity and self-determination. medical students with greater professional identity tended to exhibit greater self-determination, likely due to several interrelated factors. First, their strong intrinsic motivation, stemming from deep profound medical and a sense of mission, drived them to engage more proactively in both learning and practice [65]. Second, these students possessed clear career goals, which provided them with direction and purpose, thereby enhancing their self- determination [31,32,67]. Additionally, their heightened self-efficacy, rooted in confidence in their abilities, further strengthened their decision-making autonomy [68]. Finally, they focused on long-term career development allowed them to connect current efforts with future aspirations, making them more proactive and strategic in their career planning [32,33,69]. Medical students with a heightened sense of professional identity exhibit increased levels of self-determination, which in turn fueled their engagement in long-term career planning. This proactive approach not only benefited their personal growth but also positively impacted the advancement of the medical sector [70,71].

The professional identity of medical students aligned with prior studies [25–27], revealing a distinction between the professional identities of clinical medicine students and nursing students [27]. Medical schools should offer targeted career planning courses to assist students in defining their career goals and developing actionable pathways, while emphasizing the importance of long-term career development to align academic learning with future professional aspirations. Mediation analysis has confirmed the mediating role of professional identity in the relationship between role models and self-determination. When professional identity was incorporated into the regression equation, the predictive power of role models on the self-determination of medical students was reduced, indicating that professional identity serves as a mediator [72]. Enhancing professional identity, leveraging the inspiration from role models, and fostering self-determination in medical education can significantly advance students’ professional development and autonomy.

Limitations

The present study had several limitations. First, the cross-sectional design restricted the ability to establish causal relationships among role models, professional identity, and self-determination. Future research could adopt a cohort study design to explore the causal relationships among these three variables more effectively. Second, the use of convenience sampling from a specific region (Southwestern China) limited the generalizability of the findings, despite the multi-center design. Future studies should consider employing stratified sampling to enhance the representativeness of the sample. Third, the cultural context of the study need to be considered, as the findings might not be fully applicable to other countries. Factors such as strong family support, a significant emphasis on medical ethics, and the high-pressure pre-university education environment in China may have influenced the outcomes. Future cross-cultural studies are necessary to examine the generalizability of these finding.

Conclusions

This study revealed a moderate level of self-determination among medical students. Role models and professional identity positively influenced medical students’ self-determination, with professional identity serving as a mediating variable between role models and self-determination. This perspective introduced a novel approach to medical education, highlighting the importance of enhancing medical students’ self-determination through the improvement of role models and the development of professional identity, which subsequently facilitated their career advancement. In the context of medical education in China, prioritizing the enhancement of professional identity among medical students was imperative. To address this goal, it was essential to introduce more courses focused on the development of professional identity, enabling medical students to gain a comprehensive understanding of the roles and responsibilities of medical professionals from diverse perspectives. Medical colleges should offer courses on emotional and stress management, highlight virtuous and competent role models, and provide targeted career planning to strengthen professional identity. Furthermore, curriculum reforms should emphasize flexibility to foster autonomy, while leveraging family and social support can enhance self-efficacy. These measures aim to empower students, thereby supporting their academic and professional growth.