Xinhua critiques overwork and double standards for medical residents in China
Xinhua critiques overwork and double standards for medical residents in China
China's state news agency highlights that future physicians in the country are overworked and undervalued, calling for reforms to better support their physical and mental health.
China's medical residency system, modeled after Western practices, was initially proposed in the 1990s. However, its early implementation faced significant challenges due to inadequate support in policy, personnel, and financial resources. Recognizing these shortcomings, in 2013, China established a definitive goal: by 2020, the country would establish a nationwide residency system for all new physicians entering the medical field.
In this framework, medical students in China, after graduating from medical school, have several options for their residency program. They can join the program while employed by a hospital, or participate without professional affiliations. Additionally, many students holding a bachelor's degree opt to pursue a professional master's degree concurrently—a type of program tailored to the Chinese context that focuses on practical training—which allows them to obtain both a residency certificate and a master's degree.
However, there are drawbacks to this path. The tuition for professional master's programs is typically much higher than that for academic master's programs, which focus on traditional academic skills. Additionally, while academic master's programs do not permit simultaneous enrollment in a residency program, an academic master's degree is often regarded as more prestigious and valuable than a professional master's degree.
The distressing plight of resident doctors who are also professional master's students in China has been highlighted by multiple tragic suicides, drawing widespread attention and sparking critical debate. Critics argue that the residency system, originally designed to develop practical skills for future practitioners, has deviated from its purpose. Instead, it has increasingly turned residents, especially professional master's students, into low-paid labor. These residents endure excessive workloads, insufficient compensation, academic pressures, and a lack of meaningful learning opportunities, all of which impose a severe physical and emotional toll.
Additionally, there has been significant sharing of personal, often painful stories by residents across Chinese social media platforms, further underscoring the urgent need for systemic reform in medical residency training.
The following story by Xinhua Daily Telegraph, a newspaper under Xinhua News Agency, also reports on the prevalent "double standard" in which professional master's students are significantly less paid compared to other categories of residents.
In response, experts and officials have called for reforms to enhance the treatment of residents, advocating for equal pay, improved work-life balance, and enhanced support for their physical and mental health. The Xinhua commentary also underscores the critical role of residency in cultivating competent doctors and stresses the need to balance rigorous training with the assurance of promising career prospects for residents.
The following story, written by Chen Xiyuan with commentary from Dong Ruifeng and Li Heng, was originally published in Xinhua Daily Telegraph, the official daily newspaper of Xinhua News Agency on March 31, 2024. It is also accessible on the newspaper's official WeChat blog.
The "Double Standard" for Resident Professional Master's Students Needs to be Addressed
Within a month, a male and a female medical student took their own lives shortly before completing their residency in China. After over a decade of rigorous academic pursuit, their immense dedication was cut tragically short, mere months away from becoming true "angels in white." These deaths are deeply saddening and alarming.
Recent internet expressions such as "caring for patients at work, being a patient after work" and "spinning through clinical rotations" capture the sentiments of many medical residents. They feel they have invested significantly yet reap minimal rewards, facing high sunk costs with limited alternatives.
Xinhua Daily Telegraph observes that professional master's students in residency programs often encounter a "double standard" in how they are treated. This disparity has led to a build-up of negative emotions that urgently require attention and resolution. Several experts from 3A-grade hospitals [the highest of China's three-tier grading system] and medical schools in China have advocated for better treatment of residents. They emphasize the need to balance the demands on professional master’s students more effectively and to foster a positive and inclusive training environment.
When the light goes out near the end of the tunnel
"I have not had a good rest since the sixth day of the Lunar New Year," "I thought I came here to study and gain clinical experience, but it feels more like I'm providing unpaid labor," "I am to blame for not being a hardy slave, but I can't stand it any longer..."
At the end of February this year, a female resident in Hunan ended her life by cutting her throat in a hospital, with only a few months left to complete her residency. A suspected suicide note uploaded online revealed many details that elicited significant empathy and widespread sharing within the online medical community. In March, a 27-year-old male resident in Nanning, capital of south China’s Guangxi Province, committed suicide in a similar way despite, according to reports, having secured a job. The term "residency" has thus come under increased public scrutiny following these tragic incidents.
Residency differs from common pre-graduate internships in that it is a graduate education program that is compulsory for a medical license.
According to 2023 data from the Chinese Medical Doctor Association, since the nationwide implementation of residency programs in 2014, over 1,100 national training bases and more than 11,000 specialized training bases have been established, with a total graduation number of approximately 1.1 million and an annual enrollment averaging around 100,000. In 2023, enrollment reached a record high of 120,000.
Currently, about 300,000 medical students in China are undergoing residency, which typically lasts three years. Over the past decade, the residency program has significantly enhanced the diagnostic and treatment capabilities of doctors across the country and improved the effectiveness of medical services for the public. However, it is also crucial to acknowledge the increasing frequency of unnatural deaths among residents in recent years, highlighting the need for urgent reforms in their training and support systems.
A hierarchy of residents, with most being professional master's students
Insiders from top-tier 3A-grade hospitals and medical schools have shared that residents can be classified into several categories: "in-house residents," who are from the training hospital itself; "external residents," who come from other hospitals; "general residents," who are unemployed graduates admitted for residency training; and "professional master's students," who are enrolled at medical schools affiliated with or in collaboration with the training hospital. Additionally, some hospitals distinguish between "resident interns" and "resident students" based on whether a labor contract has been signed.
"Student's graduate studies are synchronized with their residency. After successfully completing the assessments at the end of the three-year residency, students must also graduate from their master's program. In that way, students can obtain four credentials simultaneously: a residency certificate, a medical license, a master's degree diploma, and a graduation certificate," explained the head of the medical school at a university in Jiangsu Province, east China. He noted that among the four types of residents, professional master's students are the most numerous.
In light of this information, Xinhua Daily Telegraph investigated the enrollment of residents at several hospitals for the year 2023.
For instance, in July 2023, the First Affiliated Hospital of Guangxi Medical University admitted 113 resident interns along with 280 professional master's students. In August, the Ruikang Hospital affiliated with the Guangxi University of Chinese Medicine admitted 81 resident interns and 230 professional master's students. In September, Shengjing Hospital of China Medical University recruited 635 residents, which included 216 resident interns from other hospitals and society, and 419 professional master's students. Meanwhile, the Second Affiliated Hospital of Hunan University of Chinese Medicine enrolled 144 professional master's students and 50 resident interns from hospitals and society among its 2023 cohort.
In these four hospitals, professional master's students account for 65.98% to 74.23% of the total number of residents. This substantial proportion supports the observations shared by the head of the medical school at a university in Jiangsu Province.
Excessive pressure exacerbates negative emotions
Many of the interviewed residents have expressed significant emotional distress due to undervalued contributions, especially among professional master's students. In the meantime, residents face high sunk costs and limited alternatives, leading to an accumulation of negative emotions that demand urgent attention.
Some residents reported being relegated to performing basic, menial tasks. They described feeling exploited as "free labor, errand runners, scapegoats, and unpaid baby-sitters." Furthermore, there are complaints about the lack of substantial learning opportunities, "Supervising physicians are unwilling to teach, and we spend our days just writing medical records without gaining any practical skills."
John (a pseudonym), a professional master's student currently undergoing residency at a 3A-grade hospital in central China, shared that while residents are often tasked with basic administrative duties such as writing medical records, they also have opportunities to engage in clinical tasks such as punctures and intubations under the guidance of supervising physicians.
"Some fellow residents might see writing medical records as 'mundane work,' considering it tedious and trivial, but it is indeed crucial for ensuring patient safety. The hospital is so busy every day that attending physicians are overwhelmed with consultations and surgeries. Besides, writing medical records actually serves a crucial role in reinforcing our professional foundations," John explained.
John also discussed the juggling act by professional master's students, who must manage both their clinical responsibilities and academic requirements: they spend workdays at the hospital from early morning until evening, and sometimes must work overtime to finish their tasks. The weekends are then dedicated to their academic research.
The staff in charge of student affairs at a medical university in east China detailed that professional master's students typically become eligible to take the National Medical Licensing Examination after completing their first year of residency. He noted, "After passing the exam, supervising physicians will allow them to handle more clinical tasks, which also increases their workload and stress."
How much are residents reimbursed? John shared details from his hospital: professional master's students typically receive a monthly stipend of 600 yuan [83 U.S. dollars] from their graduate program and up to 2000 yuan from the hospital, contingent on factors such as overtime hours. "External residents," who are employed by their original employers while training, typically receive nearly 3,000 yuan [414 U.S. dollars] per month from these employers, with additional compensation from the training hospital that can total about 5,000 [690 U.S. dollars] to 6,000 yuan [828 U.S. dollars] monthly. "General residents," who were unemployed prior to residency, get about 3,000 yuan [414 U.S. dollars] solely from the training hospital. "In-house residents," who are official staff members of the training hospital, usually start with a salary of around 10,000 yuan [1,380 U.S. dollars].
An insider at a 3A-grade hospital also revealed that while the other three categories of residents benefit from the protection of labor contracts, professional master's students often face a "double standard." They are treated as physicians when it comes to work responsibilities but are regarded as students when it comes to compensation and benefits.
This "double standard" is also reflected in other minor aspects of hospital life. For example, two hospital notices recently went viral among the online medical community in China. One of them instructs graduate students on clinical rotations and intern nurses not to use the staff-only elevator during rush hours, and the other prohibits residents from using the water dispenser in the department.
"We are outsiders here. We are not seen as 'one of them'," John admitted, "Even "external residents" and "general residents" are barred from the department's privileges, let alone professional master's students. What's more, not all training hospitals provide compensation to professional master's students. If they choose to pay, it's considered as a favor; if they don't, it's also acceptable because hospitals hold ultimate control over issuing residency certificates."
Is it possible to quit residency partway through? Xinhua Daily Telegraph discovered that many training hospitals explicitly state in their recruitment materials that anyone withdrawing from the program is ineligible to reapply for three years. Some hospitals even require departing residents to repay benefits received during their tenure, including basic salary, merit pay, social insurance, housing provident funds, year-end bonuses, heating allowances, and night shift bonuses.
"I'm already 25 years old. If everything goes well, I'll finish my residency next year, start working at a hospital, and earn a salary. If I quit halfway, I'd face significant losses and likely be left with just two options—taking civil servant exams or working in the pharmaceutical industry. Therefore, the only option for me is to persevere and earn the 'four certificates'," explained John.
"Residency is certainly crucial, whether in 3A-grade hospitals in major cities or public health centers in townships, to ensure patients receive reliable treatments," John said. Medicine requires lifelong learning. In some ways, continuous learning after graduation is even more crucial than classroom education. However, the intense workload and academic demands can severely impact students' physical and mental health, often leading to exhaustion and overwhelming stress.
John suggested organizing regular team-building activities and outings could be very beneficial. This approach would not only foster a sense of belonging among residents but also encourage their active participation, enhance their ability to manage stress, and create a positive cycle of work engagement.
Building an enabling and inclusive environment for residents
Several medical professionals interviewed recognized the intense pressure and significant responsibilities inherent in becoming a doctor as well as the need to improve the conditions for residents, particularly for professional master's students. To cultivate an enabling and inclusive environment, these professionals advocate for various enhancements.
Encourage equal pay for the same post and improve professional master's students' entitlements. Zhu Li, Secretary of the Committee of the Communist Party of China (CPC) at Jiangsu Taizhou People's Hospital proposed concerted efforts to enhance the sense of achievement among residents, particularly professional master's students through various channels such as government funding, scholarships, subsidies for academic research projects, performance-based incentives, and non-governmental donations.
In August 2022, Peking University People's Hospital fully implemented the policy of equal pay for the same post for students and interns alike on clinical rotations. Currently, many training hospitals have clarified the entitlements for professional master's students.
Integrate residency with professional master's programs to ensure a smoother career progression for doctors. Wang Chen, Vice President of the Chinese Academy of Engineering, President of the Chinese Academy of Medical Sciences, and President of Peking Union Medical College, proposed [during the second session of the 14th Chinese People's Political Consultative Conference (CPPCC) National Committee in March 2024] canceling the entrance examination for professional master's programs in medical schools. Instead, he recommended that graduates undertake the National Medical Licensing Examination after a year of residency. Those who pass should be concurrently educated as professional master's students; if residents fulfill the requirements for a professional master's degree during their residency, they should be awarded the degree accordingly.
Strengthen positive incentives and foster a supportive and responsive environment for residents. Chen Yunzhe, chief expert at the Jiangsu Youth Development Research Base, said it is necessary to provide a convenient and confidential system for residents to file complaints and ensure that these complaints receive prompt attention. For departments or hospitals with repeated substantiated complaints, punitive measures such as restrictions on training quotas or suspensions of research project applications should be taken. Conversely, supervising physicians and departments that exhibit dedication and responsibility should be recognized with enhanced rewards and receive favorable consideration during performance evaluations.
Pay more attention to the physical and mental health of residents. Lin Zhenping, Director of the Department of Public Administration at the School of Health and Policy Management, Nanjing Medical University, recommended that training hospitals and universities strengthen their coordination to more effectively balance the workload and schedules of professional master's students during their residency. Furthermore, he emphasized the need for both institutions to establish a robust mechanism for addressing psychological issues among residents. This should include conducting regular psychological screenings and providing timely interventions while avoiding formalistic practices such as requiring reflections on lectures, which could further burden the residents.
Xinhua Commentary
Hard training should come with promising prospects
In the vital work of saving lives and alleviating suffering, there are no minor details. A competent doctor, capable of diagnosing and treating patients effectively, cannot be developed overnight. Faced with the evolving challenges of improving medical and health service capabilities and safeguarding public health, it's crucial to consider how residency can better strengthen the professional foundation of medical students.
Residency is an essential step for medical graduates to become attending physicians. After medical school, graduates are not yet qualified to independently conduct clinical work in a standardized manner. They must undergo systematic and standardized training, primarily aimed at enhancing their clinical diagnostic and treatment skills, within designated hospitals. These young doctors represent the future of the healthcare industry and are guardians of public health. Therefore, attending to their physical and mental health is not just an investment in their well-being but a commitment to the well-being of everyone.
Many doctors have discovered that not all diagnoses and treatments can be strictly derived from textbooks once they begin working in hospitals after graduation. From identifying the causes in emergency treatments to inquiring about patients' symptoms, it is only through rigorous mentorship and repeated training that they can truly master the clinical skills necessary for saving lives and treating illnesses.
If universities are considered the "gateway" into the medical profession, then residency serves as the "training field." It plays a critical and serious role in delivering the "first lesson" in a doctor's career, a foundational experience that must not be taken lightly.
Resident doctors are required to complete a specified number of surgeries and examinations, and are thoroughly trained in recording patients' medical histories, conducting physical examinations, taking medical records, and even delivering medications to patients. While these tasks may seem simple and mundane, they are essential for cultivating clinical thinking and solidifying the basic skills necessary for a qualified healthcare professional.
One doctor shared her experience during her residency, where she and her classmates were summoned to the emergency department by an experienced doctor in the middle of the night to observe a rare medical case. This hands-on learning experience, which could not be acquired from textbooks, left a lasting impression. Many years later, this vivid memory enabled her to successfully manage a similar case.
Only through repeated practice can competence be truly forged.
While strict management is essential, it's equally important to cultivate an abundance of care within medical institutions. Many residents face high workloads and significant psychological pressures. By fostering warmth and care during residency, medical institutions can help residents not only develop their skills but also nurture a sense of professional dignity and belonging. This supportive approach helps resident doctors grow more effectively and rapidly, facilitating their crucial transition from students to practitioners.
To ensure fair compensation for residents, the Chinese central government provides a subsidy of 30,000 yuan [4,140 U.S. dollars] per person per year and extends this financial support to each graduate student to enhance their training in medical schools. Since 2015, the Chinese Medical Association has conducted random inspections and evaluations of residency training bases nationwide. Hospitals that fail to meet quality standards and do not effectively guarantee reasonable treatment are required to make corrections or risk losing their qualification to provide residency programs.
Building a healthy China and meeting the public's demand for comprehensive, high-quality healthcare necessitates the development of more skilled doctors. To further improve the residency program, it is essential to balance education investment with future career prospects. This strategy will continuously fortify the Chinese medical and healthcare system with exceptional professionals, enabling them to fully realize their potential and receive the recognition and rewards they deserve in their careers.
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