When entering university, all medical students take a solemn oath:

I pledge my dedication to health and entrust my life to this noble cause. Upon entering the sacred halls of medicine, I solemnly swear: I am willing to devote myself to medicine, love my country, and remain loyal to the people. I will uphold medical ethics, respect my teachers, adhere to discipline, work diligently, persevere tirelessly, strive for excellence, and pursue holistic development. I am determined to do my utmost to alleviate human suffering, promote health, and safeguard the sanctity and honor of medical practice. I vow to save lives, endure hardships, and persistently pursue the advancement of China’s medical and health undertakings, and the physical and mental well-being of humanity for the rest of my life!

A study analyzing patient-doctor relationship reports published in People’s Daily since the founding of the People’s Republic of China found that 45.84% of these reports focused on portraying doctors in a positive light, emphasizing qualities such as “caring for patients,” “selflessness,” “high moral character,” and “fearlessness in adversity,” presenting them as “angels in white.” Meanwhile, 29.99% of the reports highlighted the challenges faced by doctors, including “lack of safety guarantees,” “violence against medical staff,” and “poor compensation.”

It can be said that, whether in terms of self-expectation or societal evaluation, most medical students and doctors strive to embody the image of “angels in white” who save lives and heal the wounded.

So why would hands trained to save lives turn against themselves?

Zhu Jingping, a specialized master’s medical trainee in the obstetrics and gynecology department of a hospital in Guangxi, was nearing the completion of his three-year residency. From his own experience, there is a stark hierarchy within the medical profession. If one were to visualize the power structure of a hospital as a pyramid, trainees like Zhu are not only at the base of the pyramid but also at its very fringes. For trainees stepping out of the ivory tower, this reality is often brutal.

The first time Zhuheard a hospital nurse hurling “ridiculous” personal insults at him, his immediate reaction was to “endure it.” In front of a pregnant patient, the nurse ridiculed him and his fellow postgraduate trainees, saying, “You’re just a bunch of country bumpkins, complete amateurs who know nothing.” Even though Zhu knew the nurse lacked the qualifications to make such remarks, he and other trainees never argued back. “I had no choice; I needed to graduate. If I resisted and couldn’t graduate because of it, wouldn’t these three years be wasted?”

For trainees, the cost of leaving the program is enormous.

The year the residency system was fully launched also marked the introduction of the “dual-track integration” model, which essentially combines postgraduate studies and residency training. While this approach saves three years in the long term, it comes with a major trade-off: SMR trainees who fail to obtain their residency certificate cannot graduate with a master’s degree or practice medicine.

In China, becoming a certified doctor requires at least eight years of education and training, starting from undergraduate studies.

How Do Medical Students Become Doctors in China?

Once a medical student leaves a residency program, not only can they no longer become a certified doctor, but the years they’ve spent studying medicine become a waste of time—an effort in vain. Beyond that, students who withdraw from residency must also return all wages and government subsidies they received during the program and are barred from re-entering residency for the next three years.

The medical field is vastly different from other professions. To Zhu Jingping, leaving a residency program is nearly synonymous with switching careers. “It’s like I have no survival skills in society,” he said. “I’d have to depend on my parents again. To put it bluntly, how is that any different from just letting me die?”

For Li Guang, now a practicing oncologist, this sentiment also resonates deeply. Reflecting on his grueling 15-year journey in medicine, he remarked, “The entire medical profession is built on discipline.” The system actively filters people, leaving behind those who have been shaped into professionals with qualities such as precision, attentiveness, and caution. However, compliance and endurance also take root in these individuals, growing stronger under the system’s demands, making resistance nearly impossible. “These traits are essential for doctors, but this system exploits them, which I find deeply unsettling and revolting,” Li said.

In the long and arduous journey of medical training, the role of a “resident trainee” has become one of the most complex and ambiguous identities.

The word “trainee” (规培生) in Chinese contains the character “生,” which can mean both “student” and “doctor.” This duality and ambiguity in its literal meaning also reflect the reality of the trainee’s role: “When it comes to salary, they say you’re here to learn; when it comes to workload, they say you’re here to work. Essentially, you do the most work for the least pay,” said Bingbing

In 2020, the medical platform DXY conducted a survey of 3,023 doctors who had undergone residency training. The results showed that trainees in the social residency program earned the highest income, with an average monthly salary exceeding 3,000 yuan. Those in the sponsored residency program ranked second, earning an average monthly stipend between 2,000 and 2,999 yuan. Specialized master’s residency trainees earned the least, with average monthly stipends below 1,000 yuan—and 20% of them received no income at all.

Liu Jin, a renowned clinical anesthesiology expert and one of the initiators of China’s residency training system, explained in an interview that specialized master’s trainees are full-time postgraduate students throughout their training. During the 33 months of residency, they are not eligible for financial subsidies from the government or hospitals. “Government subsidies are allocated based on the number of trainees registered under the residency system governed by the National Health Commission (NHC), at 30,000 yuan per person per year. Since specialized master’s trainees belong to the Ministry of Education’s system and not the NHC’s residency system, they do not receive this funding,” Liu said.

Despite earning far less than full-fledged doctors, resident trainees endure extraordinary workloads.

Since beginning his residency, Zhu Jingping has not returned to his hometown in Hunan to celebrate Chinese New Year in three years. “Two New Year’s Eves, I was on duty. The other time, I was on shift on the first day of the new year,” he said. Zhu attends to more than 100 patients daily, sometimes as few as 70 on a less busy day. During his shifts, he often works continuously for 48 hours.

“It’s especially exhausting during rotations in obstetrics,” Zhu said.“There’s often no rest throughout the night. Because there’s always the risk of maternal or fetal death, even when you’re utterly exhausted, you must stay alert. You never know what kind of patient will come in next—sudden amniotic fluid rupture, an imminent miscarriage requiring emergency intervention, or worse, massive hemorrhaging or intrauterine fetal death. Sometimes, these situations happen simultaneously.”

Survey results show that more than half of the resident trainees reported working over 8 hours daily on average. Furthermore, 94.6% of them slept fewer than 8 hours per day, and 5.4% stated they got less than 4 hours of sleep each day.

According to World Health Organization data, each doctor in China serves approximately 419 people. This shortage of medical personnel is a persistent reality in many Chinese hospitals.

Doctor-to-Population Ratios in the Top 6 GDP Countries

（Hover for detailed information▶）

Note: Countries without residency training systems are excluded.

Data Source: World Health Organization

Zhu Jingping acknowledges the professional growth he has achieved through residency training. “With such high-intensity work, it’s impossible not to gain something,” he said confidently. “But whether your effort and gains are proportional is another matter entirely.” Each year, Zhu receives a government subsidy of 6,000 yuan, distributed over 10 months. Along with some modest “hardship allowances” for night shifts, he takes home about 1,000 yuan a month. “Every month, I still have to ask my family for money,” he said.

What frustrates Zhu more than the salary itself is the hospital’s attitude toward resident trainees. Specialized master’s residents do not have independent employee IDs in the hospital system, are not considered formal staff, and are ineligible for departmental performance-based bonuses. Additionally, they cannot log overtime hours into the hospital’s system, making them ineligible for overtime pay or compensatory leave. “We do more work than the hospital’s full-time doctors, so why are we paid the least?” Zhu feels this is deeply unfair but also resigned to the situation. “They just see resident trainees as disposable, as tools for getting work done.”

In 2021, Bingbing failed the postgraduate entrance exam. To align with her ex-boyfriend, a specialized master’s resident, she chose to join a social residency program. Two years later, Bingbing decided to leave the program, despite many advising her that “residency opportunities are hard to come by; just endure it, and it’ll be over soon.”

During her residency, Bingbing's day began at 8:00 a.m. She would take over from the night-shift colleagues, then start her clinical duties and rounds. She would examine half the patients herself, while the remaining ones were seen during professor-led rounds. Her official afternoon shift started at 2:30 p.m., during which she admitted new patients, ordered tests, wrote prescriptions, and double-checked everything to ensure no further tests were required. Theoretically, she could leave work once all this was done. However, interruptions were inevitable. “Nurses would come to find you, patients would seek you out, and your superiors would assign more tasks. It’s impossible to focus entirely on one thing while working,” she said.

“I felt utterly drained—physical exhaustion can be endured, but the mental fatigue was overwhelming,” Bingbing said.

A study published in Nature explored potential factors contributing to depression among medical trainees. It found that “long working hours” and “insufficient sleep” were significant factors in both China and the U.S. However, two additional factors—“age” and “fear of workplace violence”—stood out as unique contributors for Chinese medical trainees.

Bingbing recalled her initial experience at the residency hospital: “When you don’t understand something and ask for help, what you get in return isn’t an answer—it’s ridicule and personal attacks.” She had completed her undergraduate studies at a mid-tier university and was working at a prestigious hospital for the first time during her residency. It shook her confidence. “I thought this was just how top-tier professionals behaved,” she said. Later, with the help of supportive mentors and colleagues, she discovered that this particular department was notorious for complaints from both trainees and visiting doctors.

At one point, Bingbing changed her WeChat profile picture to a solid black image. “I thought, I want to die in this department and use my blood to awaken the attending doctor’s conscience.”

A 2023 study by Jinxingyi Wang and colleagues categorized suicidal behaviors into three levels of severity: suicidal ideation Thoughts about ending one’s life without taking any action. , suicide planning Developing specific plans, such as methods, timing, and location, or preparing for suicide. , and suicide attempts Acting on suicidal thoughts but not resulting in death. . Among Chinese medical students, the prevalence rates of these behaviors were 13%, 4%, and 3%, respectively.Compared to doctors globally, Chinese medical students reported a lower prevalence of suicidal ideation but a higher prevalence of suicide attempts. This suggests that Chinese medical students are more likely to act on suicidal thoughts and turn them into concrete actions.

According to scholar Wu Zhixin, suicide attempts can be seen as chronic protests: “I’ll show you what happens if I die—my suicide is an act of resistance.”

Li Guang, who has undergone two separate residency programs over the span of five years, embodies this sentiment. His first residency, completed in 2014, occurred before the residency system was fully implemented. “Back then, we followed the same requirements, but we didn’t receive a residency certificate,” he explained. After completing his PhD, he transitioned from surgery to radiation therapy and embarked on a second, full three-year residency. With six years of residency experience, Li realized that trainees at the margins of the system’s hierarchy “have no leverage to negotiate anything.” Even equal dialogue is nearly impossible, let alone contesting authority. From this perspective, suicide may be seen as one way for trainees to escape their confinement.

Currently, the Chinese Medical Doctor Association oversees residency programs primarily through top-down inspections. The National Health Commission (NHC) entrusts the association to conduct random evaluations of training bases across the country, focusing on base management, training quality, and welfare protections. However, when faced with unfair treatment, trainees have little recourse other than to report the issue and wait for higher authorities to address it. Protecting one’s own rights in such a system is a significant challenge.

Ultimately, Bingbing chose to temporarily exit the system. She decided to retake the postgraduate entrance exam in pursuit of her dream of becoming a university lecturer. “In my field, a bachelor’s degree is just the starting point. To have any room for growth, you must pursue a master’s or a doctorate,” she said. She thought, the difficult journey of medical students is par for the course.

The first time Zhu Jingping served as a surgical assistant, his lack of experience slowed the procedure. The chief surgeon berated him openly: “Did you even go to school? Should you go back and redo your undergraduate degree? I don’t even think you have hands. If I were your parents, I’d regret giving birth to you.” The chief’s frequent verbal abuse left a lasting shadow over Zhu. “Every night, I’d wake up from nightmares of him scolding me. I lost 10 pounds that month.” Residency felt like a transparent prison; Zhu rarely left the neighborhood around the hospital. At times, he resented his family for pushing him into studying medicine in the first place.

During his second year of residency, Zhu's mother was in a car accident and ended up in the ICU. He signed multiple critical condition notices on her behalf. He had expected to break down emotionally, but to his surprise, he faced the situation with composure. “I just believed my mom would recover,” he said.

Now in his third year, Zhu Jingping is a senior graduate student and demonstrates great patience with his junior trainees. “Since our superiors can’t protect us, we students should stand together. If I don’t teach them, after I leave, they’ll get scolded, and who will help them then?”