Why Chinese medical students are walking away from medicine
We assume that all medical students want to be doctors. However, only one in six of the 600 000 Chinese medical students who have graduated in the past five years have chosen to continue their career in medicine. Medical schools report that the number of new students is falling and many healthcare workers discourage their children from following in their footsteps. What’s going wrong?
It starts with the length of training. It takes 11 years to become an independent doctor, and another 10 to become a senior medical officer. During this time friends of medical students, who studied for shorter degrees, may have become leaders or chief executives in other professional fields. The government does not subsidise any of our fees and we must find ways to fund our studies ourselves. Tuition fees vary widely, from around ¥5000 (£520; €660; $810) to ¥15 000 a year. Most medical students in China are supported financially by their families, putting themselves and their families under financial strain during this long period of training.
Once qualified, doctors face considerable professional pressure. Many doctors who want to switch profession blame the heavy workload and a highly pressurised working environment, with little time for rest or family life. The demand for healthcare services in China is rising rapidly and the numbers of doctors in the workforce has not kept up. Outpatient episodes rose by 420 million in the year to 2013, with 7.3 billion episodes in total. In the same period, numbers of medical workers rose by 680 000 to 9.8 billion. In one hospital in Beijing, the ratio of patients per doctor admitted each day rose from 13 to 19 between 2001 and 2012. The situation is exacerbated by the Chinese health system, which allows people to present to secondary and tertiary care without referral from primary care. Most Chinese doctors only manage to take up to one week of annual leave a year, and see 50 patients a day. Unsurprisingly, many doctors in China experience burnout and illness. The incidence of hypertension among 40 year old doctors is twice as high as in the general population..
Traditionally, demanding professions pay well. But in China doctors are poorly paid compared with other professionals. Three quarters of Chinese doctors have a monthly salary of ¥1000 to ¥3000. According to the newspaper People’s Daily, the income of healthcare professionals is just 18% higher than the national average wage, yet doctors in developed countries are paid between three and five times the national average wage. Many feel that the salary does not merit the cost incurred when training to be a doctor. A survey of 11 910 doctors wanting to quit medicine found 57% cited dissatisfaction with income as the main reason.
Lastly, violence against doctors is becoming a major problem. According to the Chinese Medical Doctor Association, there were 17 243 violent attacks on healthcare workers in China in 2010 alone. Violence against medical staff increased from 20.6 assaults per hospital in 2008, to 27.3 per hospital in 2012, based on hospital reports. Ninety-six percent of medical staff say they were abused or injured in 2012.
Attacks range from verbal abuse to physical attack, including stabbings, and acid attacks. A survey of media reports of violence against doctors showed 29 murders and 52 serious injuries over 10 years from 2000. This is likely to be an underestimate. Why does it happen? Chinese people pay for much of their medical care themselves, and may have unrealistically high expectations. The system of payments means doctors can supplement their low salaries by prescribing expensive drugs and ordering extra investigations, which can cause tension. In addition, the difficulties of the compensation system for medical errors means some people resort to taking direct action against hospitals and their staff.
The crisis in the medical workforce in China is unprecedented. Although there have been some welcome moves by the Chinese government to increase pay for training resident doctors, and to deal with the problem of security in hospitals, the situation requires more fundamental action.
The struggle to meet demand for healthcare reflects the relatively low level of gross domestic product (GDP) allocated to services. China spends just 4.3% of GDP on healthcare, or $146 per person. Compare this with the United States or the United Kingdom, which spend 15% and 8% of GDP on healthcare respectively, with per person spends of $7164 and $3547.  It is clear that health in China is underfunded.
With China predicted to be the world’s largest economy by 2016, it needs to raise the proportion of its GDP spent on health to an appropriate level that adequately matches the needs of the nation. However, simply throwing money at the situation is unlikely to improve things. We also require wide reaching reform of the medical hierarchy and the system of payments and health insurance for patients too. But if risks to health and safety, poor wages, and lack of respect shown to doctors are left unaddressed we will continue to see more medical students turning away from a career in medicine. which will make these badly needed reforms even more difficult to implement.Nian-Cun Qiu, third year medical student1, Miao-E Liu, third year medical student2, Ying Jiang, fifth year medical student 1
1Second Military Medical University, Shanghai, China , 2Zhejiang University, Zhejiang, China
Correspondence to: firstname.lastname@example.org
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
- Ministry of Health of the People’s Republic of China. Statistical Bulletin of Chinese Health Service Development in 2011. [In Chinese.] www.moh.gov.cn/zwgkzt/pnb/201204/54532.shtml.
- Xuan Jiao Bai. It takes 21 years for doctor to earn a title of a senior professional post, Jiao Yahui said about Chinese doctor’s road to purgatory. CN-healthcare May 2014. [In Chinese.] www.cn-healthcare.com/article/20140525/content-457655-all.html.
- Chinese doctors in profession change tide. Ding Xiang Yuan 27 June 2013. [In Chinese.] http://sr.dxy.cn/article/54830.
- Ministry of Health of the People’s Republic of China. Statistical Bulletin of Chinese Health Service Development in 2013. [In Chinese.] www.nhfpc.gov.cn/guihuaxxs/s10742/201405/886f82dafa344c3097f1d16581a1bea2.shtml.
- Xu W. Violence against doctors in China. Lancet 2014;384:745.
- Ling-Ling Wang, Chen Wang, Yan-Lin Cao, et al. Analysis and thoughts on trend and harm of hospital violence. Chinese Hospital 2014;18:4-6. [In Chinese.]
- The survey made by DXY. CN and Medscape about job burnout feeling in China and the United States. Ding Xiang Yuan 30 May 2013. http://6d.dxy.cn/article/53805_2DXY. [In Chinese.]
- The situation in China is hard to improve: the issues of “difficulty of getting medical service” and “high cost of getting medical treatment” in the eyes of a doctor. Ding Xiang Yuan 24 February 2012. http://6d.dxy.cn/article/19186. [In Chinese.]
- Ying Ruo Xue. China’s doctors are really worn out. Lifetimes 17 December 2013 http://6d.dxy.cn/article/65590.DXY. [In Chinese.]
- Yi Xue Jie. Medical workers’ pay. hxyjw.com. 17 April 2014. http://news.hxyjw.com/news/show-131330. [In Chinese.]
- Jian Feng Bai. Who will be doctors tomorrow? China People’s Daily 22 November 2012. http://cpc.people.com.cn/pinglun/n/2012/1122/c78779-19658299.htmlError! Hyperlink reference not valid.. [In Chinese.]
- Zeng J, Zeng XX, Tu Q. A gloomy future for medical students in China. Lancet 2013;382:1878.
- Ling Feng. According to the policy of National Health and Family Planning Commission of the People’s Republic of China, the monthly salary of doctor receiving regulatory training will be 4000 Yuan. China Medical Tribune 22 May 2014. http://neur.cmt.com.cn/detail/510073.html. [In Chinese.]
- Hesketh T, Wu D, Mao L, Ma N. Violence against doctors in China. BMJ 2012;345:e5730.
- Ministry of Health of the People’s Republic of China. China Health Statistics Yearbook 2012. Peking Union Medical College Press, 2012. [In Chinese.]
- World Health Organisation (WHO). Global health expenditure database. Health system financing by country. 2014. http://apps.who.int/nha/database/Country_Profile/Index/en.
Cite this as: Student BMJ 2015;23:g7552