The Urban Legend of “4 Million Medical Students Who Switched Careers”: How Much Anxiety Is This Industry Hiding?

People worry they can no longer get expert enough care. Doctors believe they are the ones being treated unfairly.

Wu Qiao left the hospital for good in April 2016. She had already been through eight years of clinical medical training, but had not yet reached the point of signing a formal contract with the hospital. In the emergency room she had seen patients threaten to throw punches — fortunately, the fight never happened. Rather than enter another three years of professional training, Wu Qiao decided to sign with a multinational drug company in Shanghai.

A study published in October 2016 in volume 388 of The Lancet, one of medicine's most authoritative journals, set out to show that Wu Qiao's choice had become fairly common among China's medical graduates in recent years. In that study, “10-year trends in the production and attrition of Chinese medical graduates: an analysis of nationwide data,” the researchers said they had found some startling numbers: between 2004 and 2015, 4.728 million medical students graduated in China, but only 752,000 new licensed physicians were added. If nothing else was at play, that means more than 84% of medical graduates never became doctors.

If the trend held, the researchers added, the result would be that in certain specialties and in remote areas people might not be able to find a doctor at all.

The numbers went beyond anything medical students and doctors saw day to day, and in private they argued about whether to believe them — but a conclusion published in this authoritative medical journal still struck a chord with many. Those who read it as bad news wrote things like, “What can we do to keep you, our doctors?” Others treated it as a warning bell: people should think hard about a mess of their own making — they had heaped too much misunderstanding on the medical profession, and might now be tasting the “bitter fruit.”

DXY, a 16-year-old medical website, published an article on February 28 arguing that fierce competition and a poor working environment were driving graduates away. In March, another piece posted online, “Kill One Doctor and Tens of Thousands Are Buried With Him,” cited the same figures and ran through nearly every grievance doctors hold. Chen Guangming, a 29-year-old doctor at a county people's hospital, read it afterward and, forwarding it, said that was about right.

Wu Qiao took no part in this collective declaration. But she remembered that when she filed her resignation paperwork, a hospital administrator told her that over the past two years slightly more students and doctors had switched careers than in the two years before.

Did More Than 80% of Clinical Medicine Graduates Really Switch Careers?

Where medical graduates end up has always been something of a mystery.

The 2012 version of the story was that “of every 600,000 people, only about 100,000 get to put on a white coat.” “According to a figure I have —” said Li Ling, a professor of economics at Peking University's National School of Development, in an interview with China Youth Daily at the time; she gave no source for the number. At a forum called “Healthy China” in November 2015, another study's data likewise showed that from 2008 to 2013, nearly 80% of “graduates of higher medical education” did not become clinical doctors. Caixin, the serious political and economic news magazine, reported on that study at the time.

Fan Peizhen is the first author of this latest, similar study. She got her entire medical education in the United States — a master's degree from Harvard, then a doctorate from Johns Hopkins — and is now an associate professor of neurology in the Department of Medicine at National Yang-Ming University in Taiwan.

Discussing the choices young medical students make in mainland China may be something of a challenge for a US-trained Taiwanese scholar. She has not yet published a formal paper on the subject; she presented these preliminary findings at a health summit organized jointly by The Lancet and the Chinese Academy of Medical Sciences in October 2016 (The Lancet-CAMS Health Summit, 2016). The summit, held in Beijing, was only in its second year.

As an early version of the paper, the abstract of the report was published in full in The Lancet's October 2016 conference supplement, though none of the other abstracts caused anything like the stir this one on “medical students switching careers” did.

At that conference, Fan Peizhen listed the total number of medical graduates from 2005 to 2014 alongside the number of licensed physicians added in those years. From those figures came the conclusion that more than 84% of medical graduates had switched careers. The details of her method come from the slide deck Fan Peizhen sent to QDaily by email, which includes material that does not appear in the abstract.

That material shows the study mishandled its key data. As a result, it described wrongly whether medical students “switching careers” had become a trend. Huang Lei, a co-author of the report from Tongji Hospital, affiliated with Tongji University, said by phone that she had heard some challenges to the data, and that the figures were still being checked.

To count graduates, the researchers used “number of medical-program graduates from regular institutions of higher education,” a figure that can be looked up directly in the China Health Statistics Yearbook the National Health and Family Planning Commission publishes every year. That figure covers every medicine-related major, but in fact only graduates of a handful of programs — clinical medicine, dentistry, traditional Chinese medicine, preventive medicine, and ophthalmology and optometry among them — may sit the licensed physician exam, which is the precondition for becoming a clinical doctor. No systematic data shows what share of medical students those programs account for, but judging by the enrollment plans published by some public medical schools, the share is usually somewhere around 20-50%. Since not every graduate passes the licensed physician exam, the number who actively chose to switch careers would be smaller still. That brings the pool of potential new doctors down to somewhere between 1 million and 1.3 million. And the other figure used for comparison — the 750,000 new licensed physicians — does not, judging by what the commission has made public, account for doctors who quit or retired.

More than five interviewees backed this reading. Staff at medical schools said they had seen no rise in the number of medical students switching careers in recent years. At Shanghai Medical College of Fudan University, the head of the career guidance center said more than 90% of clinical medicine graduates go on to work in hospitals, and that the figure has held fairly steady. In cities like Dali and Wenzhou, medical students still scramble for hospital jobs.

What medical students and researchers see suggests that young people's appetite for practicing medicine may not be what it once was — but to say that switching careers on graduation has become a trend too big to ignore is, frankly, bluster.

They have grown used to hearing it anyway. “The same old story,” said Tian Jishun, a 36-year-old former obstetrician-gynecologist. “So miserable, so pitiful, we've given up so much, doctor-patient relations are so bad — people have been saying this for ten years.” He left his hospital last year for DXY.

Are Bad Doctor-Patient Relations Scaring Young Medical Students Off?

Even for ordinary people, changes in the medical trade matter more than architects or actuaries switching careers, because everyone eventually needs a doctor. It is just that people worry they can no longer get expert enough care. Doctors believe they are the ones being treated unfairly.

“We can't even count on our own safety!” they say, in a tone that asks for nothing more, when they complain about conflict with patients. Some doctors want stories like “medical graduates switching careers” told again and again; they are betting that alarming facts, repeated often enough, will finally change doctors' “terrible situation.”

But the fact is that these urban legends about a “terrible situation” — including the one about where medical graduates end up — are, like the rumors about doctors “doing evil,” not all reliable.

Zhang Meiyin, an anthropology PhD candidate, is running a study on how medical students grow into their careers. A few years ago she began noticing that quite a few medical students around her were changing majors. She also noticed that the media had tied this to worsening doctor-patient relations.

Plenty of researchers, meanwhile, have wanted to find a link between the two. Over the past decade, the number of papers on how doctor-patient conflict affects medical students has risen year after year. In 2017 it is expected to approach 400.

The Lancet alone wrote in a May 2012 editorial, “Ending violence against doctors in China” — the second time, after 2010. And in another letter to the editor in December 2013, “A gloomy future for medical students in China,” the author cited data from the Chinese Medical Doctor Association — 17,243 violent attacks on medical staff in 2012 — and argued that such cases were directly driving down the number of medical graduates who go into practice.

Newer researchers, Fan Peizhen among them, have been shaped in large part by these popular views: that young Chinese medical workers are suffering badly from doctor-patient relations and probably cannot hold out much longer. In her report she drew on media coverage and a few news photographs, including a rather theatrical one of a young man in a white coat with a couplet written on his back, the horizontal line across the top reading “Don't Study Medicine.”

The facts may be more complicated than the pictures.

Zhang Meiyin interviewed more than 20 medical students. She did find cases of young doctors who regretted studying medicine after unreasonable complaints or threats of violence from patients, and some students she interviewed said news of patients attacking doctors left them cold. But her preliminary research shows: “Of the medical students I have interviewed so far who changed majors, not one did it because of doctor-patient relations today.” Current incidents and disputes between doctors and patients do not directly push medical students to change majors; many who give up on medicine do so for other reasons. (Her interviewees so far are limited to students at Fudan University's medical school.)

Some publicly available papers reach similar conclusions. They cover students at a wider range of medical schools at different tiers, and generally find that medical students have little direct experience dealing with patients — most learn about these incidents through the media. Only half of medical students said the news left them feeling under real pressure.

Our interviews largely bore this out. Most of the people QDaily interviewed had no first-hand experience of conflict with patients, though they always had a friend or two who had been through something ugly. The exception was Hong Xia, a medical student who graduated last year from an eight-year clinical medicine program, who said he had been “punched” himself. “If it had been a knife, I wouldn't be able to talk to you right now,” he said, trying to convey how bad it can get, adding that to head off these frequent conflicts, emergency rooms in every newly built hospital block are now designed so they don't open onto a public exit.

Still, he has also learned to borrow the language of clients and vendors from business to explain patients' sometimes overheated emotions. “It's the relationship between Party A and Party B — Party A gets to throw its weight around a bit,” which is fair enough. Last year he joined a tertiary Class-A hospital in Guangdong. “At the time I really wanted to be a doctor,” said the doctor, who is under 30. “In that situation, not making it as a doctor would have felt like failure. If I didn't become one, I'd have studied for nothing.”

Doctors' Status Is Said to Be Slipping — Is It Still a Respectable Job?

Chen Dankai did not join the hospital where he had interned after he graduated. He rarely even picks up a scalpel now, though he still considers himself a doctor. He likes to joke, “I tell my dad, the moment you set foot in a hospital you'll get fleeced” — but he believes that to most people, “doctor” is still a respectable title.

This odd contradiction usually shows up in patients: they find it hard to trust the doctor in front of them, yet in daily life they are glad to make friends with doctors, which can come in handy. One medical student Zhang Meiyin interviewed described two entirely different receptions: in clinical work, patients were sometimes wary; but at a group blind-date event, away from any clinic, he found his identity as a doctor was popular — plenty of people wanted a connection and a measure of trust with him, a social resource for future care. The common complaint that doctors have “low social status” therefore tends to oversimplify, and the opposite view — that “the white coat hides inexperience and confers privilege” — does not hold in every setting either.

A doctor's dignity is a complicated business. Chen Dankai worked this out while still a student, choosing his specialty. He picked plastic surgery — even though most of the work in that department today is cosmetic rather than reconstructive, which means less professional satisfaction — because what mattered more, by comparison, was that it is easier to leave a public hospital and go out on your own.

“It's mainly a money question,” said the 28-year-old doctor; the calculation about income outweighed the nerves about stepping off the usual track.

Negative talk about doctors' incomes is common, but mostly vague. Data given in another 2013 letter to The Lancet, “What future for doctors in China?,” had it that “even in cities, many doctors earn only 5,000 yuan a month.” The letter also said 80% of doctors at secondary and tertiary hospitals felt they worked beyond capacity for pay that fell short.

Given how far incomes diverge by seniority, it helps to break this down. A 2012 DXY survey found that resident physicians work at least 80 hours a week, and chief residents sometimes reach 120. Residency is the junior stage before becoming an attending physician, a period that usually runs two to five years; residents draw 2,000 to 5,000 yuan a month, write up at night the medical records that pile up during the day, and squeeze in research and papers on top. At most hospitals, evaluations for professional titles have no direct connection to treating patients — they turn on published research.

Even for older doctors, income is uncertain. Once he saw he could not get into the orthopedics department of a tertiary Class-A hospital in Shanghai, Chen Dankai chose plastic surgery, and planned to leave the hospital three years later. The high-earning departments are the ones with heavy demand, or the ones that use a lot of equipment. One interviewee who had once considered joining a drug company said the cuts on devices and drugs are real: roughly 20% to the doctor, 30% to the equipment dealer, and the remaining 50% or 40% the actual cost. He said he had heard that the head of orthopedics at the hospital where he interned made more than 10 million yuan a year, though that depends on “whether you're willing to take some of it.”

One interviewee argued that gray income is this common because it works as an informal way of compensating doctors under the current system. But he asked to stay anonymous for an opinion that sounds indefensible. Most other medical students disliked the subject — partly because they found it morally shameful, partly because the industry's unmentionable pay structure left them at sea, with no clear path ahead.

This would have been unimaginable in the past. Medicine used to be favored for being “useful” and “stable.” Wu Qiao's parents picked the clinical medicine program at Shanghai Jiao Tong University for her ten years ago; she comes from a small county town in Sichuan.

By the time she left the hospital, Wu Qiao had realized: “Everyone cries poor at you, but nobody actually knows what anyone else makes. Even if I made department head one day, I wouldn't know what income that meant.” Her monthly pay at the drug company is over 10,000 yuan, more than most of her classmates from the same year.

Do Doctors' Parents Always Forbid Their Children to Study Medicine?

Another piece of medical-world lore says doctors don't want their children in the profession, going through the same bad working life all over again. Tian Jishun has heard it so often he is a little tired of it. “Plenty of doctors — back when I was a medical student, at least, my teacher said that if his kid wanted to study medicine, he'd break the kid's legs.”

Tian Jishun thinks this is just the usual workplace grumbling, not very clever, and that it happens to architects, teachers, accountants and anyone else who doesn't like the job enough.

Yet doctors' warnings to their own children have traveled further than anyone else's.

Three scholars from Peking Union Medical College and Tsinghua University wrote a paper called “Motives for Choosing to Study Medicine and Expectations of Social Mobility.” They surveyed and interviewed 2,054 master's students at the Chinese Academy of Medical Sciences and found that family influence is still an important factor in the decision to study medicine. These parents believe the field has clear job prospects and a stable, decent income, and that “it's handy to have someone at home who can treat you” — as it has always been.

Doctors believe they know the real world under that surface: high-pressure work, fierce competition, murky income, the mental load that comes with it, and the occasional fight. But they don't all give the same career advice.

Hua Xi is a medical student doing her master's. She and her friends have talked this over privately, and drew a line based on experience: “It's probably the doctors at big hospitals — the ones who have a name now, whom everyone respects, whose income is good and who live with dignity — who encourage their children to become doctors. But a small-time doctor, with heavy pressure and low pay, is less willing to let a child go into medicine.” Hua Xi's father is a doctor; he told her to be ready for plenty of trouble, but “he didn't try to talk me out of it.”

Because they came of age during a reform of medical education, though, students like Hua Xi ran into problems their parents' generation never faced: extra training for resident physicians. The policymakers say they hope that forcing medical students to spend longer training in hospitals will improve their clinical skills. After “Standardized Residency Training” came the National Health and Family Planning Commission's “Standardized Specialist Physician Training” policy in January 2016. Researchers at medical schools wrote yet another letter to The Lancet saying this had left young Chinese doctors and medical students frustrated, even resentful.

“Everyone fell apart when they heard,” said Hua Xi, who counts herself among the frustrated and resentful. “We're all pretty unhappy with the commission, because they make a small change every year and a big one every three.” Counting from the day she entered medical school, she works out that finishing all the required training could take her 15 years. She even worries a little: “After all that, will they still let me be a doctor?”

The path through a medical career used to be clear; now it is the opposite. “Our fate in medicine is being quietly sentenced to death by transitional policy — we will not be the sacrifice for a policy,” read a petition written by academic-track clinical medicine graduate students in the classes of 2013 and 2014 at Tianjin Medical University.

Lü Jingbao, head of the career guidance center at Shanghai Medical College of Fudan University, said “Standardized Residency Training” caused only “a certain amount of turbulence” among that year's graduates in 2010, when it was first introduced. Even so, nearly every medical student interviewed believed the policy might yet push them out of hospitals, or already had. Some also believed hospitals are the only real winners from this stream of training policies, which help them cut labor costs.

Do the People Who Don't Become Doctors All Become Drug Reps?

What can be confirmed is that being a doctor or a medical student appeals to young people less than it used to. They have more options now. According to the China Health Statistics Yearbook, growth in medical school enrollment has lagged far behind growth in overall university enrollment since 2005.

In 2013, Shanghai Medical College of Fudan University began recruiting separately instead of sharing an applicant pool with the wider university. The medical school hoped this would bring in young people more committed to medicine and stop later losses to students changing majors. That year, applications to the medical school fell short of expectations. That, too, made a certain amount of noise as news, and suggested that some young medical students may have treated the major as a tactic when filling in their college entrance exam preferences, with no intention of becoming doctors.

Medical graduates did feel at the time that failing to get into the department they wanted at the hospital they wanted, within a tolerable stretch of time, and giving up medicine as a result, “was a failure.” But once they turned around and looked for something new, “in the end they found another industry might suit them better.”

Unfortunately, on this point people's impressions may still be stuck fifteen or twenty years back. Back then, a sales rep job at a multinational drug company was the best option for medical graduates and doctors who had quit. Wu Qiao had heard that their income was more than ten times an ordinary doctor's at the time; other rumors put the gap as high as “30 times, for the top earners.” But the reputation of drug reps has taken a beating in recent years, and the income gap has narrowed. At her company, Wu Qiao has not met a single drug rep with a clinical medicine background.

Wu Qiao works in her company's medical affairs department, which handles research on drugs after they reach the market, communicates the findings to doctors, and provides academic support to hospitals. Her hard-won lesson is that leaving the hospital is not something you can put off. Drug companies like people with clinical backgrounds, but like most big companies, they worry more that as people get older, one life event after another will interrupt the work. “Of course what they'd love is for you to have six or seven years of clinical experience — and still be 24!”

Chen Dankai joined a startup team, where he handles operations. The team works like a doctor group: they invite public-hospital doctors to operate at private clinics, and also assemble teams invited to practice at other hospitals. This used to be the gray-zone business of doctors moonlighting with the scalpel at outside hospitals, but just last week a newly announced policy said doctors may register with several medical institutions and practice freely. That is a big deal, Chen Dankai said. Other young public-hospital doctors interviewed said the real winners from the policy are the older doctors in public hospitals — the young ones have no time to spare for it.

A former medical student who joined Fosun Healthcare to work on hospital investment, and a newcomer to health insurance who finished only five of the eight years of undergraduate coursework, both said they have been getting a lot of calls from friends lately — would-be doctors still inside the hospitals, wanting to know what suitable opportunities exist on the outside. Both of these people who left are pinning their hopes on policies that favor private hospitals and commercial health insurance.

Because the entry requirements are so high, very few go to the United States to practice medicine or do research.

When Tian Jishun joined DXY, he thought the combination of healthcare and the internet was exactly the window to catch. He added that the odds of failure might be nine in ten, but that the venture at least satisfies what young people care about most: “I think I'm doing pretty well, and I want the growth I want, a better platform — that's a given. I should be able to see my own future.”

But most of these choices happen in big cities. In Wenling, a small city in southern Zhejiang, Bao Renhui became a forensic pathologist after graduating from medical school, which is not a doctor's post. He also handles psychological counseling for police officers, which is where his interest lies. Even in Guangzhou, a provincial capital, Hong Xia feels a bit far from the new opportunities in healthcare; he guesses his old computing skills might one day let him work on AI-assisted diagnosis. For now, he is a resident in urology.

(Wu Qiao, Chen Dankai, Hong Xia and Hua Xi are pseudonyms, at the interviewees' request.)