Note: China’s public hospitals are classified into three tiers, with tier 3 being the highest level. Each tier is further divided into three grades — A, B, and C — by regional health authorities. The higher the tier and grade, the more advanced and better-equipped the hospital.

In recent years, a series of sudden deaths among anesthesiologists has drawn attention to the profession’s challenges in China. It started with Jiang Jinjian, a 30-year-old anesthesiologist at Shanghai’s Ruijin Hospital who died of cardiac arrest in November 2019. Four months later, 29-year-old Dong Tian, another anesthesiologist in the central Hubei province, died of a stroke. Their demise was followed by two more anesthesiologists — Pan Chuanlong, 34, dying while on duty in the southern Guangdong province in April 2022, and Zhu Xiang, 46, dying from a sudden illness in January 2024. These deaths highlight three major challenges facing anesthesiologists in the country today: high technical requirements, high risks, and high workloads. Despite increasing demand for anesthesia services, the profession continues to be overlooked by hospitals, especially lower-tier institutions.

Over the years, the development of anesthesia-assisted procedures, such as gastrointestinal endoscopies and epidurals for labor, has made anesthesiologists increasingly crucial to modern medicine. According to a 2021 study in the Lancet, from 2015 to 2017, the workload of anesthesiologists in the Chinese mainland increased by over 10% annually, with more than 51 million sedations in 2017 alone. In contrast, the number of anesthesiologists grew by only 6% during the same period.

“Anesthesiology is like a foundational platform, supporting general surgery, orthopedics, and other departments,” says Liang Wen, chief of the anesthesiology department at a tier 2 hospital in the northwestern Qinghai province. “It could be likened to an aircraft carrier, with other departments serving as combat units. The hospital will naturally support the combat units first over the platform unit, which is why anesthesiology usually feels neglected in small hospitals.”

A marginalized profession

Historically, anesthesiology has occupied a marginal position in Chinese hospitals. Back in 1989, the Ministry of Public Health mandated that anesthesia units be converted from medical technology departments to clinical departments, but implementation has been limited. According to the data from the Lancet report, only 38% of tier 2 hospitals and 24.7% of tier 1 hospitals have independent anesthesiology departments. At some lower-tier county hospitals, anesthesiology remains classified as a medical technology department with relatively poor conditions. While clinical departments directly manage patient admission, diagnosis, and treatment, medical technology departments are considered “non-clinical” and merely provide support services.

“It started out with surgeons and even nurses performing anesthesia, as the hospital didn’t consider it important,” says Yang He, who has worked in anesthesiology at a county-level hospital in the southern Guangdong province for over 10 years. “When the anesthesiology department was short-staffed, they recruited from clinical departments and trained as anesthesiologists,” he says. Most of the doctors in Yang’s department come from backgrounds in clinical medicine rather than specialized anesthesia. Yang himself became an anesthesiologist after completing a refresher course.

Liu Chunyuan, deputy chief of anesthesiology at Liangping People’s Hospital, a tier 2 hospital in the southwestern megacity of Chongqing, notes that dedicated anesthesia undergraduate programs didn’t appear in China until the late 1980s and early 1990s. The low status of anesthesiologists means many tier 1 hospitals lack adequate equipment and training opportunities, creating a significant gap between their anesthesiologists’ expertise and that of those in large tier 3 hospitals.

This disparity is even more pronounced in primary care facilities. “Township-level hospitals, including small private facilities, often lack qualified anesthesiologists,” Liu explains.

Anesthesiology departments typically rank at the bottom in terms of hospital performance metrics. Yang explains that departmental performance pay, which accounts for 30% to 50% of doctors’ total salary, is proportional to service volume. Unlike clinical departments that can generate revenue through outpatient services, anesthesiology departments depend entirely on supporting other departments’ procedures. In other words, their performance is effectively tied to that of clinical departments.

Liang notes that as a support department, anesthesiology struggles to generate direct revenue while simultaneously bearing significant costs. His department provides supplies for surgeries but receives no portion of the surgical fees. As department chief, Liang advocated for cost-sharing between anesthesiology and surgical departments but abandoned the effort when the hospital proved unable to accurately track expenses. While conditions are much better in tier 3 hospitals, Liang says smaller facilities tend to overlook anesthesiology as it doesn’t directly generate profit. When Liang requested specialized equipment for a difficult procedure, he was told that the respiratory department had priority: “The reason is very simple — other departments provide medical treatment, while anesthesiology must make do with what it has.”

Resource allocation also disadvantages anesthesiology departments in lower-tier hospitals. Zhang Huixian, an anesthesiologist at a county-level hospital in the central Hunan province, says her institution lacks outpatient anesthesia equipment, and operating room resources are limited to monitors and anesthesia machines — only two of which are modern. “When there are multiple or major surgeries, doctors compete for better equipment,” she says, a system she feels is unfair. The department has spent years requesting specialized medications, including fast-acting muscle relaxants and elderly-appropriate anesthetics, without success.

Always on call

According to the Lancet, anesthesiologists at tier 3 hospitals must complete 592 cases on average per year, while their tier 1 or smaller counterparts handle 317 — less than one case per day. Liu, the deputy chief of anesthesiology in Chongqing, believes anesthesiologists face different but significant challenges across hospital tiers. “Large hospitals have high surgical volumes, while smaller ones lack adequate staffing.”

In 2018, multiple government agencies, including the National Health Commission, jointly issued guidelines acknowledging and addressing China’s anesthesiologist shortage. While major facilities like the West China Hospital of Sichuan University’s Anesthesia and Operation Center in the southwestern Sichuan province currently employ more than 1,300 staff members, including Ph.D. supervisors and specialized nurses, lower-tier hospitals operate with skeleton crews. Zhang’s county-level hospital has just five anesthesiologists, while Xie Xinlong’s tier 2 Liangping Second People’s Hospital in Chongqing has only three: one attending anesthesiologist on assignment, one practicing physician, and an assistant.

Xie, who joined the hospital in 2021, works from 8 a.m. to 6 p.m. on weekdays and remains on call on weekends. “Emergency cases can come at any hour — it could be as early as 2 or 3 a.m., and the anesthesiologist has to get there right away,” he says. The month before and after Chinese New Year is the busiest time of year as many migrant workers return home for the holiday. “Normal months see about 10 surgeries, 40 gastroscopies, and 20 colonoscopies. However, during the holiday period, their numbers can triple,” he adds. Xie recalls leaving a family dinner during Chinese New Year to perform emergency appendicitis anesthesia, driving 40 minutes to reach the hospital. Zhang’s hospital requires evening shifts from Monday through Saturday. The main shift runs from 8 a.m. to 5:30 p.m., but evening shifts can extend until 8 a.m. the next day. The high volume of surgeries sometimes requires working through the morning.

Lower-tier hospital anesthesiologists face both constant availability demands and heightened risks associated with anesthesia procedures. Liu points out that the anesthesia-related mortality rates are higher in these facilities than in larger hospitals. Professor Yao Shanglong, chief of the anesthesiology department at Wuhan Union Hospital, also noted in an article published by Voice of Anesthesia and Perioperative Medicine that while large hospitals have achieved international safety standards, smaller facilities continue to experience frequent adverse events due to staffing shortages, overwork, inadequate training, and substandard conditions.

One issue is the prolonged stress involved. “When it comes to some cranial surgeries, they can go on for five to six hours, sometimes even seven to eight,” says Zhang. “The patients’ vitals are entirely entrusted to the anesthesiologist, and we can’t allow even the slightest issue to arise with the patient.” Meanwhile, Xie adds that due to the outflow of the younger working population from rural areas, the lower-tier hospitals mostly receive elderly patients, often with multiple health conditions, increasing anesthetic risks.

Compensation fails to reflect these demanding conditions and high workload. Salaries consist of base pay and surgical anesthesia fees. Many anesthesiologists in lower-tier hospitals report earning in the bottom to middle salary range for hospital staff. Yang’s quarterly performance bonuses fall significantly below other departments, partly because the administration underestimates the department’s risk level. In Zhang’s hospital, anesthesiologists earn roughly half what surgeons make, without holiday or overtime pay.

Professional stagnation

Recent years have seen widespread adoption of medical imaging and endoscopic technologies in China, with clinical anesthesia trending toward automation and digital imaging. While Liu’s hospital acquired such equipment almost 10 years ago, many lower-tier hospitals still lack ultrasound visualization tools. Zhang’s colleagues have minimal continuous medical education and haven’t adopted these new technologies. Though Xie studied advanced techniques during his training, his hospital hasn’t purchased the relevant ultrasound equipment.

Advancing medical technology requires constant learning. Liu believes they need broader knowledge than other specialists because they can’t easily consult colleagues during procedures — they must understand all organs and systems in the body to deal with any emergency.

But opportunities for refresher courses and training are lacking. “Anesthesiologists in their 40 to 50 working years may only have one to three opportunities to go out for further study,” Liu says. Meanwhile, in Zhang’s department, no one pursues further education because “only base salary is paid during training periods.”

Even when anesthesiologists are willing to undergo additional training, staffing shortages create obstacles. Xie recognizes the risk of falling behind without continuous education, but he knows his three-person department couldn’t function if he left for training. Liang’s hospital faces a similar dilemma: only four anesthesiologists are available to handle operating room and outpatient procedures daily. “If one takes vacation and another leaves for training, how could the other two anesthesiologists be able to maintain department operations?”

Some anesthesiologists in lower-tier hospitals started resource-sharing efforts to address technical challenges. In 2011, Liu founded the Network for Anesthesia in Low-tier Hospitals and created China’s first free online anesthesia education platform, “Anesthesia Lecture Hall,” inviting domestic and international experts to teach online. Liu said that he wants to give those anesthesiologists working in lower-tier hospitals who lack opportunities for further education a chance to participate in continual learning. The ad-free site, supported by a mix of Liu’s own money and donors, helps isolated practitioners pursue professional education. Associated chat groups with over 30,000 active users can provide immediate consultation support.

Outpatient anesthesia services offer another development path. Following the release of national guidelines encouraging anesthesiology clinics in 2017, Liu’s department opened outpatient services in July 2018.

Liu believes outpatient care improves patient assessment and public understanding of anesthesiologists and anesthesia risks. It’s also key to a hospital’s overall performance. “Anesthesiology determines a hospital’s development ceiling, just as a skyscraper requires a strong foundation for support,” Liu says.

(Due to privacy concerns, Yang He, Zhang Huixian, and Liang Wen are pseudonyms.)

A version of this article originally appeared in The Paper. It has been translated and edited for brevity and clarity, and is republished here with permission.

Translator: Eunice Ouyang; editors: Wang Juyi and Elise Mak.

(Header image: An anesthesiologist at work, Qingdao, Shandong province, 2018. VCG)