Background <p>Global primary healthcare providers are grappling with workforce shortages, regional development imbalances, and inconsistent service delivery models. Rural-oriented tuition-waived medical students (RTMSs), who are the focus of standardized residency training (SRT), play a pivotal role in enhancing grassroots medical capabilities. This study focuses on the current situation and satisfaction level of RTMSs participation in SRT, with a particular emphasis on the deeper factors that influence their willingness to continue practicing in rural areas after completing the program.</p> Methods <p>In June 2022, a multicenter cross-sectional observational study was conducted across eight hospitals in Yunnan Province, surveying 643 RTMSs enrolled in the SRT program. Descriptive and analytical statistical methods were used to analyze the data.</p> Results <p>Findings indicated that 91.29% of the respondents endorsed the SRT, believing it significantly enhanced their core competencies, and 81% were satisfied with the training. However, only 28% expressed willingness to continue practicing in rural primary healthcare institutions after their contractual service. The low retention intention was mainly associated with expectations for higher income, positive psychological states, frequent skill training and lectures, regular psychological counseling, and team-building activities, as well as an enhanced sense of identity as RTMSs.</p> Conclusions <p>The study underscores the critical role of SRT in improving professional competences for RTMSs. Although training satisfaction has improved, their willingness to remain in rural practice after contract completion remains low. Immediate measures should include increasing rural allowances and improving housing conditions, while long-term strategies require government-level reforms to enhance remuneration, living conditions, and career development pathways.</p> Trial registration <p>Not applicable.</p>