Only a limited infrastructure supports CME curriculum. And only imperfect processes ensure that doctors actually complete course work for which they receive credit. Some hospitals impose their own CME requirements on staff members and develop their own tracking system for CME credits. The Chinese Medical Association (CMA), the accrediting body, subcontracts some of the curriculum development and program administration to outside providers. The primary media for CME are symposia, print, and audiovisual recordings. Doctors in rural areas and sparsely populated provinces take advantage of Web-based CME programs. As physician standards are raised, it seems reasonable to expect some changes in the CME system. One can speculate, for example, that other accrediting bodies may be added and/or that ultimately an equivalent to the Accrediting Council for Continuing Medical Education (ACCME) in the United States may be established.

The Doctor-Patient Relationship

While most doctors in China still enjoy a good relationship with most of their patients, the status of the healing profession has fallen over the past decades. Physicians in China enjoyed a brief resurgence in popularity during the SARS outbreak, when they were praised for their brave efforts to save lives while jeopardizing their own safety. As memory of the epidemic faded, the public returned to a critical, often disrespectful attitude toward doctors.

More important, consumers resent bearing an increasing burden of healthcare costs. During the period from 1978 to 2002, the government's share of healthcare expenditures decreased from 80 percent to just over 15 percent, while the consumer's share rose from 20 percent to nearly 60 percent, according to the Ministry of Health. Even though Chinese citizens save 40 percent of their income, increases in healthcare costs may soon become burdensome. In the past five years, the average income in cities rose by nine percent, while healthcare costs increased by 14 percent. In rural areas, income has increased by just over two percent, while healthcare costs have gone up by nearly 12 percent.

Although Chinese consumers do not sue their doctors for malpractice, as Americans are wont to do, they often yell at them in public, which is nearly unthinkable behavior in the United States. Patients waiting in the lobby to see a doctor may overhear, as I did on a recent trip to Beijing, the all-too-familiar scene of an angry patient, flanked by family members, screaming at a doctor in an exam room. In this case, the patient was disputing charges. Such outbursts by patients are not unusual. Quite often, verbal abuse turns into physical assault when patients vent their frustration about healthcare costs, the slow progress of therapy, or a poor outcome following surgery. Hundreds of assaults on doctors are reported every year, some of which result in injuries requiring hospitalization.

Finally, the doctor's low salary further jeopardizes professional authority by putting him or her in a position to receive additional compensation under the table, sometimes directly from patients. It is no secret that "red packets" containing cash, given before and/or after a procedure, are de rigueur for surgeons. Red packets have also changed hands to ensure an appointment with the doctor of choice. Clearly, such practices not only compromise the doctor's position as a credible, authoritative figure, they help patients justify demands for good results.

Too few primary-care physicians serve as gatekeepers. "Many of the patients coming to our hospital have a simple case of hypertension, something that really does not require the attention of specialists," says Dr. Xi Zhimin, a cardiologist at Fu Wai Hospital for Cardiovascular Medicine in Beijing. "Patients have no way of knowing when they need a specialist, so they, or more often their families, decide to see the specialist, thinking they will get better care."