There are limitations in the study. Data testing was limited to only resident physicians at the 19 collaborating hospitals which are relatively large teaching hospitals in China. The quality of physicians in these hospitals may be different from those work in smaller, community-based hospitals that are not affiliated with academic medical centers. We are not sure whether resident physicians in other parts of China would have similar performance profiles. There were only 1 attending doctor, 2 resident peer, 3 nurse, 7 patient and 2 office staff evaluators per resident physician in this study. Future research should increase the number of evaluators per resident to improve the reliability for the overall questionnaire. In addition, most teachers in China are usually not inclined to give low scores in evaluations like this, which may explain the relatively high scores (16).

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