have widened the gap between western and Chinese ID physicians [18,19]. The survey also showed that ID physicians endured more mental stress, smaller salaries and greater dissatisfaction than other physicians in China. The annual income of most ID physicians was below $15,000, the third lowest among Chinese physicians [20]. This - was only 70% of the annual income of anaesthesiologists (the highest paid specialty) and was 1.2 times the national average salary in China [20,21]. By contrast, a Medscape survey in 2016 reported that the average annual income of an ID physician in the USA was $215,000, 20 times that of a Chinese counterpart's [20,22]. Most participating physicians in this survey (81.2%) reported high workloads and work-related stresses, whereas only 48% were satisfied or very satisfied with their jobs. Only one-third reported that they would again choose to specialize in ID if given another Table 2 The characteristics and professional practice of infectious disease physicians in China Items All Hospitals (1071) Tertiary Hospitals (770) Secondary Hospitals (301) p-valuea Range Mean ± SD Median Range Mean ± SD Median Range Mean ± SD Median Age, years 31e44 36.00 31e44 36.00 31e45 37.00 Sex (male/female) 47.3/52.7 44.8/55.2 53.8/46.2 < 5 h/5e10 h/>10 h. C. Zhang et al. / Clinical Microbiology and Infection 24 (2018) 82.e5e82.e10 82.e8 chance. In a national survey, 55% of physicians were satisfied with their jobs and 45% would choose to specialize in the same area if given another chance [20]. This study had several limitations, including the possible bias associated with non-anonymous replies, the large number of physicians who did not return questionnaires and the inability to compare responders and non-responders. In conclusion, the ID specialty in China has become marginalized because of its lack of adaptability to modern medicine. In addition, the huge workloads, stress and career uncertainty of ID physicians discourage continuing professional development [23e25]. This situation has arisen for a number of reasons. First, the needs of the public for ID physicians have been underestimated and neglected. Moreover, the authorities are not fully aware of the value of ID physicians in the healthcare system [2]. In almost all studies, the interventions of ID physicians were associated with a significant improvement in the appropriateness of antibiotic prescribing as compared with prescriptions without any ID physician input, and with decreased antibiotic consumption [26]. Second, ID practice has not adapted to changing demands of the system, and ID physicians have not been involved in treating emerging infections. Because of the potential safety hazards existing in sterilization of medical devices, the lack of bacterial culture and drug-sensitive analysis in patients and so on. Most hospitals are unable to strictly enforce the national staffing standards for antibiotic stewardship or hospital infection control [27]. Third, the lack of positive relationships between ID physicians and their clinical microbiology and infection control colleagues has resulted in a lack of motivation of the former. Fourth, lower salaries and greater social pressure have made ID specialty less attractive to younger physicians. Fifth, the reductions in science and technology budgets devoted to ID in Chinese medical institutions and the reduced revenue provided by ID departments have resulted in limited investment in both financial and human resources [28]. Fig. 2. Career status and annual income of infectious disease (ID) physicians in China: (a) workload and mental pressure; (b) career satisfaction; (c) annual income; (d) willingness to re-choose IDs as their job. Abbreviations: AH, all hospitals; TH, tertiary hospitals; SH, secondary hospitals; SP, Senior physicians; AP, Attending physicians; JP, Junior physicians; PD, Doctor of Philosophy; MAB, Master and Bachelor; JCAB, Junior college and below. 82.e9 C. Zhang et al. / Clinical Microbiology and Infection 24 (2018) 82.e5e82.e10 The current difficulties facing ID practice in China should encourage ID physicians to enhance their competitiveness by extending the purview of the field, taking on new responsibilities, and optimizing their work structure.