Every year for the past six years, a CA-3 resident has visited Hangzhou, China as part of a clinical exchange program at the Second Affiliated Hospital of Zhejiang University School of Medicine (SAHZU). This year, I had the opportunity to go to China for four weeks and learn from a very welcoming team of anesthesiologists at this busy teaching hospital with over 3,200 beds and a volume of over 60,000 surgical cases per year. Founded in 1869, SAHZU is one of the largest and earliest Western medicine hospitals of Zhejiang province.
The core of the rotation was main OR, neurosurgical, and cardiac anesthesia. This is where I spent most of my time learning from Chinese anesthesiologists as they cared for patients. I observed anesthetic techniques tailored to manage patients with familiar surgical diseases in an unfamiliar (to me) Chinese healthcare system, with different resources and patient attitudes.
The three OR floors, multiple procedure rooms, and PACU are very busy. Efficiency and lean workflow are crucial for managing the high volume of patients. There are strategies in place to streamline processes outside the OR to reduce turnover time. For example, the preoperative procedure room is dedicated to placing awake central lines, arterial lines, and peripheral nerve blocks prior to surgery. While ultrasound is available and actively taught, residents use anatomic landmarks to guide needle placement in preparation for practice in more rural areas of the country. Postoperatively, patients emerge from anesthesia in the PACU and await extubation there.
I was given the flexibility to focus the rotation on two areas of interest: pain medicine, which will be my subspecialty area of training, and Traditional Chinese Medicine (TCM).
Pain medicine is still an emerging field in most developing countries, but at SAHZU the anesthesia pain team has been managing a busy clinic and performing advanced interventional pain procedures for several years. This group first described a novel approach to treating trigeminal neuralgia, and I saw the procedure performed to help a patient with intractable facial pain. 
On the other end of the spectrum is TCM, China's most ancient medical art dating back several thousand years. TCM is very much an active part of the Chinese healthcare system, sought out by patients and incorporated into the multimodal treatment model of the hospital. Lectures on TCM introduce concepts such as the "Yin and Yang" doctrine, and the flow of "qi" (or "chi" the energy that animates and imbues all things) through the body's meridians and collaterals. Acupuncture is widely practiced, and a long list of other therapies such as herbal, mineral, and animal medicines are prescribed for patients. On rounds, I saw these concepts translate to treatments. A carefully palpated pulse or closely examined tongue, taken in the context of the patient's illness, would inform the next TCM remedy.
If you walk a few miles west of the hospital, you escape the traffic and noise of the city and arrive at the famous West Lake, surrounded by misty hills, bamboo forests, and ancient Buddhist temples. One of my most memorable trips was hiking to the steep tea terraces of Longjing village and buying tea from the farm. Here, on the last weekend of the trip, I realized that the month spent at SAHZU had not only given me the opportunity to deepen my clinical understanding of anesthesiology, but it also allowed me to meet new colleagues from across the world and form valuable friendships.