Seeing a patient in the inpatient rheumatology service ward. (Click to enlarge.)
After nearly two full days of flying, I finally arrived at my destination—Hangzhou, China, a modern metropolis with a rich history. As I looked out the car window, skyscrapers loomed against a backdrop of lush green vegetation. Over the next two weeks, I would be working in this bustling city of 11 million, home to both ancient culture— it was the capital of the Southern Song Dynasty more than 1,000 years ago—and cutting-edge innovation.
Through a partnership between my institution and Sir Run Run Shaw Hospital (SRRSH), I had the opportunity to explore firsthand how healthcare systems differ across cultures. SRRSH, founded in 1994 and affiliated with Zhejiang University Medical School, is a large hospital complex with nine buildings housing 1,200 inpatient beds, research centers and outpatient clinics.
Upon my arrival at SRRSH, I noticed that the subway station led directly into the hospital. The seamless integration of public transportation into healthcare facilities was a striking contrast to the U.S., where such connectivity is rare. The lobby was expansive, with multiple levels that drew the eye up to the high ceilings. Although it was 5 p.m., the hospital was still bustling.
The Outpatient Clinic
The rheumatology team at Sir Run Run Shaw Hospital. (Click to enlarge.)
Yongmei Han, MD, chief of rheumatology, and senior fellows Ning Shen, MD, and Nan He, MD, warmly welcomed me. I began my rotation in the outpatient clinic, where the differences from the U.S. system were immediately apparent.
Outside the doctor’s door, I could hear patients chatting and waiting for the clinic to open. One patient remarked, “It’s not time yet,” as the minute hand inched toward 8:00 a.m.
As soon as the minute hand hit the hour, the first patient walked in and declared, “I’m the first patient!”
In contrast to U.S. outpatient clinics, which run on scheduled appointments, here, patients take a number and line up to be seen. Arriving early to secure a number is crucial because each half-day clinic session had a limited number of spots available. As in the U.S., patients would sometimes ask to be seen as add-ons if there were no spots left, and I noticed the doctors often obliged.
West Lake in Hangzhou, a UNESCO World Heritage site. (Click to enlarge.)
The pace was quick; fellows and attendings often saw between 30 and 60 patients in a half-day shift, which was mind boggling.
The electronic medical record system at SRRSH was more streamlined than what I’m accustomed to in the U.S. There was no endless scrolling through irrelevant information. Patients brought concise printouts of lab results, imaging and assessments from other doctors, making it easy to quickly evaluate their condition. Some patients even brought physical copies of X-rays from as far back as 10 years ago. Patients are expected to bring their own records, and their records seemed more portable than in the U.S.
Another major difference was the absence of the dreaded inbox that’s so prevalent in U.S. medicine—an endless stream of patient messages, insurance denials and results to review. Here, patients had to review their lab results or get medication refills in person. This approach seemed to contribute to a more efficient workflow in a system with a high patient volume. On the other hand, it may require more effort from patients and families.
Looking out from the rheumatology workroom to the cityscape view of Hangzhou. (Click to enlarge.)
Given that China’s population of 1.4 billion is about four times larger than the U.S.’s, and Hangzhou alone is home to 11 million people, the number of patients seeking care is enormous. Many also travel from rural areas to seek specialty care at SRRSH. With only about 25 physicians per 10,000 people in China, compared with 36 in the U.S., patient volume remains a significant challenge.1
Due to Hangzhou’s high population density, the expectation of personal space and privacy is less than in the U.S. In one instance, an older woman in the clinic sat in the examination chair while a young man stood nearby. I assumed they were mother and son. However, it turned out they were both patients and did not know each other. I was a bit taken aback that the young man had listened in on the older woman’s exam! I quickly learned this was not uncommon. At times, several patients would crowd into the same examination room to try to assure they would be seen by the doctor.
At the end of the visit, patients could often immediately get labs or imaging done, sometimes returning later that same day to discuss results with the doctor. This felt faster than the U.S. system, in which one may have to wait months for insurance approval and scheduling for something like an MRI.
Guozhuang Garden, with its classical Chinese garden style. (Click to enlarge.)
The Inpatient Ward
After observing the outpatient clinic, I was eager to see the inpatient care system, which differed significantly from what I was familiar with in the United States.
In the U.S., non-surgical patients are typically admitted to a general medicine ward. However, in China, each internal medicine subspecialty runs its own ward. In the emergency department, patients are evaluated by specialists before being admitted to the most appropriate specialty ward.
At SRRSH, the rheumatology department has its own dedicated ward, with about 30 beds. For infusions, patients are typically admitted for an overnight stay, during which they have labs drawn and are seen by the doctor. This is in a contrast to the U.S., where patients generally go to an outpatient infusion center.
The Grand Canal, the earliest parts of which were completed in the 5th century BCE, with a modern skyscraper in the background. (Click to enlarge.)
I witnessed a memorable case involving a young man with a fever, rash, sore throat and inflammation in the myocardium and pericardium on a PET-CT scan. The team called for a multidisciplinary conference. Doctors from cardiology, infectious disease and radiology all examined the patient together. Next, we had a productive group discussion. Later, I learned the patient was diagnosed with a post-streptococcal allergic reaction.
The inpatient rooms were clean and utilitarian. On this inpatient floor, three patients typically share a room. Each room has ample space to store personal belongings. A major contrast with U.S. hospitals was the lack of IV pumps; instead, IV medications were hung from hooks dangling from the ceiling. The medications were manually titrated using an IV roller clamp, which made me wonder if the precise flow rates we demand in the U.S. may not always be necessary.
There were no televisions in the hospital rooms. The rooms served their primary function as spaces for medical workups and treatment, rather than the hotel-like environment sometimes touted by U.S. hospitals. By contrast, I’ve seen single-patient rooms in U.S. hospitals with massive flat-screen TVs.
Dr. Liu in front of SRRSH. (Click to enlarge.)
At SRRSH, I frequently saw family members at patients’ bedsides, often bringing fresh fruit as a snack for their loved ones. The emphasis on the family unit reflects the Confucian values deeply rooted in Chinese culture, in contrast to the emphasis on individualism in Western culture.
The Pathway to Rheumatology Care
In China, a unique aspect of healthcare is that many patients self-refer directly to specialists, bypassing primary care physicians. If a patient is unsure what type of doctor they need, they can see a triage nurse. This means some patients are sent directly to rheumatologists. This can expedite care for patients who need it, but may also lead to unnecessary consultations for those who do not. For example, we saw a new patient with hand pain of three days’ duration. Unfortunately, we did not have much to offer her.
In the U.S., patients typically see a primary care doctor first, who acts as a gatekeeper and refers patients to specialists only when appropriate. Sometimes a referral also requires insurance authorization. This approach may filter out unnecessary specialist consultations, relieving the burden on rheumatologists stretched thin. Conversely, it can delay care for those who truly have a rheumatologic diagnosis, meaning the patient’s condition may be much worse by the time they reach us.
Clinical Differences
Sir Run Run Shaw Hospital entrance, with the large hospital campus in the background. (Click to enlarge.)
While treatment patterns in the U.S. and China are similar, there are a few notable differences. In China, I encountered three Eastern-medicine-derived medications commonly used in conventional treatment. The first was iguratimod, a weak disease-modifying anti-rheumatic drug (DMARD) for rheumatoid arthritis approved in Japan and China.2 It is often combined with other medications, such as methotrexate or lei gong teng (Tripterygium wilfordii), another weak DMARD. Bai Shao, derived from the Chinese peony, is used for rheumatoid arthritis and lupus.3
A more potent medication used for treating mild to moderate systemic lupus erythematosus and rheumatoid arthritis is telitacicept, which targets B lymphocyte stimulator (BLyS) and a proliferation-inducing ligand (APRIL).4 This fusion protein has been approved in China since 2021. Other drugs, such as tacrolimus, thalidomide and cyclosporine, are also commonly used.
In gout treatment, febuxostat is the first-line pharmaceutical treatment, replacing allopurinol due to the high risk of severe cutaneous adverse reactions in the Han Chinese population.5
In addition to the use of rheumatoid factor and cyclic citrullinated peptide to treat rheumatoid arthritis, patients are routinely tested for anti-keratin, anti-RA 33 and anti-mutated citrullinated vimentin antibodies. Imaging tests often involve PET-CT scans and joint ultrasounds, with radiology frequently used to assess synovitis.
I also saw many more cases of Takayasu’s arteritis and IgG4 disease.
Cost of Care
Food options in the hospital cafeteria for workers, all freshly prepared on site. (Click to enlarge.)
China provides universal medical insurance, which covers 96% of the population, more than 1.36 billion people.6
I observed that the cost of healthcare in China is strikingly transparent. A typical outpatient visit costs around ¥15 CNY (approximately $2 USD), and for expert outpatient services, it ranges from ¥25–200 CNY ($3.50–27 USD).
Medications, lab services and imaging all have clearly listed prices. Doctors can easily discuss the costs of different management options with patients—an approach that’s rare in the U.S., where costs can vary widely depending on a patient’s insurance.
The doctors at SRRSH can discuss treatment costs with patients, even sharing specific prices for medications like rituximab. This allows for more informed patient decisions than in the U.S., where we often can’t offer such clarity due to the complex insurance landscape. On the other hand, it can be argued that when it comes to health, patients should not have to consider cost.
Trainee Pathway
In China, following graduation from high school, prospective doctors study medicine and complete an internship in college. Xu Cheng, MD, described the post-graduate rheumatology training:
“In China, the competition among medical students is extremely fierce. For example, to join the rheumatology and immunology department at SRRSH, a medical student typically needs to complete five years of undergraduate study, followed by three years of masters [studies] and three to four years of doctoral research. During this, they must obtain a clinical physician qualification certificate and a resident standardized training certificate. This requirement is not unique to SRRSH; it is the standard recruitment criteria for most university affiliate hospitals.”
To obtain these certificates, students must complete either clinical or research requirements, as well as standardized testing.
After entering the rheumatology department, they spend three years as a resident and at least five years as a fellow. Senior fellows often lead the team or have their own clinic. They make treatment decisions largely independently, functioning similarly to a junior attending in the U.S. context. Fellows must complete a significant research requirement to become the Chinese equivalent of an attending. (The terminology for medical titles in China and the U.S. may not correspond exactly.)
I asked my colleagues why they chose rheumatology and many cited its complexity, fascinating pathophysiology and challenging cases. One trainee remarked, “The diagnostic process is like solving a mystery,” adding “perhaps I would also be well-suited to being a detective.”
Mentorship and a supportive culture from the rheumatology faculty were also influential. Other factors included a better work-life balance in rheumatology compared with other specialties.
Shared Challenges & Joys
Despite different healthcare systems, I found that doctors and patients face similar challenges worldwide.
Patients discontinued medications without supervision, much to the surprise of their family members. Others expressed hesitation to start medications due to concerns about side effects.
Language barriers were also common, especially for patients from rural areas who don’t speak Mandarin. In these cases, they often brought along an adult child to help with interpretation.
This highlighted the importance of communication in healthcare.
“The biggest challenge [in rheumatology] is that patients have difficulty understanding their disease, high expectations for disease cure and low compliance with recommended testing and treatments,” shared Liuyan Nie, MD.
“Staying abreast of the rapid development of technology and knowledge is also a challenge,” Nan He, MD, added.
Lastly, balancing research, clinical duties and one’s personal life seems to be a universal dilemma.
Final Thoughts
My time at SRRSH was a once-in-a-lifetime experience. I had the privilege of learning from an exceptional team of doctors and staff who provided fresh perspectives on healthcare. My experience there made me reexamine our practice and healthcare system through a new lens. Though my time there was brief, I felt I made lasting connections.
The opportunity to collaborate, exchange ideas and learn about different healthcare systems was invaluable. I hope we, as rheumatologists, can continue to build connections and share knowledge across global healthcare systems.
Audrey Liu, MD, recently completed her rheumatology fellowship at Loma Linda University, California.
References
- World Health Organization. Density of physicians (per 10 000 population) 2025 data. Accessed on 12 March 2025. https://tinyurl.com/mt4sr6sm.
- Xie S, Li S, Tian J, Li F. Iguratimod as a new drug for rheumatoid arthritis: Current landscape. Front Pharmacol. 2020 Feb 26;11:73.
- Mei L, Gao K, He X, et al. Editorial: Disease-modifying antirheumatic drugs: Approaches and lessons learned from traditional medicine. Front Pharmacol. 2023 Feb 3;14:1135803.
- Fan Y, Gao D, Zhang Z. Telitacicept, a novel humanized, recombinant TACI-Fc fusion protein, for the treatment of systemic lupus erythematosus. Drugs Today (Barc). 2022 Jan;58(1):23–32.
- S-I Hung, W-H Chung, L-B Liou, et al. HLAB* 5801 allele as a genetic marker for severe cutaneous adverse reactions caused by allopurinol. Proc Natl Acad Sci U S A. 2005 Mar 15;102 (11):4134–4139.
- Chen C, Liu M. Achievements and challenges of the healthcare system in China. Cureus. 2023 May 15;15(5):e39030.
