The Art of Medicine Has No End; It Is Forged under Pressure

In the foreseeable future, human medicine will hardly reach perfection. From my own experience, the art of medicine has no end; the more it is pressed, the more refined it becomes.

When a person studies medicine and applies it clinically to heal others, they always encounter critically ill patients who trust them completely. These patients' diseases are extraordinarily thorny, beyond what ordinary medicine can solve.

At such moments a doctor's spirit of inquiry and psychological mettle are tested. Giving up on a patient is easy—and also hard. A single thought can make one abandon them, but when a patient has wholeheartedly trusted the doctor, that single thought is hard to bring oneself to.

Their problems may indeed be very hard to solve, but for the sake of survival patients are willing to try anything, even to be a doctor's clinical-trial subject. Under the patient's persistence, it is hard for the doctor to harden his heart and walk away.

My rapid progress in treating cancer over these years stems fundamentally from a cohort of highly adherent patients. They would rather die in my hands than not let me treat them boldly, willing to take great risks.

Cancer is hard to treat; it is a disease doctors everywhere fear. Honestly, I am afraid of treating cancer too, especially advanced cancer. But now there is nowhere left to hide; many patients' lives and the happiness of their families rest on me.

I often feel my medical skill is poor, because I cannot solve all my patients' problems. Yet if I abandon them, no other doctor is skilled enough to bring them back from the brink. So I can only grit my teeth, search the literature, take risks, try new approaches, and keep moving forward.

Once a patient told me not to study so much, that specializing in just one approach to cancer would be enough. That is easy to say, but very hard to do. The reason I keep learning new things is that clinical experience has taught me every single treatment method has a limited success rate.

When one method fails and we helplessly tell the patient we cannot solve the problem, what then for the patient? When the same patient, on whom a regimen worked at one stage, no longer responds at another, how am I to face that patient's powerful will to live? To abandon them and plunge them into despair is a cruel thing.

The late-Ming/early-Qing physician Yu Jiayan once said: rather than let the patient die untreated, let him die taking the medicine. If a physician does not act and gives up on those who seek help, medicine cannot advance.

A patient entrusts the doctor with life and death; the doctor bears grave responsibility for the patient's life and must continually risk himself for it. This profession requires its practitioners to have a certain courage and sense of commitment.

Another Ming-dynasty master physician, Zhang Jingyue, said a doctor must have "the eye of an eagle and the gall of a lion"—able to pinpoint the patient's problem sharply, and bold enough to take risks and use heavy herbs to solve it.

I studied TCM and, without noticing, became an emergency physician, often called in to rescue critically ill patients. Not every attempt succeeds, yet I have repeatedly brought patients back from the dead.

To many, TCM is a slow physician. But emergency cases brook no delay and change by the moment; when using TCM in rescue, it must take effect quickly, or the consequences are unthinkable.

There is no trick to this; it only requires the rescuer to possess a daring and insight that ordinary people lack. Much of the TCM knowledge we learn can be applied in rescue, yet most medical students tremble before life and death, lack daring, and dare not act. Over time, they lose the life-saving techniques that TCM once possessed.

Each time I join a rescue, the family says to me: "We ask nothing else; we only beg you to treat a dead horse as a live one and do all you can to save our loved one. If you succeed we will thank you; if you fail we will thank you too."

Although in reality, after a failure, many families, swallowed by grief, not only fail to honor that promise but may even lash out at the doctor, still, many times I have braved the risk to act.

Such trials have rapidly improved my skill. Now when I treat tumors, patients often report back after taking the medicine for about a week that their tumor has shrunk.

Such outcomes astonish those who hear of them. At first I was excited and skeptical; now such reports no longer surprise me. Having taken part in so many life-and-death rescues, my style of prescribing—fast, forceful and aggressive—is set, and the results naturally come quickly.

Many formulas and dosages I once dared not use I now dare. Why? There are always patients hanging on the razor's edge of life and death; only by breaking with routine and prescribing boldly can their lives be saved. With such experience one knows that past fears were unnecessary, and that what books record is not to be fully trusted—only practice yields true knowledge.

Gentle medication treats minor ailments but cannot conquer major diseases like cancer. When I am old, I do not know whether I will still have my present daring; if by then I have begun to shrink, I will stop treating major diseases.

Because fearing disease at the bedside delays the patient's treatment. Though using strong herbs carries high risk, for terminal patients, using milder medicine is riskier still, because once the therapeutic window is missed the patient has no further chance to live.

As a child I was very bold. My late mother often joked that when I was small I always climbed to the top of a tree, while a crowd below shouted encouragement for me to jump down, and dazedly I would jump. That is why I carry many scars on my head and face that remain to this day. My mother always said that if my life had not been tough I would have died long ago from my reckless daring.

When I was in high school, on every exam the teacher who set the paper would greet me in advance: "Zhou Zhiyuan, the final problem this time is very hard; I set it especially for you, to see if you can solve it." The moment I heard that, I was filled with fighting spirit; if I could not solve it during the exam, I would spend the next few days forgetting food and sleep until I cracked the final problem.

Once, to solve a single math final problem, I set aside all my other studies for a whole week, buried myself in calculations, and finally worked it out. After reading through my solution, my math teacher was so excited he thought I had invented a new theorem, and submitted it to a math-and-science magazine—only to be told it was the well-known inclusion-exclusion theorem of advanced mathematics.

A doctor's character shapes the style of his practice. Reading the case records of Sun Bingyan, what I admire most is his daring. The herbs he used are such that, among doctors worldwide, few would dare use them. Yet in a lifetime of treating advanced cancer, the life-saving miracles he created are beyond what other doctors can match. I often think that a doctor like Sun, had he not practiced medicine but fought on a battlefield, would surely have been an outstanding commander.

Once I read an article by one of Sun's disciples—himself a patient of Sun's—recalling that in his lifetime Sun often sighed, "The mountain gate is hard to open, and hard to close," unable to enjoy even a few quiet days. From that sigh I understood how hard Sun's lot had been.

Sun did not start out prescribing so boldly. He too must have been pressed by the pleas of desperate supplicants around him, forced again and again to grit his teeth and break through his own limits, trying stronger herbs and riskier doses. A bodhisattva's heart, a thunderbolt's hand. To save people in their hour of despair, the doctor's hand must be firm.

I do not know how much longer I will keep risking myself on the medical road before I leave this world. But I know that once one enters medicine—especially the treatment of major disease—a truly retired life is impossible in this lifetime.

Countless patients will find you regardless, and once found, their powerful will to live drives us doctors forward. For a doctor, truly, there is no end to learning, and no end to risk.