My Medical Philosophy: When Cure Eludes—Reflection and Return in Medicine

Our first class of the new semester was Introduction to General Practice. In the textbook Introduction to General Practice, compiled under the leadership of professors from Capital Medical University, there is this passage: "In the late 1950s, because population aging accelerated, the prevalence of chronic noncommunicable diseases and degenerative diseases rose, and modern medicine's ability to cure proved limited, the importance of primary health care re-emerged, and a large number of doctors were needed to provide long-term care for patients in the community and at home."

The textbook also has this passage: "Today, when modern medicine is highly widespread and developed, as people discover the limitations of modern medicine in its methods and application, they cannot help but miss the once simple, natural, and harmonious ways of thinking, service practice, and doctor-patient relationship. The emergence and development of general practice is a successful, spiraling-upward practice in which the medical profession adapts to the needs of the times and the people by reviving the essence of ancient medicine in the present day."

Having practiced frontline clinical work with my mentor for nearly twenty years, I feel deep resonance with these two passages.

"To cure sometimes, to relieve often, to comfort always"—this is the truest portrait of treating refractory disease. Clinical practice repeatedly brings us frustration and, occasionally, a sense of achievement. Whenever we are full of hope, reality always strikes me mercilessly; when we are discouraged, a heartening miracle occasionally appears.

Over time, I no longer dare to expect too much from success. But I can see a glimmer of hope in regimens whose effect I have repeatedly obtained. I always hope to keep improving treatment plans and raise the effective rate a little more, so I keep feeling my way toward better regimens. But this is a long process, and I do not know when I will find a truly reliable cure.

In the past, all doctors were generalists; a doctor served, within a geographic boundary, a fixed small group of people living nearby. Doctor and patient were not only physician and patient but also neighbors and friends, and some were even relatives. Such medical care, though it could treat only common minor ailments while serious diseases had to be referred to specialized hospitals in big cities, nevertheless handled most of what people actually got—mostly minor complaints, which could basically be solved by such a generalist.

Under this model, the doctor-patient relationship was harmonious and treatment cost was low, carrying many advantages that modern hospitals lack. Not only patients miss that plain medicine; I, too, have long wanted to go to the grassroots and be that kind of general practitioner (or, as the Americans call it, family doctor). Fortunately, our school offers Introduction to General Practice; among medical schools nationwide, only about twenty offer general-practice-related courses, and ours happens to be one.

Even more fortunate, the teacher who teaches our general-practice introduction is very good. After two classes, she did an in-class survey to see how many students were willing to become general practitioners. Of our class of more than 130, about two-thirds were willing—clearly her teaching is quite compelling.

Perhaps it is not only her teaching but, more crucially, that modern society has an urgent need for general practitioners. Rushing to the tertiary hospitals in first- and second-tier cities whenever one is ill, with patients concentrated in a handful of tertiary hospitals, has made medical care hard and expensive, and ordinary people have long suffered from it. Spending a lot, struggling to register and queue, traveling back and forth—and yet the outcome is that most patients are ultimately not cured but only temporarily relieved, left with complex follow-up rehabilitation problems.

Recently I saw a set of data released by Singapore showing that, after discharge, a chronic-disease patient on average needs to pay about SGD 170,000 in various rehabilitation and nursing costs. Comparing the purchasing power of Singapore and Beijing, I calculated that in Beijing such a patient's care costs would be around RMB 350,000. If two elderly people in a family both need such care, the cost would be about RMB 700,000. For an ordinary family, that is a heavy burden.

Of course, the above is calculated at Singapore's fee schedule; in reality, the fee levels for medical staff in our country fall far short of that. Even so, the average nursing cost for chronic patients in our country is also very high. I have felt this personally: in her last years, my mother suffered doubly from stroke sequelae and cancer, and the burden on me was heavy; she herself often felt guilty about the financial burden she placed on me and the great effort her care required.

In fact, most stroke sequelae and advanced cancers do not improve much in the large tertiary hospitals, yet the cost is astonishingly high. I have encountered many families of such patients; they want to use TCM for home-based care for two reasons: first, to lighten the financial burden, and second, to care for family members nearby rather than always going to the hospital, while young people can still hold down jobs.

Over the past century, modern medical technology has advanced by leaps and bounds. People were once optimistic that, with the development of biomedical technology, every disease problem could be solved by advanced modern medicine. So the tall buildings of specialized hospitals grew ever more numerous, while the status of family doctors and grassroots community doctors steadily declined.

At the same time, patients' expectations of cure rose with medical development, far beyond what doctors can deliver, which objectively led to ever more frequent doctor-patient disputes. The economic and time costs that patients and their families pay during treatment are high, so rising expectations are a natural phenomenon.

But as time passed, life expectancy rose, and the disease spectrum changed, the medical community found that most refractory diseases—heart disease, cancer, hypertension, diabetes, Alzheimer's, stroke sequelae, COPD, and so on—share the problem of cure eluding us. Letting these patients recuperate in tertiary hospitals with advanced equipment and extremely high staff costs is no better than letting them recuperate at home under the care of a family doctor (or, as we call it in our country, a general-practice or community doctor).

So family doctors in developed countries, including the United States, are now enjoying a revival. More and more patients choose to be treated in convenient, affordable general-practice clinics or community hospitals.

Our country has entered an aging society and will soon enter a super-aged society; the proportion of elderly and chronic-disease patients will keep growing, and family and social burdens will keep rising. We need grassroots community doctors to take on greater responsibility and help patient families close at hand.

What I most want to do in future is exactly such a community doctor or village doctor, providing medical services to local people. Of course, I also know that, given my personal influence, I may find it hard to simply be this kind of grassroots doctor; many patients who have heard of me will come from elsewhere to where I work.

My writing will be oriented toward such a group. I hope to summarize my experience treating these kinds of chronic diseases into a book, for grassroots doctors to refer to, and for the families of these chronic-disease and elderly patients to refer to.