When Cure Is Beyond Reach: Reflections and a Return for Medicine

The first class of our new semester was Introduction to General Practice. In our textbook Introduction to General Practice, compiled under the leadership of professors from Capital Medical University, there is a passage that reads: "In the late 1950s, with the accelerating aging of the population, the rising prevalence of chronic non-communicable and degenerative diseases, and modern medicine's inability to cure, the importance of primary health care re-emerged, requiring large numbers of physicians to provide long-term care for patients in communities and at home."

The textbook contains another passage: "In an era when modern medicine is highly prevalent and developed, people inevitably look back with nostalgia upon the simple, natural, and harmonious ways of thinking, modes of service, and doctor–patient relationships of old, as they discover the limitations of modern medicine in its methods and applications. The emergence and development of general practice represents a successful practice of spiral ascent, in which the medical community, adapting to the needs of the times and of the people, has brought the essence of ancient medicine back to the present day."

Having spent nearly twenty years in frontline clinical practice under a mentor's guidance, I feel deep resonance with both of these passages.

"To cure occasionally, to comfort often, and to help always"—this is the most truthful portrayal of treating refractory diseases. Clinical practice repeatedly brings us frustration and only occasionally a sense of accomplishment. Whenever our hopes run high, reality mercilessly strikes us down; and when we are disheartened, an uplifting miracle occasionally appears.

Over time, I have learned not to hold too many expectations of success. Yet I can still glimpse a glimmer of hope in certain regimens that repeatedly produce therapeutic effects. I always hope to keep improving my treatment protocols and to raise that response rate a little further, so I keep exploring and refining my approaches. But this is a long process, and I do not know on which day a truly reliable cure will be found.

In the past, physicians were all generalists. A physician served, within a geographic boundary, a small, fixed population living nearby. Doctor and patient were not only physician and patient but also neighbors and friends, and sometimes even relatives. Such practice could treat only common minor ailments; serious diseases had to be referred to specialist hospitals in large cities. But in fact, most of the time people suffer only minor ailments, which can essentially be resolved by such a general practitioner.

Under this model of care, the doctor–patient relationship was harmonious and the cost of treatment very low—advantages that modern hospitals do not possess. Not only do patients yearn for that plain, simple medicine; I myself have always wished to go to the grassroots and become such a general practitioner (or, as it is called in the United States, a family physician).

Fortunately, our school offers Introduction to General Practice. Among the medical schools across the country, only about twenty offer courses related to general practice, and ours happens to be one of them.

What is even more fortunate is that the teacher who taught us Introduction to General Practice is an excellent lecturer. After two class sessions, she conducted an in-class survey to see how many of us would be willing to become general practitioners. The result was that, of the more than 130 students in our class, about two-thirds were willing—a sign of how compelling her teaching was.

Perhaps it is not only the appeal of the teaching. What matters more may be that modern society has an urgent need for general practitioners. Patients with illness rush to top-tier hospitals in first- and second-tier cities, becoming highly concentrated in a small number of such hospitals, which has long made access to care difficult and expensive and caused ordinary people untold suffering. They spend large sums of money, struggle to get an appointment, endure long queues, and exhaust themselves traveling. And yet, in the end, most patients are not cured but merely temporarily relieved, leaving behind complex problems of follow-up rehabilitation.

Recently, I saw a set of data released by Singapore showing that, on average, a patient with a chronic disease pays about S$170,000 in various rehabilitation and nursing costs after discharge. Based on a comparison of actual purchasing power between Singapore and Beijing, I calculated that, if the same patient were in Beijing, the cost of care would be around RMB 350,000. If both elderly members of a household required such care, the total cost would be roughly RMB 700,000—a heavy burden for an ordinary family.

Of course, the above calculation is based on Singapore's fee schedule; in reality, the fees charged by medical staff in China are far below that level. Even so, the average nursing costs for chronic disease patients in China are still very high. I know this from personal experience: in the last years of my mother's life, she suffered from both the sequelae of stroke and cancer. The burden on my shoulders was heavy, and she herself often felt guilty about the financial strain she placed on me and the enormous amount of energy my caregiving demanded.

In truth, most cases of post-stroke sequelae and advanced cancer see little improvement even in large top-tier hospitals, yet the cost is astonishingly high. I have come into contact with many families of such patients, who wish to provide home-based care with traditional Chinese medicine for two reasons: first, to ease the financial burden; and second, to care for family members close at hand, without constantly running to the hospital, so that younger family members can also keep up with their work.

Over the past century or so, modern medical technology has advanced by leaps and bounds, and people were once optimistic that, with the development of biomedical technology, all disease problems could be solved by advanced modern medicine. As a result, the high-rises of specialist hospitals multiplied, while the status of family physicians and grassroots community physicians steadily declined.

At the same time, as medicine has advanced, patients' expectations of a cure have risen ever higher, far exceeding what physicians can deliver—which has objectively contributed to the increasingly frequent doctor–patient disputes in modern health care. It is only natural that, having paid such high financial and time costs during treatment, patients and their families see their expectations rise accordingly.

Yet as time has passed, life expectancy has risen, and the disease spectrum has changed, the medical community has found that most refractory diseases—such as heart disease, cancer, hypertension, diabetes, Alzheimer's disease, post-stroke sequelae, and chronic obstructive pulmonary disease—remain beyond the reach of a cure. Letting such patients convalesce in top-tier hospitals equipped with advanced facilities but burdened by extremely high care costs is no more effective than letting them convalesce at home under the care of a family physician (or, as we commonly say in China, a general practitioner or community physician).

That is why family physicians in developed countries, including the United States, are now experiencing a wave of revival. More and more patients are choosing to seek treatment at convenient, affordable general practice clinics or community hospitals.

China has already entered an aging society, and before long it will move into a super-aged one. The proportion of patients with geriatric and chronic diseases will keep growing, and the burden on families and society will become ever heavier. We need grassroots community physicians to take on greater responsibility and provide help close to patients' families.

What I most want to do in the future is to be such a community physician or rural doctor, providing medical services to the local people. Of course, I am also aware that, given my personal influence, it may be difficult for me to be purely a grassroots physician: many patients drawn by my reputation will travel from elsewhere to find me where I work.

My writing will be oriented toward this group of people. I hope to distill my experience in treating such chronic diseases into a book, for the reference of grassroots physicians as well as the families of patients with these chronic and geriatric conditions.