Image source: Figureworm Creative
"A large amount of data suggests that kitchen fumes may be an important cause of lung cancer in women." Wang Xing, attending physician of the Department of Thoracic Surgery at Shanghai First People's Hospital, writes in his new book, "Patients' Families, Please Come Here." He then explained the surprising reason behind this: many women have to take care of their children alone, and in order not to let the noise of the smoke machine affect their children's movements, they often choose not to turn on the range hood.
Behind such a large health price is the silent sacrifice of our loved ones that we have neglected in the past. This detail was read by a female blogger and shared on the Internet, which aroused huge attention that Wang Xing and the editor did not expect.
But fighting cancer is not a battle that can be solved just by talking about feelings, and like a large number of decisions in the real world, it is necessary to find a delicate balance between "money" and "love". In the book "Patient's Family, Please Come", Wang Xing emphasized the important role of patients' families in care, and emphasized the decision-making position of family members in treatment.
Wang Xing also has personal experience as a "patient's family". When his mother-in-law suffered from cancer, he also fell into the dilemma of choosing "domestic drugs" and "imported drugs" with similar efficacy. He spends a lot of time "talking about money", trying to help cancer patients understand that they can find a balance between measuring the cost of money and the effectiveness of treatment, and hopes to relieve them of the emotional burden of pocket shyness - no matter how much money or how little money, the doctor will help you find the best solution for the patient within his professional scope.
Prior to the publication of the book, Wang Xing had published a novel depicting the different situations brought about by several doctors who had made difficult choices between profession, future, human feelings, and money. In some ways, the novel and the new book are actually written from the same topic from two perspectives: how to face some real problems in the Chinese medical environment, including the problem of "money". In Wang Xing's view, the lack of discussion on these issues is the reason why many domestic medical dramas have been spat out and have become workplace love dramas. The film and television market voted with its feet to agree with him. The film and television rights to the novel have been sold, and Wang Xing himself has been hired to become a screenwriting consultant to check the details of the medical profession.
"Patient's Family, Please Come"
Wang Xing/Author
Shanghai Translation Publishing House September 2021
| interview |
From "people and money" to "controllable chronic diseases"
The Economic Observer: For a long time, everyone mentioned "cancer" and had a fear that it was "the king of all diseases" and "a terminal disease that cannot be cured". But in fact, in 2006, the World Health Organization first proposed that "cancer is a controllable chronic disease" and put it into the category of chronic diseases. As a frontline physician, how do you see cancer? And how do you view this fear of cancer?
Wang Xing: "Fear" is indeed the first feeling of ordinary people when they hear that they have been diagnosed with cancer. If you tell a person that he has high blood pressure and coronary heart disease, he may feel that he is sick; but if you tell him that he has cancer, he feels that he is going to die. These are two feelings.
From a doctor's point of view, cancer can be considered a chronic disease that can be cured, partially cured, or can survive with tumors. Although we medically classify cancer as a so-called chronic disease, it is still difficult for people as individuals to accept the direct impact of the possibility of death. So as a doctor, I also understand the fear that every patient has when they are diagnosed. This fear is justified because a significant proportion of cancers are likely to be incurable and eventually die.
In fact, the process of treatment is a process of slowly accepting fear. At first, the patient may feel that the cancer cannot be cured, and after receiving treatment, he feels as if the cancer can still be cured, and when the treatment is over, after 10 years or 8 years, the lesion has not recurred, and the patient will feel that the cancer can indeed be cured. The fact that every cancer patient is cured can also slowly influence those around him to build confidence and overcome fear.
As a doctor, my personal feeling is that people are no longer as afraid of cancer as they used to be. When I was in school and choosing a major, my father asked me not to choose oncology. He was influenced by the public perception of cancer at that time, believing that tumors must not be cured, and could only spend a bunch of money, and then people and money were empty. But over the past few years, I have been able to clearly feel that although my patient thinks that the tumor is terrible, he does not think that the tumor is incurable. Behind this transformation is what I call the imperceptible confidence that cured patients bring to those around them.
Advances in the public's understanding of this treatment can actually help doctors to carry out their work. In the past, some patients had the opportunity to be treated a lot of times, but because of some of their wrong obsessions, they were not cured. Now people will be more active in cooperating with the doctor to complete the treatment.
The financial account of the patient's family
The Economic Observer: The title of your book is "Patient Family, Please Come", in your opinion, what is the status of the patient's family in the treatment of cancer, or what role should it play?
Wang Xing: I have also been a patient's family member, and I have had the feeling of being a "patient's family".
When I am a doctor, I only need to explain to the patient how to treat the disease, how prognosis is, what drugs to use, and how much to spend. The patient may give me an answer after a long discussion, and then I will arrange treatment, and that's it. And when my own mother-in-law had stomach cancer, I found that the patient's family actually had to consider a lot of things, for example, whether the drug was imported or domestically produced. Do you want to choose surgery? Who is responsible if the surgery goes wrong? How are the siblings in the family? Who will take care of the patient? For the first time, I realized that there are a lot of real problems that are beyond the scope of medical treatment. I thought I should write a book for my patient's family and friends like me. Because I stand on the dual identity of a doctor and a family member, I can help patients recover more smoothly by imparting my professional knowledge and skills, as well as my understanding and cognition to them.
In fact, in China, the decision-making position of family members in the treatment process is very high. We doctors often communicate with the family first, and then the family decides whether to tell the patient or not. Although from the point of view of the priority protection of the patient's "right to informed consent", it is not so reasonable. But in today's medical environment, it actually costs money to see a doctor. Whoever spends the money, then who decides. If the patient is an elderly person with no savings, it must be the child who bears the cost of treatment, even if the doctor informs the patient first, the real dominance of the choice of treatment plan is still in the hands of the child. In the end, it was slowly transformed into a model that patients, families, and doctors could accept, which was a result of the game, which was actually beyond the scope of the use of the "right to informed consent".
During the treatment process, the practices of different families will also affect some differences in treatment results. For example, some family members will prevent medical staff from helping patients with spouting because they need to pat their backs and pick their throats, and they will feel that this is causing pain to the patient. But the result of the prevention is that the patient does not cough up the phlegm well, and there are complications of pneumonia or even more serious. At this time, the family will regret it and even complain to the doctor. But without the wrong intervention of family members, this influence should not have occurred. Other family members can do a good job of the doctor's instructions. How should the patient eat, what disease the patient has before, he will remind the doctor, and even some family members can help the doctor to correct the error, such as reminding the doctor before the operation, the patient ate aspirin a few days ago. Through their own care and even professionalism, these families can help doctors and patients avoid many treatment risks.
Therefore, the role of the patient's family is really very large. In China, family members always position themselves as a kind of "escort" or such a position as a caregiver, but in fact, the family can do and should do more, at least some things should know not to do. So I wrote a book like this to share some relatively complete information with my family. Your family has cancer, and I understand that you must be very anxious and want to do something, but there are some things that you will be fine if you don't do it, but it's good not to do it. Some patients' families will give patients the so-called "big supplement" soup after the operation, and the big supplement he understands is bone soup and chicken soup. This is actually a misinterpretation of the doctor's order, the doctor asks for "protein supplementation" at any time, which means that the patient can eat meat, but do not drink soup. Soup is actually water, salt and oil, no nutrition. Moreover, after many people drink the soup, there will be a very serious omission when doing lymph node cleaning. Lymph fluid will seep outward because there is too much oil. Some patients' families understand that helping patients is not actually helping, but helping.
The Economic Observer: For Chinese, talking about economic accounts before such a big issue of life and death will feel more cold-blooded and unkind. Including you yourself in the book, you also wrote that when considering whether to use imported drugs or domestic drugs for your mother-in-law, you chose imported drugs.
Wang Xing: I did an experiment during the lecture and asked a few questions. First, "If you assume that one of your parents has cancer, the doctor tells you that you can be cured for 10,000 yuan, and there is a 95% cure rate. "Everyone raised their hands and said they wanted to heal. Second, "If you want to spend 1 million to get a 95% cure rate, cure or no cure?" "Everybody still has to be cured. To the third, "If you spend 1 million, but only get a 50% cure rate, cure or no cure?" Half of them will choose to give up.
One of the listeners explained that there were two reasons behind it. First, even those who really want to cure it are exhausted at that point and have no financial resources and energy. At the extreme, if several elders are sick and have to choose this plan, ordinary families really can't pay this money. I understand him, he means to spend money, treatment of cancer becomes a real problem, cost and benefit issues may affect decision-making. Second, spending so much and the cure rate so low will also put a lot of pressure on the patients themselves, thinking that they are a drag on the family. I think that if we ourselves are parents, when we encounter such a situation when we are old, we will also be afraid of dragging down our children, so we simply do not want to be cured and do not want to live. Even if you trick the patient into going to this plan for treatment, the cure rate of spending a lot of money is often low, and it is likely that people will run out of money, and the patient will suffer from the side effects of hair loss and vomiting during treatment.
Man's desire for health is infinite, but infinity has a cost. Although we can have corresponding treatment, it is only a few more percentage points of cure that may require a lot of cost. Life is equal, but there is a cost to pursuing health. All treatment is inseparable from the problem of money. Since we can't do without it, we will understand why even if it is the same degree of disease, for a specific patient, we still have to discuss what kind of plan is suitable for the family.
My advice is that patients can tell their doctors about their financial status. Some patients will say that we have insurance, or that the unit will reimburse us, and that any medicine can be used. In this way, the doctor has no choice, he can choose relatively good evidence or use better and more reasonable drugs. Some patients' families will say that the family conditions are average, and there is really no money. Then we will also choose a more suitable plan for him. It's not about choosing a bad one, it's about the right one, because that's enough. Recently, I had an operation on my own to cut a lung. When cutting this lung, there was a difference of one centimeter in the end, because the patient's economic conditions were relatively general, and then I used a small clip worth 500 yuan, clamped the last centimeter, and then burned it with an ultrasound knife, and did not choose to add another nail groove, that is, a cutting closed device. This cutting and closing device is worth 5,000 yuan, which can save the patient's family 5,000 yuan.
As doctors, we can find the best solution for our patients within our professional scope. Therefore, the patient or family member can show his or her status to the doctor, and the doctor will recommend that you choose a suitable plan. The patient's family should not bear too much of this moral burden, and do not equate "choosing a cheap solution" with "not filial piety". Let yourself be able to let go, because this is what the doctor recommends you, the doctor tells you that these two are almost the same, then you must be right to choose the cheap, so that you can let yourself go.
From prevention to tranquility
The Economic Observer: I saw the latest global cancer burden data released by the World Health Organization's International Agency for Research on Cancer (IARC) in 2020, of which lung cancer is the first cancer in China in terms of national disease rate and mortality. As a thoracic surgeon, how do you think we should prevent or detect lung cancer sooner?
Wang Xing: In terms of the incidence of cancer in China, for men, lung cancer is still the first, and for women, breast cancer is the first. Overall, lung cancer was a very difficult disease to treat before. It can also be reflected in the expression of terminal illness in literary and artistic works. In the TV series, the general protagonist covers his mouth with a handkerchief and coughs, coughing up blood, which means that this person has lung cancer and will soon die. But in fact, there is a little blood sputum, usually not in the early stage, but in the middle and late stages. Because of the disease of the lungs, if it can produce bloody sputum or pain, it is very much progression or metastasis.
At present, in beijing, Shanghai, Guangzhou and other big cities, it will be obvious that lung cancer has become more, but it can be cured. This is because our current medical examinations are widespread, including the current new crown pneumonia epidemic, which will cause many people to go to CT screening, and some people accidentally find lung problems. We may operate on about 10 patients in their 30s every month, and after the operation, pathological examinations often find that they are in situ adenocarcinomas and micro-invasive adenocarcinomas. In the past, when there was no CT, these early adenocarcinomas were put for 5 years, 10 years or 20 years, and he may develop advanced lung cancer at the age of fifty or sixty, so it is some early screening methods that allow us to intervene in the progression of cancer in advance. The role of the doctor is to move backwards when you go from the queue to death, but it may also change your future life.
So I'm hoping that people over the age of 45 can maintain the habit of regular check-ups on their health.
Compared with regular check-ups, the value of prevention is very small in my personal opinion. As long as we don't smoke, we have already removed one of the biggest cancer factors. But I personally do not recommend or guide patients to do some active prevention, such as eating garlic, eating broccoli, or hearing that eating red meat will cause cancer, so I resolutely do not eat red meat, do not eat barbecue. These may indeed reduce, say, the incidence by 20%, but if you subtract 20% from a three-in-a-thousand probability, it actually becomes a two-in-a-thousand probability, and the difference is very small. I think we can focus more time and energy on how we go about living our lives well. We maintain exercise and eat healthily so that we can have a good attitude and a more comfortable mood, not that we do a lot of things to avoid cancer. If you live just to avoid cancer, it is actually a meaningless thing. Just put some energy into going through a physical exam and screening every year, or every two years, which is much better than eating more health products.
The Economic Observer: Some experts believe that early screening for cancer can also lead to the problem of overdiagnosis, what do you think? At the same time, hot money has poured into the cancer early screening industry, which has also brought a lot of speculation and fraud, as ordinary consumers, how to identify reliable early cancer screening projects?
Wang Xing: In the 1970s, then-US President Richard Nixon signed an anti-cancer bill. At that time, the first time the United States sent people to the moon, it would think that everyone could go to the moon, and there was nothing that could not be cured of cancer. This opened up a boom in scientific research on cancer treatment in the United States. But 30 years later, a medical journal in the United States published an article saying that after so many years and so much unlimited financial investment, this movement is basically a complete failure. Until now, we haven't conquered cancer. At present, the only solution is that we can detect the disease early, screen out some of the early patients, and achieve a better treatment. But if the cancer has metastasized, or is in an advanced state, although there is a lot of progress in the drug, no one can guarantee that every patient can have the drug to treat.
Unlike smallpox, which can be said to be "wiped out," the elimination of cancer itself does not exist. Because cancer is not a foreign product, it cannot be eliminated by some drugs, it is a very subtle mutation in our own cells, so it is difficult for us to distinguish cancer cells perfectly from normal cells.
Therefore, until now, various countries have taken early diagnosis and early screening as the main direction of cancer research. Because the efforts of previous generations have confirmed that no matter how much energy is invested in advanced cancer, the results are very subtle. At present, there are many early screening institutions that will conduct genetic testing or detection of circulating tumor cells, including the detection of some autoantibodies, which is more common in the field of lung cancer and other diseases. We have seen in the news that some institutions will claim to use a tube of blood or urine, or a mouthful of phlegm, to help you detect whether there is an early sign of cancer. But as of now, from the medical data, there is no particularly effective means to screen tumors better than CT of the chest. The accuracy of these early screenings is very poor, and sometimes it only brings anxiety and does not solve the problem.
In terms of screening for prostate cancer, there used to be a prostate-associated antigen called PSA, which is very accurate as a forward-looking antigen and is almost the most accurate marker in all tumor markers. However, later studies found that many patients with elevated PSA had gone to the prostate for puncture and follow-up treatment, but later found that the side effects and complications caused by puncture were far higher than the real trauma after imaging diagnosis of prostate cancer and re-treatment. Most patients with such elevated SPA have an ineffective puncture and then complications such as bleeding of the prostate or leaky gut. So the guidelines were revised: only a subset of patients with elevated PSA were allowed to have punctures.
New technologies will continue to emerge, and our doctors' thinking is that we do not reject new technologies, but after the emergence of new technologies such as early cancer screening, we will also reflect on whether it will bring the possibilities and risks of over-medical treatment. If it is possible, we will correct it in the opposite direction.
The industry of early screening is definitely a more promising industry in the future. However, the product research and development of each company should be closely integrated with clinical experiments to explore whether the product can obtain a better accuracy and satisfaction in the future. At least for now, there is still no early screening product that can truly replace chest CT. Chest CT only costs about 250 yuan, the amount of radiation is also very small, and it can be checked at any time. The price of the early screening product is 10,000 or 20,000, and sometimes the results of the very metaphysical results are sometimes obtained, which is still not so reliable at present.
The Economic Observer: The public often has a misconception that the purpose of receiving treatment is to cure the disease at all costs, but the focus on the quality of life is not enough. I've seen you write more than once that patients may smoke more and more ascites, but when it's good for their quality of life, it's necessary to pump. As a front-line physician, how do you see the quality of life of terminally ill patients?
Wang Xing: In fact, the most information source for patients' families is other patients. Because they are hospitalized at the same time, they will talk to many patients and WeChat to talk about how they are treated. Doctors are not gods, but also through the accumulation of experience in treating patients, to give the next patient better diagnosis and treatment. The patient's family's approach is actually the same, but it is only that the patient's family sees very little, and only sees what the people around him have done and what has been done, and what has been said, he will feel that it is right. Of course, as long as he sees enough, we talk about "long-term illness and medicine", he himself will definitely have some experience, and his experience may even be on par with doctors sometimes.
But until you see enough, don't think you're necessarily right, and listen to your doctor's advice. For example, this problem like pumping ascites, indeed they understand it correctly, the more they smoke, the more they will smoke. Doctors also don't go to patients for ascites indefinitely. But I feel that when we are dying, we can relax our requirements a little. The protein of the patient with ascites is lower, and the protein is low, so it is not bad to let the patient who is tossing and turning on the bed and suffering go earlier. At this time, in fact, you can ask a doctor friend or the right medical institution to help you make some decisions, you can explore how to do more to make the patient more painless. Your common goal is to enable patients to walk more comfortably. At this late stage, you can't go wrong with everything you do, because nothing is right. But just because I saw on the Internet that it said that ascites could not be released, I let the patient hold back, and then it was particularly uncomfortable, and I felt that it violated this principle of non-pain as the principle of "late palliative care".
I think there is still some room for more efforts in the so-called "late palliative care" area. At present, there are many secondary community hospitals to undertake the care of some terminal patients, including rehydration, pain relief and other problems. There are no beds in the top three hospitals that can be freed up for this batch of patients. Under the current charging model, the benefits that one terminal patient may produce will not achieve one of the benefits of this bed for other patients.
To put it simply, you need to be able to activate the subjective initiative of the doctor, for example, a doctor can be responsible for a terminal patient, you have to explain clearly what he will do in the future, how to take drugs, and how to do palliative medical treatment. This is also equivalent to increasing the value of a bed, which is a win-win for both doctors and terminal patients. In this way, many hospitals below the third level, other medical institutions and medical service industries will invest in "advanced palliative care", and there is no need to let the patient's family members go everywhere to ask for beds when the patient is really late, and they will not take care of themselves at home, becoming very confused. Although there is no such medical institution or medical service industry for the time being, I hope to be able to slowly emerge so that these patients in the late stage or at the end of their lives have a place to go.
Read more articles from the author