Chapter 113 The Reality We Face

In the hospital courtyard, Professor He speaks to Evan about the price a doctor may have to pay.

That night, Evan and Professor He stayed at the Chinese medicine hospital. They sat on the raised edge of a flower bed in the courtyard.

Professor He opened a newly bought pack of cigarettes and felt through his pockets. Only then did he realize he hadn't bought a lighter.

“Professor, I thought you didn't smoke?” Evan asked.

Professor He nodded. “That's right. Never have. For some reason I just wanted a cigarette today. Bought the cigarettes and forgot the lighter.”

He shook his head, gave up on the lighter, and took out a cigarette. He put it between his lips and left it there, unlit.

Teacher and student sat together in silence.

The darkness deepened. All the streetlights had come on.

Evan slowly lowered his head.

“I'm sorry, Professor,” he said quietly. “I've made you worry.”

Professor He looked up at the stars, his gaze distant.

“It isn't quite worry,” he said. “I just think you've become too good.”

“Isn't that a good thing?”

Professor He shook his head. “No.”

Evan looked puzzled.

Professor He bit lightly on the cigarette.

“I've always considered you my best student. I always thought you'd improve quickly once you began clinical work, that in a few years you'd be able to manage on your own.

“But I still underestimated you. Your clinical skills have improved too quickly. I don't know who you've been studying with lately. Is there really a whole group of the country's finest physicians taking turns teaching you?”

For a moment, Evan didn't know how to answer.

“Even if there were, you couldn't improve this fast,” Professor He continued. “Perhaps you really are a genius. I'm beginning to feel your medical skill is already no less than mine.

“I'm your teacher. Seeing you surpass me should make me happier than anything. But right now I can't even smile.”

He turned to look at Evan.

“I see Li Ke in the things you say and do, in the way you prescribe, in your thinking about medicine. You're as gifted as he is, and you have the same anger. Have you been studying with one of Dr. Li's disciples lately?”

Evan kept his head down and said nothing.

Professor He watched him for a while. When Evan wouldn't answer, he stopped asking.

“But you and Dr. Li are different. He's already made his name and earned his standing. He can afford to be angry. You can't. You have the skill, but no standing. If you get into trouble, no one will protect you.”

Evan didn't quite know what to think.

Professor He took the cigarette from his lips and tucked it back into the pack.

“The medical climate is very bad for Chinese medicine. The pharmacopoeia hems us in from above, and forensic medical assessments close in on us from below. It's hard for us to practice.

“Treating serious and critical illnesses is harder still. To treat them, we have to take risks. You know about Yong'an Tang, don't you? Forty grams of banxia, and they had to pay five million yuan.”^[1]

Evan nodded.

“I know how much you admire Dr. Li's thinking,” Professor He said. “Then you should know that whenever he uses banxia, he uses it raw. And he dares to use forty or fifty grams.

“Hardly anyone in clinical practice dares use raw banxia anymore, even though everyone knows that's what Zhongjing used. Dr. Li has demonstrated its value through his results, and shown from experience that adding an equal amount of fresh ginger reduces its toxicity. Zhu Liangchun, a National Master of Chinese Medicine, uses raw banxia too.^[2]

“Still, nobody dares use it. Nobody dares go far beyond the dose limits. They're all frightened. After the Yong'an Tang affair, the pharmacies in every Chinese medicine hospital and independent clinic could only dispense strictly according to the pharmacopoeia. No exceptions.”

He addressed Evan directly.

“Evan, I know you're angry. You're angry that so many provincial specialists saw this patient, yet none dared use the amounts of wutou and fuzi in the classical formulas. They couldn't break through the ice and thaw him out. Instead, they let him deteriorate into a critical case.^[3]

“We all know the actual amounts in the classical formulas. But nobody dares use them. You saw that his previous doctor had already used several times the standard dose of wutou and fuzi. Of course, to you that wasn't nearly enough. But do you know how much pressure he had to bear just to write that prescription?”

Evan was taken aback.

“He has to explain over and over why he's using such potent, toxic medicines. He has to chase down signature after signature before the pharmacy will dispense them. He has to get the patient to sign a liability waiver and sign an agreement himself. Even then, the hospital is reluctant. It doesn't want the responsibility.^[4]

“I know you've always had the spirit of a great physician. You've set your heart on saving people without considering what you stand to gain or lose.

“But can you bear the consequences? You don't have a wife or children, but you do have parents. Who can afford an enormous compensation payment? What happens to your parents if you lose your license—or even go to prison?”

Evan's lips trembled.

A helpless expression touched Professor He's mouth.

“Those specialists have elderly parents and young children too. If they give themselves wholly to saving a patient, who's going to protect them? Really… doctors shouldn't be treated this way. All the risk shouldn't be passed on to them.”

Evan sighed and lowered his head. For the first time, his eyes showed uncertainty.

Professor He shook his head.

“Let me tell you another story. Two years ago, I saw a patient who'd had cirrhosis for seven years and been hospitalized several times. Eventually he went to a private Chinese medicine clinic in the provincial capital. The doctor took his test reports and prescribed for what they showed.

“Hardening? Add guijia and biejia—turtle and soft-shelled turtle shell—and other medicines to soften hardness. High transaminases? Use wuweizi, or taizishen. Modern pharmacological testing has found that schisandrol in wuweizi can effectively lower transaminases. Active components in taizishen do the same.^[5]

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“When he saw yellow urine, he used banlangen to promote bile flow and reduce jaundice. When he saw low hemoglobin, he added shen, qi, gui, and di. Then he insisted on a diet with ‘three lows and one high.’ Treat each disease as it appears, each symptom as it appears. He treated the patient entirely according to pharmacological tests.”^[6]

Evan shook his head. “Idiot!”

“Yes. An idiot. The patient felt unwell all over after taking his medicine. Later, after being careless with his diet, he had bleeding from an esophageal vein. Emergency treatment stopped the bleeding.

“After that, someone referred him to me. I found the true qi of his five zang organs was failing. He was already in danger. I immediately set about saving his Stomach qi and protecting the five zang, using Lizhong Tang combined with Shenling Baizhu San.^[7]

“After taking it for a while, his symptoms eased.

“He also learned from me how this quack had harmed him. He was furious and took the man to court, demanding that he be held responsible.”

“What happened?” Evan asked.

Professor He shook his head. “The patient lost.”

Evan's face fell too.

Professor He's voice grew heavier.

“Every dose the quack prescribed complied with the pharmacopoeia. So long as it was within the limits, failure to cure the patient was put down to individual differences. It wasn't the doctor's responsibility.

“As for his combinations, Chinese medicine doctors are entitled to devise their own formulas. He didn't understand pattern differentiation. He treated disease solely from pharmacological reports. A symptom appears, treat the symptom. A disease appears, treat the disease. To us, he was completely wrong. A quack harming people.

“But the forensic assessment agency conducted very scientific pharmacological tests. They established that wuweizi really did contain an active substance that could lower transaminases. That active components in shen and qi really could nourish the blood. That banlangen really did act against endotoxins.

“So there was no fault in his prescribing. And there was certainly nothing wrong with the ‘three lows and one high’ diet. The authority to interpret Chinese herbal medicines passed out of the hands of Chinese medicine doctors a long time ago.”^[8]

Evan's breathing grew heavy.

Professor He sighed.

“After that, I kept an eye on this quack. He's been taken to court several times, and every time he's walked away unscathed.

“Hah… All these years he's been marketing himself on the internet, promoting himself every way he can. Patients come from out of town because of his reputation. He gets plenty of first-time patients, but very few come back. Who knows how many patients have had their treatment delayed because of him over the years?

“They say he's already bought three apartments in the provincial capital. Quite a success, isn't he?”

Professor He looked helpless.

“Evan, this is the reality we face.”

Reader Notes

Reader Notes

1. ↩︎ The pharmacopoeia and prescribing limits. A pharmacopoeia is an official collection of standards for medicines. China's 2007 Prescription Administrative Measures also require a reason and another signature when an exceptional dose is used. This supplies context for the signatures discussed here, rather than deciding whether a particular prescription is appropriate. The novel does not identify its pharmacopoeia edition. The Yong'an Tang story retains Professor He's figures of 40 g and five million yuan; the underlying judgment has not been verified for this edition. Sources: WHO — What a pharmacopoeia is; National Health Commission — Prescription Administrative Measures, article 6(9), PDF p. 4 (in Chinese).
2. ↩︎ Raw banxia and ginger. Raw banxia is unprocessed Pinellia tuber, distinct from its processed forms. Hong Kong's health authority lists the unprocessed material among toxic Chinese medicines. A laboratory study investigated ginger's effect on irritating needle-shaped crystals from the tuber; it examined changes under particular experimental conditions. That finding helps explain the traditional association with ginger, but does not establish the safety of the equal-weight combination or the 40–50 g doses in this dialogue. The clinical claims remain Professor He's account of the physicians' practice. Sources: Hong Kong Department of Health — Toxic Chinese herbal medicines; Fueki et al. — Pinellia crystals and ginger extract, abstract and discussion.
3. ↩︎ Wutou and fuzi. The Chinese shorthand wufu groups related aconite medicines; it does not make the names interchangeable. The earlier prescription used chuanwu and fuzi. This passage gives neither a new dose nor a processing specification, so none has been supplied. “Breaking through the ice” is Professor He's image for treating the severe cold condition discussed in the preceding chapters. It describes his therapeutic reasoning, rather than a measured fall in the patient's body temperature. Source: Hong Kong Department of Health — Aconite medicines: identity, processing, and toxicity (in Chinese).
4. ↩︎ Signatures and liability. The doctor describes both a patient's waiver and an agreement he himself must sign; the passage gives neither document's terms. As in the previous chapter, a waiver should be distinguished from informed consent and from legal immunity. For comparison, China's Civil Code addresses consent, medical fault, and clauses excluding liability for personal injury separately. These provisions explain the distinction between the concepts; they do not determine the effect of an unspecified document in a scene whose year is unstated. Source: Supreme People's Court — Civil Code, articles 506 and 1218–1219 (in Chinese).
5. ↩︎ Medicinal names and “softening hardness.” Guijia and biejia name different shell materials. Wuweizi is schisandra fruit; taizishen is a medicinal root. “Softening hardness” is a traditional treatment category, which Professor He says this doctor applied to cirrhosis. A whole medicinal material is distinct from an isolated constituent. The source calls one constituent schisandrol without specifying a subtype. The claims about lowering transaminases are retained as dialogue, rather than inferred from the names or from the traditional category. Sources: HKBU — Wuweizi; HKBU — Taizishen; WHO — TCM Terminologies, entry 2544.
6. ↩︎ Test results, abbreviations, and the diet. Transaminases are enzymes, including ALT and AST, whose levels help assess liver injury. They are different from hemoglobin, the oxygen-carrying protein in red blood cells. Shen, qi, gui, and di are abbreviated medicinal names; qi here is not the theoretical qi. The exact shen material and processing forms are unstated. The “three lows and one high” diet also leaves its nutrients unnamed. These gaps have been retained. The laboratory terms do not by themselves establish the effectiveness of the medicines described. Sources: NIDDK — Cirrhosis: blood tests; MedlinePlus — Hemoglobin test.
7. ↩︎ Stomach qi and the combined formulas. In Chinese medicine, the five zang are the Heart, Liver, Spleen, Lung, and Kidney functional systems. True qi and Stomach qi belong to that theoretical vocabulary; their “failure” here is Professor He's assessment, not an additional laboratory finding. Lizhong Tang is the decoction form of a formula also known as Lizhong Wan. Shenling Baizhu San is another named formula, traditionally associated with supporting Spleen qi and addressing dampness. Combining them does not specify the ingredients' amounts or how the preparation was made in this case. Sources: WHO — TCM Terminologies, entries 188 and 232; HKBU — Lizhong Wan, including its decoction form; HKBU — Shenling Baizhu San.
8. ↩︎ The court story and pattern differentiation. Pattern differentiation means analyzing the clinical picture as a whole to identify a traditional pattern; it differs from choosing one medicine for each symptom or test result. That distinction underlies Professor He's criticism. His explanation of why the patient lost remains his account of an unnamed case. Compliance with a dose limit is not, by itself, a complete statement of medical liability: for comparison, China's Civil Code also addresses fault and the duty of care. No original judgment for this anecdote has been identified here. Sources: WHO — TCM Terminologies, entries 546–550; Supreme People's Court — Civil Code, articles 1218 and 1221 (in Chinese).