On the road of practicing medicine, there are pains and joys. Along the way, some stories are deep in my mind and indelible. They may touch my heart, or hurt my heart. It’s like a lump in my throat, and I can’t stop talking about it. Here is a record or two to share with you. One day, a doctor from the emergency department contacted me, saying that a 32-year-old male patient B had his pleural fluid drawn in the emergency department and was eligible for tuberculous pleurisy, and that he should receive inpatient treatment from my tuberculosis department. I asked the physician in our group to arrange an inpatient bed for him and he was admitted 2 days later. One day, the resident in our group told me that patient B, the one with TB pleurisy, was admitted yesterday and she told B that he should be treated with diagnostic anti-tuberculosis, but B refused. What? How can a patient be like that? I decided to go and talk to the patient myself. But after two visits to the ward, the patient was not there. Later the attending doctor told me that she had talked to both Patient B and the family and they still refused anti-TB treatment. I thought: Could it be that our doctor did not talk to the patient clearly and thoroughly enough? Did the patient not really understand? Because I’ve met patients who initially refused diagnostic anti-TB treatment, but accepted it after hearing me present the pros and cons in detail. No, I had to talk to him personally. Then I went to the ward again, this time with B and the family (his cousin), and I talked to them in detail for about half an hour. First I told them: Since you came to us for treatment, we are responsible for you. I know what disease you have, how to treat it, and what the consequences will be if you don’t. I have an obligation to tell them what I know. I am obligated to tell you what I know, and if you approve of what I say and agree with the treatment plan I give, I will treat you. By taking your medical history and taking chest fluid tests, we initially determined that your disease is “tuberculous pleurisy” and needs to be treated with anti-tuberculosis drugs. B and his cousin questioned: How can you diagnose me with tuberculous pleurisy when you did not find TB bacteria? Is it just based on the elevated ADA of the pleural fluid? I replied: There are diagnostic criteria for diagnosing TB pleurisy, and elevated pleural fluid ADA is one of the most important ones, along with others: 1. the patient is young; 2. there is fever; 3. the pleural fluid is yellow rather than bloody; 4. the pleural fluid is exudate; 5. single nucleated cells reach 90%; 6. the pleural fluid ADA is elevated to 90; 7. half of the patients with pleural fluid in China have TB pleurisy. All this adds up to a correct diagnosis of TB pleurisy of at least 90%. Of course there are other diagnostic indicators that can make the diagnosis more correct, such as blood T-SPOT TB (tuberculosis infection T-cell test), but we cannot check these blood items because you refuse to draw blood for any test. In our clinical experience, if the probability of TB is 70-80% and there is no or unwillingness to take other methods of confirming the diagnosis, such as surgical biopsy, then diagnostic anti-TB treatment can be used. Not to mention a 90% probability. B and his cousin asked another question: We heard that anti-TB drugs have a lot of side effects and hurt the liver, so we are reluctant to use them. I patiently explained to them that anti-TB drugs do have side effects, but the incidence is about 15%, and most of them are not serious and can usually be solved through timely and correct treatment by the doctor, and only a few parts per thousand or even a few parts per million are really serious enough to be life-threatening. After anti-TB treatment, about 90% of patients can be cured. In the days when anti-TB drugs were not invented, within five years, about 1/3 of people with TB would die, 1/3 would become chronically ill, and 1/3 would heal themselves (get well on their own). The answer is obvious: if one fights TB, the cure rate is 90%, and the death rate due to side effects is only a few thousandths, while if one does not fight TB, the self-healing rate is 33% and the death rate is 33%. I think it’s clear when I talk about this. In my past experience, patients generally already understand and know whether they should receive anti-TB treatment or not. But I really underestimated these two oddballs, who still persistently questioned our diagnosis and still said what makes you diagnose TB. Then I wondered if they were also medical professionals with a deeper understanding and higher expectations of medicine, so I asked them if their professions were medical-related, and got the answer that B was a driver and his cousin was a seaman. I guessed that their sporadic medical knowledge probably came from the Internet, so I told them: I have been studying medicine for 8 years and working as a doctor for 19 years, and I am a specialist in a tertiary hospital, so is my medical knowledge and diagnosis of diseases not as good as what you get from searching the Internet? They didn’t say much, but “I don’t use anti-TB drugs”. I think I’ve been very thorough in addressing the main reasons for not wanting to fight consumption: doubting the diagnosis and worrying about the side effects of anti-TB drugs, and there’s nothing more to say. But I didn’t want to give up yet, I still wanted to make a final effort. I said: I will tell you everything I should tell you as a responsible doctor, and then you can make your own decision. If I don’t tell you repeatedly and persuade you, it’s my fault; if I tell you, and you really refuse to resist consumption, then you are sorry for your own life, I have no conscience on the line. And according to the rules of our medical profession, if you refuse treatment, even if I know you are wrong, I cannot force you to accept treatment, but can only tell and persuade you. Now I clearly know that your decision was wrong. I really wanted to save you. It’s as if you fell into the water and couldn’t swim, and I threw over a rope and told you to grab it and I pulled you to shore. But you firmly do not grab the rope, think I throw the rope is trying to strangle you. Not I see death, but you want to kill yourself. I spoke painstakingly for half an hour, and the patient and family members next to me said I had a point, but they remained silent. Finally I asked: Is it true that you are sure that you are not anti-TB? Then you need to sign to say no to anti-TB, and B replied I sign. Well, I completely abandoned my rescue plan, because the rescue subject insisted on refusing my rescue. I then asked B: If you refuse anti-TB treatment, why are you here in the hospital? B replied: All you have to do is pump out my chest fluid and take a CT scan of my chest. Well, that doesn’t sound too demanding. I said: We will do both the chest fluid extraction and the CT, but the fluid will grow back because it is not easy to get rid of without anti-TB and without treatment for the cause. So I left the ward and went back to the doctor’s office to inform our group of doctors of the results of my conversation with B. We all reached a consensus: 1. this patient and his family were really strange; 2. we did our best; 3. we asked him to sign to refuse anti-TB because we needed black-and-white evidence so that we would not be bitten back later; 4. we did all the other diagnostic and treatment measures that we could do except anti-TB. Two days later, Sick B’s chest fluid was not much, and a chest CT was taken, which revealed that both lungs had tuberculosis lesions, a typical manifestation of tuberculosis. So our tertiary care doctors took turns talking to B about the fact that he had TB and brought up the need for anti-TB again, but B still calmly and firmly refused, unwavering and unmoved. So I said, “Now that the chest fluid is gone and the chest CT film has been taken, your requirements have been met, so let’s discharge him tomorrow (Saturday) or next Monday,” and B said, “I’m not discharged tomorrow, I’m discharged next Monday. I said, “Okay, then. If the story ended here, it would not be very unusual, just some ordinary episodes that we encounter from time to time in our work. But there are more interesting plots to follow, more interesting than what the writers of TV shows make up. The next Monday morning, I was checking in, and B rushed over aggressively and said, “I’m not discharged, I didn’t agree to be discharged, my chest fluid is still there, how can you let me be discharged? I feel chest tightness, I want a chest ultrasound.” I said, “You agreed to be discharged today; it has been prescribed in advance to be discharged today; the chest ultrasound can be done in the outpatient clinic; and as I told you before, the chest fluid will grow again without anti-TB.” The resident told me that on Sunday B was so loud and rowdy that he called the doctor on duty to remove the chest tube. b dropped the line, “I’m not being discharged today, I’m going to sue you at the dean’s office.” Shortly thereafter, I received a call from W, the staff member in charge of medical complaints in the medical office. W said, “Your patient B came to the medical office to tell me that you were not treating him.” I told him in detail what had happened and mentioned that B had signed a refusal for anti-TB and that the surrounding patients and family members could testify that our tertiary care doctors had repeatedly explained his condition to him and recommended anti-TB treatment. w said, “You’d better have audio or video evidence.” I said, “We hadn’t thought to prepare for that at the time.” Then W said, “B asked you to give him anti-inflammatory drugs, or you should give him anti-inflammatory.” Oh, that’s really layman’s talk. I said, “We found out that B has TB, not pneumonia, so how can we give him anti-inflammatory drugs? It’s like, if a patient doesn’t have lung cancer, can you give him an anti-cancer drug? We were going to give anti-tuberculosis drugs, and he adamantly refused to use them.” W backed off and stopped insisting that we give B an anti-inflammatory. What became of this patient, I didn’t see him again, but I can guess that it must have been bad and his condition would have worsened. I just wonder if, as his health gets worse and his symptoms get worse, he will wake up quickly enough to seek medical help and receive anti-TB treatment. If he never wakes up or wakes up too late, then what awaits him is likely to be an early walk to the end of his life. This is his choice. I often tell our other doctors my principle of practice: I am responsible for my patients as long as they come to me, whether in the outpatient or inpatient setting. Within my ability, I must tell the patient what I know and what I think is the best treatment, even if he does not accept it, I am obliged to tell him. I have to tell the patient even if he doesn’t want to listen, and after I have finished I will have done my duty and will be able to live up to my conscience. It’s my fault if I don’t tell him, and it’s his fault if he doesn’t listen after I tell him. I must have a clear conscience. This is the principle I have always insisted on. Some doctors feel that the patient does not want to hear it, so they do not say. Not bad, our medical office is not as long as the patient to go to the complaint even if we are wrong, but depends on the specific situation, the doctor is really wrong to count the complaint, to be punished. So this one is not likely to be our fault. But it was depressing enough for us. And in that short period of time (less than a month), three patients actually went to the medical office to “report” our problems, all with trumped up charges, which really made my chest sulk, how can we be so “lucky”? How can I be so lucky? Stepping on shit one after another? Next time, I will share with you other strange patients.