I recently read a book by an American surgeon, Arturo Gwynedd, entitled “The Doctor’s Refinement. Gwendolen wrote a book called “The Doctor’s Refinement” and got a lot from it, and a lot of it is relevant to our patients, so I would like to talk about how we should treat patients in the context of what we have read. The first chapter recommended to you is “The Bell Curve”, which introduces how to evaluate the quality of medical care of hospitals and even doctors in the U.S. This evaluation is a difficult problem not only in China but also in the U.S. After all, the severity of the disease and the different conditions of the disease itself set different difficulty factors for the evaluation, so the author tries to explore with a disease, which is a congenital genetic disease – cystic fibrosis ( CF is a disease of Hispanic origin, caused by a disorder of cellular ion channels, and is characterized by systemic dysfunction of multiple organs, in the lungs due to overly viscous secretions in the airways leading to secondary bronchodilatation and development of respiratory failure, in the pancreas leading to poor digestion and secondary malnutrition due to failure of pancreatic juice to drain into the intestines, and in the intestines, prone to Dilatation of the intestine and intestinal obstruction. The average life expectancy of these patients was less than 10 years 50 to 60 years ago, and even in the 1970s it was less than 20 years, but now the average life expectancy is 40 to 50 years. Is this because of new drugs, gene therapy, or lung transplants? Neither. I have seen such patients in the United States and have asked local doctors about treatments, and they told me that there is no once-and-for-all cure for CF, and that even lung transplants are not effective. The main cause of death in CF is bronchial dilatation and respiratory failure, and the reason for bronchial dilatation is the high concentration of chloride in the secretion, resulting in sticky sputum, which is not easily expelled; then the focus of treatment is to dilute the sputum and expel it by physical means, and at the same time reduce and inhibit the infection secondary to bronchial dilatation. So according to this principle, the first thing to do is to dilute the sputum, and one of the first American doctors came up with the idea of putting the child with CF on an airtight crib and placing a humidifier on the crib to keep the humidity on the crib just out of sight; nowadays, the patient is given nebulized inhalation therapy several times a day. The next step is to expel the sputum, which can be done in various ways, the main ones being (1) by the patient’s own coughing, (2) by a simple sputum expeller such as ACEPELLA, and (3) by an electric machine such as VEST. an example is given in this book where a doctor in the United States who focused on treating CF supervised a female high school student with CF and asked her to insist on expelling sputum every day by the actions he required. The girl wanted to be lazy and do it less often because of the inconvenient application of the nebulizer and the fact that she was feeling fine. The doctor first gave her a lecture: if you do sputum evacuation every day, your daily chance of pneumonia is only 0.05%, i.e. your chance of being normal is 99.95%; while if you don’t do sputum evacuation, your daily chance of pneumonia is 0.5%, i.e. your chance of being normal drops to 99.5%; don’t underestimate this 0.45% difference, when accumulated to one year, the former The likelihood of being normal is still over 80%, while the latter drops to 18%. Therefore, your daily adherence to seemingly boring actions will have an impact on the changes in your condition later. This concept is also one I hold in high esteem, that persistence is the winning formula. When working in the outpatient clinic I often encounter patients with chronic conditions that do not listen, such as COPD, asthma and sleep apnea syndrome, and the common denominator is their long-term adherence to treatment – be it medication or lifestyle. However, many patients have two bad ideas: first, they hope that the treatment will be once and for all and that there will be some fundamental solution; second, they lack the patience to fight a long-lasting battle, and they have no confidence when they think of long-term treatment with medication, or they stop medication without permission when they feel better, until they come to the hospital to hang saline after an acute exacerbation. I do not know that as long as there is an acute exacerbation will have a negative impact on the prognosis, and a difference of 0.45% per day will bring a difference of 60% after a year, so persistence is the only way to overcome or at least fight against chronic diseases. The first step is to bend down in order to compress the lung volume first, the second step is to straighten up quickly and bend backward in order to increase the lung volume rapidly, and the third step is to cough hard to expel the sputum immediately afterwards. Of course, patients who are in a position to do so or who are weak can purchase a sputum expeller like VEST, which can effectively expel sputum. The third point of treatment for this disease is nebulized antibiotics, the choice of which is tobramycin, although it is important to tell you not to use nebulized antibiotics at will, but always to choose drugs with evidence-based medical evidence. Even today, the antibiotic for CF nebulization has been tobramycin, and there is no another drug yet, and there has been no clinical study to confirm whether tobramycin can be used in our country’s branch expansion due to the different pathogenesis.