About the Doctor-Patient Relationship Attitudes toward the doctor-patient relationship in mainland China are very different from those in the West. The lack of trust between patients/families and physicians, partly due to the relative scarcity of general practitioners in urban China, has contributed to the long-standing lack of a healthy doctor-patient relationship. The perception is that treatment is provided only for private gain, more so than in the West. In mainland China, when someone gets sick, he or she goes directly to a hospital, including a traditional Chinese hospital, but never to a medical practitioner who is not part of the hospital system. Hospitals can provide almost all medical services. For example, if some patients need to receive chemotherapy once a week, or radiotherapy 5 days a week, they will happily stay in the hospital 24/7. It is especially attractive that these patients can lie on the VIP floor and stay in the hospital for more than a month, during which time they are fed and housed in the hospital. About Oncology in China An unintended consequence is that, thanks to the role of the government, it is not expensive to find a doctor to see. This has led to a widespread complaint about medical care among the Shanghai public: doctors have a really limited amount of time to spend on each patient. A good surgeon who has to see nearly 40 patients in 2 hours means spending 3 minutes on each patient, which is about$40 per patient. On another day, this doctor would need to see 80 to 100 patients and charge each patient$3.50 for registration. In those few minutes, very few doctors have time to perform a physical examination on the patient. It is usually just a few questions, a brief glance at imaging results, lab test results and tumor markers, and that’s about it. Regarding patients, physicians Chinese patients who believe they have or have been diagnosed with cancer will request certain tests, but physicians will not argue about their necessity, choosing instead to acquiesce and not relay these patients’ complaints to hospital administrators. What doctors need to beware of is the risk of administrative warnings, lawsuits or even physical harm to doctors, especially surgeons, if the patient has a poor outcome. About Respect for Life While the Western physicians at our center see difficult cases as challenges, Chinese physicians consider their own risks first and are hesitant to help patients. We once saw a 55-year-old lung cancer patient who was denied treatment by radiologists at another hospital because he was coughing up blood badly because, they said, the bleeding was too severe. The reality was that they didn’t want to be held responsible for a bad outcome. About advice vs. opinion Patients inevitably seek advice from their doctors, which often causes confusion for patients/families. Friends, friends of friends, or friends of doctors, will offer advice, but none of them know much about the condition, but they are often more trustworthy and valued than the formal advice received from a doctor. About treatment: who pays and how much? As a private institution that can provide radiotherapy, chemotherapy and imaging services on site, the expenses and costs at the author’s center are higher than at public hospitals. What initially surprised patients was that the price of anything, even a full blood count, was negotiable at this new, free-run facility in China. The center’s policy is that patients must pay in advance for each visit and procedure, including once-daily radiation therapy, with no refund. Western oncologists at our center use guidelines as a reference when making treatment plans, whereas Chinese physicians usually do not read guidelines at all. For example, dexamethasone has been used in the West for years when reducing edema in spinal cord or brain injuries, whereas Chinese physicians routinely use mannitol, sometimes on a daily basis, lest adverse events be reported as a result of dexamethasone. The use of adriamycin for lymphoma patients also appears to be more limited, possibly due to excessive concern about the risk of heart disease. Differences in transfusion criteria between Western oncologists and Chinese physicians are also evident. Chinese physicians will never transfuse a patient if the patient’s hemoglobin is not less than 6.0 g, regardless of the patient’s age or symptoms. And many outpatient procedures that seem relatively simple to Western doctors become complicated in China. About communication and translation Although the nurses at the center are fluent in English, they are often unable to accurately translate the words of patients or families. About the cases encountered Some patients have seemingly unrelated cancers, such as renal cell carcinoma and breast cancer. Although this is rare in the West, it often needs to be considered in China, rather than just assuming that one lesion is the result of a metastasis from another. However, Chinese physicians often consider this to be only one type of cancer. This is due in large part to a lack of comprehensive oncology training. As a result, most patients with two curable cancers are treated as incurable metastatic cancers. There are approximately 8,000 registered oncologists in China, but their knowledge is narrow and they are caught off guard when faced with a problem outside their specialty, such as breast or lung cancer. Doctors in radiotherapy, medical and surgical oncology see each other as competitors, not as peers. Treating cancer patients depends on which specialty is seen first. Surgeons and radiologic oncologists can administer chemotherapy. Thoracic surgeons and medical oncologists often do not agree that local treatment is an adequate therapy. For patients with superior vena cava obstruction, patients with brain metastases or spinal cord metastases, and patients with unknown pathology scores, only a change in chemotherapy regimen is required. Patients with metastatic or stage IV breast cancer are often treated with two- and three-drug combination regimens, as if they were only early stage patients, and anti-estrogen therapy is rarely considered. In addition, it is common to see pathology or imaging reports without follow-up with the pathologist or radiologist. It seems that they lack the understanding and application of comprehensive oncology concepts. Regarding patient privacy There does not seem to be any such thing as patient confidentiality or privacy here. In fact, while talking to one patient, another patient or family member will listen sideways, interrupt the conversation, make comments or even express a different opinion. In large hospital outpatient rooms, there are three groups of people in addition to the medical staff: patients waiting to be seen (who are definitely accompanied); another group of patients waiting to be seen; and another group of patients who have been seen before. In addition, there may be another group of patients represented to get a glimpse of how things are going. In short, the level of confusion is indescribable. Regarding quality control of treatment, drug expenditure and availability Chinese patients usually buy the cheapest drugs (e.g., capecitabine), but the quality of drugs made in China or India is really not complimentary, as quality control measures in these places are better than nothing. Even in public hospitals, anti-cancer drugs are inexpensive. Therefore, although many new monoclonal antibody drugs and tyrosine kinase inhibitor drugs are available, the general public simply cannot afford them except for the wealthy in the past. For other drugs including lapatinib, amilorubicin, eribulin and everolimus, they can only be obtained from neighboring countries or Hong Kong. Since the radiotherapy facility needs to treat 100 to 140 patients from morning to night every day, quality control of radiotherapy is a concern, even if one wants to do so. Regarding compliance and trust issues The lack of trust in the physicians means that once treatment is not effective, patients choose not to report on the treatment but simply transfer to another hospital, not knowing or even caring that we might try other treatments. They believe that since the physician cannot successfully administer treatment, there is no need to trust them to control the condition by other means. Most of the patients seen by the author were late and severe and had been treated previously. Therefore, the likelihood of the author finding an effective initial rescue treatment option was not high. All in all, the author’s experience was challenging. You cannot anticipate in advance what you will face. You may achieve success, but never efficiently. You need to understand and respect Chinese culture and try (which can be difficult) not to make judgments as others ask. Patience is a must, as is the need to give sufficient weight to what is called “face,” which is also a common Chinese trait.