Prof. Tan Xianjie: Hello Dr. Lang, thank you for your interview with the Chinese Journal of Practical Gynecology and Obstetrics. As the medical model is changing from the traditional biomedical model to the modern biopsychosocial model, the value of humanistic care in medicine is becoming more and more important. We know that you have deep knowledge in this field, can you give us an overview of what humanistic care in medicine is? Lang Jinghe: The so-called medical humanism is how a doctor, or the public, views medicine or the medical treatment practiced by doctors, which reflects the view of the true meaning of medicine. We say that medicine is an expression of human kindness and emotion, and doctors must show care for patients in the process of practicing medicine, and this care is humanism, which is an expression of love and kindness to people. It is true that doctors need medical technology to complete medical behavior. However, no matter what kind of medical technology, it must serve the patient, not just for the sake of medical technology. That is why we say that medicine is a knowledge and a technology, but it is not only knowledge and technology. Doctors only help patients through knowledge and technology, to relieve pain, to remove disease, to let patients get kind care, this is the purpose of medicine. Therefore, the so-called humanistic nature of the doctor is actually the humanistic nature of medicine, that is, the doctor, benevolence; benevolence, benevolent art. Prof. Tan Xianjie: As you said earlier, the humanism of the healer is actually the humanism of medicine. Then, why do you say that in the diagnosis and treatment of malignant tumors, humanistic care should be emphasized more? Academician Lang Jinghe: Very good question. Indeed, the humanistic nature of medicine should be reflected most for tumor patients. Tumors, especially malignant tumors, pose a great challenge and threat to patients’ health and life, and impose a great burden on patients and their families. Doctors need to face this problem in diagnosis and treatment, which involves two aspects of medicine, one is scientific and the other is humanistic. From the scientific point of view, malignant tumors are very difficult to treat, especially the advanced ones, and many of them are incurable. At the same time, the treatment itself, including surgery, chemotherapy, radiotherapy, etc., will also bring a lot of pain to patients. How to treat it? From the scientific point of view, the treatment of malignant tumors is a difficult task. From the humanistic point of view, patients need care, encouragement and confidence. It is impossible to ask patients to treat tumors optimistically, but at least they need to treat them correctly. Therefore, we say that the process of malignant tumor diagnosis and treatment needs to reflect humanistic care most, because both the scientific nature of treatment and the humanistic nature of medical treatment should be taken into consideration. If we only consider humanism, it is obvious that we cannot cure the disease. However, on the other hand, if we only emphasize the treatment and ignore the humanity, it is also not good. For example, patient’s psychology and patient’s quality of life should not be neglected. Therefore, in the diagnosis and treatment of malignant tumors, we should pay more attention to humanistic care. Prof. Tan Xianjie: For gynecological malignant tumors, the current treatment methods include surgery, chemotherapy, radiotherapy and biotherapy, etc. What are the humanistic aspects that need special attention in these treatments. First of all, please talk about surgery. Academician Lang Jinghe: This involves a very important issue in the treatment of malignant tumors, which is early diagnosis and early treatment. Early diagnosis and treatment are usually more effective, regardless of the type of tumor; if the diagnosis is very late and the treatment is not timely, the effect will not be very good. For gynecological malignancies, except for choriocarcinoma, surgery is the first choice, such as ovarian cancer, cervical cancer and endometrial cancer. Therefore, it is important to give the patient a very good and standard surgery at the beginning. We usually say that the best treatment is given at the beginning, and what is given at the beginning should be the best treatment. Patients are very lucky if they can find the right hospital, the right surgeon, and get the standard surgical treatment through the right surgical method. This requires gynecologic oncologists to improve their surgical skills to provide the best treatment for patients. However, we need to look at the value of surgery in the treatment of gynecologic malignancies in a dialectical way. For example, in ovarian cancer, we usually consider surgery to be the most important. Therefore, when Dr. Wu Baozhen and I wrote “Lin Qiaozhi’s Gynecologic Oncology”, we said that the biggest mistake in the treatment of ovarian cancer was not to perform surgery. In the case of recurrent ovarian cancer, the biggest mistake is rash surgery. Prof. Tan Xianjie: In addition to the best and standardized surgical treatment for patients with surgical opportunities, what do you think are the humanistic issues that need attention in chemotherapy or radiotherapy for gynecologic malignancies? Lang Jinghe: This is a very difficult issue. Both radiotherapy and chemotherapy are very painful for patients, especially chemotherapy. Chemotherapy is the use of chemical drugs to treat tumors. Although there are many kinds of chemotherapy drugs, including cell cycle specific, cycle non-specific, anti-metabolic drugs, etc., all of them have cytotoxic effects, which are very harmful to patients and have many side effects. We advocate that the general principle of chemotherapy is timely, adequate and standardized. However, while mastering this general principle, we should also pay attention to the patient’s feelings and quality of life. For example, according to the principle, a patient may need many courses of chemotherapy, but for a specific patient, the patient’s side effects should be taken into account. If the side effects are very serious, chemotherapy may need to be stopped, and it is important not to “stop chemotherapy while life lasts”, which is a deviation from the original purpose of treatment. For chemotherapy of recurrent cancer, I think we should emphasize two points: one is the quality of survival, to prolong the patient’s life while reducing pain. The other is value-based medicine, that is, the value of the intervention. This value is not simply the amount of money spent, but the amount of benefit to the patient. I attended the European Oncology Congress last year (2011) and was struck by one of the presentations. The authors did a comparative study of a large group of patients with advanced breast cancer, recurrent prostate cancer, and several other advanced cancers. One group was given very intense chemotherapy, while the other group was given milder treatment or palliative care. The results showed that the patients who received intense chemotherapy lived as little as 6 months and as much as 18 months longer. This prompted people to think, how significant is it that such intense chemotherapy does not cure the tumor, but only prolongs the patient’s life by half a year or more? Let’s not talk about the quality of survival of patients in these six months or a year. The value of this chemotherapy is worth considering, why not let the patient live better? In addition, although we say that value-based medicine is not just about cost, it is also something that should not be ignored. Because health care is for the whole population. If a lot of money is spent on one patient, it may cost money for others who need it more. Wouldn’t it be more valuable if the limited medical resources were spent on more needy, more meaningful, more people? Prof. Tan Xianjie: At present, there is a common view of “technology first” in the treatment of malignant tumors, and some of them even conflict with humanistic care. Then, how do you think to resolve the conflict between “technology first” and humanistic care in gynecological tumor diagnosis and treatment? Academician Lang Jinghe: In the process of medical treatment, if we want to balance or resolve the conflict between technical supremacy and humanistic care, the most important thing is to grasp the duality of medicine, that is, the scientific nature of natural science and the humanistic nature of social science, which both doctors and the public need to understand. We need to focus on quality of life, value-based medicine and evidence-based medicine, especially evidence-based medicine. Whether a technique or a treatment is useful or valuable should not be the personal experience of one or two people, but the experience of the majority of people, and large group analysis, prospective studies or meta-analysis should confirm that it is the best treatment option. It should be evidence-based, value-based, quality of life, humanistic, scientifically based, and patient informed. If these principles can be combined organically, I think the treatment given is good treatment, so there is no contradiction between the two. Prof. Tan Xianjie: Recurrence of malignant tumors is still an unavoidable problem, usually more complicated than the initial treatment, so what humanistic factors do you think should be considered when dealing with recurrent gynecologic malignant tumors? Academician Lang Jinghe: Recurrent cancer, no matter what kind of gynecological tumor, is a very difficult problem to deal with. It is important to evaluate the recurrence of the tumor in a comprehensive manner. Although the principles of evaluation are usually mentioned for ovarian cancer, they are also suitable for other gynecologic tumors. First, it is important to determine whether the tumor is recurrent; second, it is important to determine the site of recurrence; third, it is important to analyze the type of recurrence, such as chemotherapy-sensitive, chemoresistant, or recalcitrant; and finally, it is important to consider the patient’s current status, quality of survival, and patient’s wishes. These factors need to be combined to design an individualized treatment plan. First, is the recurrent tumor curable or incurable? In some cases, although the tumor has recurred, the lesion is isolated and can be removed, which may be curable. However, there are times when recurrent tumors are not curable, such as extensive liver metastases or brain metastases. At this time, we must admit that it is not curable. Secondly, the appropriate treatment plan should be developed after adequate evaluation. Whether it is reoperation, chemotherapy, or supportive therapy. Conservative treatment is not a pejorative term, nor is palliative care. In London, England, there are three palliative care hospitals, which are different from the hospices where patients are waiting for death to come and dying. Palliative care hospitals provide patients with acceptable symptomatic support that can keep them alive for many years. This includes pain management, quality of life improvement, and nutritional enhancement. Therefore, for recurrent gynecologic malignancies, we need to determine the plan based on the above principles, rather than blindly treating them. We may have a good intention, but we may not be able to win by pursuing the tumor. This does not mean that we do not want to advance, it does not mean that we do not want to explore, it does not mean that we rest on our laurels, it is called facing the reality, it does not contradict medicine to continue to explore and overcome the difficulties. Prof. Tan Xianjie: At present, in the treatment of malignant tumors, especially recurrent tumors, there is a tendency of over-treatment, how do you think about this problem? In addition, how do you think about the problem of ineffective treatment? Prof. Jinghe Lang: Indeed, overtreatment of malignant tumors is very common. For malignant tumors, it seems that if we do not give several courses of chemotherapy or operate once more, the doctors themselves will feel wrong and regret. However, the combination of these two factors may lead to overtreatment, which may cause more damage to the patient than no treatment at all. In fact, this so-called over-treatment is not the malicious over-medication of a charlatan doctor, but a well-intentioned and well-intentioned one. Again, it is understandable that the doctor is well-intentioned and the patient has a request, but the outcome may not be good. Secondly, doctors should know that not all good and comprehensive treatment will necessarily lead to a successful outcome. Conversely, not all unsuccessful treatments must be wrong. Sometimes, when a doctor has done his best, a patient may not be cured and may be called unsuccessful. But just because the outcome is not good, it does not mean that the doctor did not do enough or did not do a good job. This has a lot to do with the disease and the patient’s specific situation. As long as a doctor does his best, he has a clear conscience, but sometimes there is nothing he can do, and there is nothing he can do for many tumors. Just like our understanding of things, we all have limitations, especially in medicine. Everything else, including the understanding of nature and things, has its limits, and there is not absolute truth, so it may not be successful. In other words, unsatisfactory treatment may not necessarily mean that the treatment is wrong. Prof. Tan Xianjie: Some people think that life should end well and die well, or life is born to die. How do you think about this view in the diagnosis and treatment of gynecological malignancies? Dr. Jinghe Lang: Very often, we as doctors are not willing to talk about death. Because patients come with the hope of life and doctors are working for the life of patients, so we usually do not talk about death. However, neither the doctor, nor the patient, nor the family can avoid this fact. One foot up, the other foot down, there must be life and death. We come from the dust, will return to the dust, this is the law of nature. The doctor’s responsibility is to save lives, so it is not usually possible to comfort the patient with the previous point of view. But doctors should know, and even patients should know, that sometimes no one can avoid this topic, and that at some point there is nothing anyone can do. If you approach the end of life in this way, you may be more open and relaxed. Doctors will not feel too guilty and repent themselves. I want to write a book called “Confessions of a Doctor”. Not simply to confess their mistakes, but to review their own practice of medicine, what they did well, and what they still regret. Prof. Tan Xianjie: How do you think gynecologic oncologists in China should improve their humanistic cultivation? Academician Lang Jinghe: Generally speaking, Chinese gynecologic oncologists are very good, with a neat medical team and high technical and technical skills. It would be better if we can pay attention to humanistic care in the process of diagnosis and treatment, and improve humanistic cultivation in practice. In my opinion, the humanistic cultivation of doctors should be like this: How do you think about medicine and medical treatment? How do you think of yourself? How to deal with their own relationship with patients? How to deal with the relationship between doctors and doctors? The quality and character of a doctor should not only be technically competent, but should also be charismatic. I do not advocate using the term “God” to refer to each other, because the whole society is serving and caring for each other. Patients are human beings and so are doctors, so they should be treated equally. For the doctor, the textbook is the teacher, the senior doctor is the teacher, but the real teacher is the patient. Patients are the demonstrators of pathological phenomena, and the doctor’s eyes glow with wisdom only in front of them, not in books. Therefore, it is the patient who makes the doctor more competent. We have to respect life, which belongs to everyone, and only once. We have to fear the patient because he gives his life to you. We have to fear medicine because it is a “sea of unknowns”. We have to respect nature, because things happen according to the laws of nature. We have to respect the patient, because he gives us his life and health, because he teaches us to be a doctor. Perhaps we do not lack the appropriate knowledge and skills, or we value them so much that our professional insight, our professional wisdom, and our professional spirit seem a bit empty and pale, so we have to make up for it in humanistic cultivation. Humanistic cultivation includes many aspects, which need to be accumulated, to learn some literature, art, philosophy. Science seeks truth, art seeks beauty, and medicine seeks goodness. In fact, medicine combines the truth, goodness and beauty, so it is not easy for doctors to learn some literature, art and philosophy. Truth, goodness and beauty are the pursuit of human beings, but also the obligation of a doctor. The emotions of literature, the beauty of art, the dream of music, the magic of painting and calligraphy, often bring sobriety and spirituality to a doctor’s tired mind and dull life. Bacon said: “Reading enriches, talking makes one quick, writing and note-taking make one precise, literature makes one wise, poetry makes one clever …… mathematics makes one fine, museum makes one deep, ethics makes one dignified, logic and rhetoric make one eloquent”. So let’s learn. The scientist appeals more to reason, the artist to feeling, and the doctor to passionate feeling and calm reason. The following 32 words have taken me a lot of effort to summarize. In my opinion, to be a doctor, one should have: ( 1) benevolence: benevolence, benevolent art; love for others, love for the profession. (2) Enlightenment: reflection, thinking; inference, deduction. ( 3) Rationality: calm and steady; objective and evidence-based. ( 4) Spirituality: randomness, adaptability; skill, innovation. Prof. Tan Xianjie: Besides improving one’s own humanistic cultivation, how do you think we can improve humanistic care in the management of gynecological malignancies from the educational or institutional level? Academician Lang Jinghe: It is very important to pay attention to humanistic care at the educational or institutional level, but this is precisely a neglected issue. Not only oncology and oncologists, but also other medical education and continuing medical education after graduation, should strengthen humanistic education. With the rapid development of science and medical technology, young doctors and even senior doctors focus on knowledge and skills, and even too much on skills. As a result, the humanistic nature of medicine is neglected, and humanistic care is neglected, which is a shortcoming and a matter of great concern. When a patient is admitted to a hospital, they have to undergo many modern tests, and they feel like they are on a cold assembly line. They feel like they are in a cold assembly line. They have a tomography, an ultrasound, an MRI. …… They are in the hospital, and there are many doctors walking past them, and there should be this rule: after taking over the patient, you should first tell the patient that I am the doctor in charge of you, and you are my patient; before doing the surgery, you should tell the patient that I am going to do the surgery; when doing the surgery, you need to go to the operating room first. Before the surgery, you should tell the patient that I am here for you, and before the patient is put under anesthesia, you should tell the patient that I am here for you. This kind of warmth, this kind of care, this kind of reliance, this kind of solidity, is so important to the patient! If we create a situation where a patient doesn’t know whose doctor he is, or who his supervisor is, how terrible that is, that’s the desertification of medicine, the stagnation of medicine! This is very wrong, this is what Osler said more than 100 years ago, the dehumanization of medicine. As time goes on, this trend is likely to get worse, and it deserves our attention. Dr. Qiaozhi Lin once warned us that doctors should always go to the patient’s bedside and do face-to-face work. It is only at the bedside that both the doctor and the patient can find their dignity. For the doctor, I am your doctor, I undertake your medical work, which is very sacred; also at the bedside, the patient will know who is her doctor in charge, and will feel respected. Isn’t this a very important relationship between doctor and patient? Medicine is developing rapidly, so it is easy to over-intellectualize and technicalize medicine, but medicine is a more humane profession than other sciences and other jobs. Because both sides are human, the doctor is human, the patient is human, both are a living organism, both are an organism with thoughts, feelings, wishes, consciousness. Why can’t we communicate properly? Many problems arise as a result of the lack of good communication, the lack of humanity. Prof. Tan Xianjie: Indeed, as you said, medicine needs to be humanized too much. The last question is, you once said that the first prescription a doctor gives to a patient is care. How can we interpret this statement in the diagnosis and treatment of gynecological malignancies? Academician Lang Jinghe: This is indeed my saying. The Beijing Evening News wanted to start a column called “Prescription for Concord”. The title is good and creative, and the intention is to have authoritative experts from the Peking Union Medical College talk about the prevention and treatment of some diseases. I was asked to write the first prescription by the publicity office of Concordia Hospital. What do I want to write? It seemed too abrupt to start with specific diseases such as uterine fibroids and endometriosis. Then I thought, “As doctors, what should be the first prescription we write for our patients when we first meet them? It should be care! In fact, it is not only for gynecological tumors, it is not only for tumors, it is also for all diseases. Isn’t it? First you have to care for the patient, then you have to see the patient, then you have to cure the patient, and care itself is the best treatment. Remember this: care is the best treatment! We have to do our best to serve our patients, and we should also remember the words of Trudeau: sometimes it’s a cure, often it’s a help, but always it’s a comfort!