godfather of surgery

Chapter 1388 Get it all figured out
On Tuesday afternoon, Tashi was sitting in the demonstration room revising the fifth draft of his paper when his phone rang. It was Professor Yang.

"Come to my office!"

Zaxi put down his computer, jogged over, and knocked on Professor Yang's office door. Yang Ping looked up, pointed to the chair opposite him, and said, "Sit down!"

A pile of literature was spread out on the table, all about Clostridium difficile infection. Zaxi recognized several of them; they were the ones he had consulted when writing his paper. Yang Ping was also holding a printed copy of the paper, the one Zaxi had written, still with red pen annotations.

“I’ve read the paper, it’s the fifth draft!” Yang Ping put the paper on the table and turned to the first page. “It’s much better than the fourth draft, but there are still problems.”

Zaxi's heart tightened: "What's the problem?"

Yang Ping didn't answer directly, but instead asked him, "Let me ask you a question: how long did it take you to write this paper?"

Zaxi thought for a moment: "I wrote it on and off for about a week."

“One week!” Yang Ping nodded. “So, did you thoroughly understand this disease in that week? All the horizontal, vertical, and intersecting knowledge surrounding this disease…”

Zaxi opened his mouth, wanting to say "more or less," but swallowed the words back. To be honest, he had indeed consulted a lot of literature and written case reports, but he knew in his heart that his understanding of Clostridium difficile infection was still at the level of "being able to write a case report." If asked a few more questions, such as what the pathogenic mechanism of this bacterium is, why this particular patient was infected and not someone else, how to determine the course of antibiotic treatment and the indications for stopping the medication, and what the risk factors for relapse are, he couldn't answer any of them.

Looking at his expression, Yang Ping seemed to already know the answer.

"Zaxi, do you know Li Min?"

Tashi nodded.

"Do you know how Li Min rose to prominence?" Yang Ping asked.

Zaxi shook his head.

Yang Ping leaned back in his chair, his gaze fixed on the window, as if recalling something. "When Li Min first came, he was about the same as you, with a decent foundation but nothing particularly outstanding. One day, he helped me admit a patient with lumbar disc herniation, a very common condition, and I put him in charge of this patient."

He paused, looking at Zaxi: "Do you know how I had him manage it?"

Zaxi shook his head.

Yang Ping said, "I asked him to thoroughly study this patient from head to toe, not just in terms of diagnosis and treatment, but in all related knowledge. What is the anatomical structure of the intervertebral disc? Where does the blood supply come from? What are the pathophysiological changes after nerve root compression? Why does it hurt? Why does it feel numb? Under what circumstances is conservative treatment effective? Under what circumstances is surgery necessary? What are the surgical methods? What are the advantages and disadvantages of each method? How to prevent and manage postoperative complications?"

Zaxi's eyes widened in astonishment.

Yang Ping continued, “I had him go to the library and read through all the books on lumbar disc herniation, search for all the relevant literature on PubMed, and observe every possible lumbar spine surgery in the operating room. A week later, he came to report to me. I asked him, ‘How much do you understand about this disease now?’ He said, ‘I think I understand about 80%.’ I said, ‘Not enough, continue.’ Another week passed, and he came to report again. I said, ‘And now?’ He said, ‘Ninety percent.’ I said, ‘Still not enough.’ The third week, he came to report again. I said, ‘And now?’ He thought for a while and said, ‘I understand about 10 percent.’”

Zaxi was stunned: "Ten percent?"

Yang Ping laughed: "Yes, ten percent. He said that the more you learn, the more you realize how much you don't know."

Zaxi sat there, a strange feeling churning inside him. He recalled the process of writing his paper: consulting over a dozen articles, writing a case report, and feeling he was almost done. But compared to Li Min's "three weeks," his "one week" seemed like a joke.

Yang Ping looked at him, his tone becoming serious: "Zaxi, do you know why I'm telling you all this?"

Zaxi shook his head.

Yang Ping pointed to the pile of documents on the table, and then to Zaxi's paper: "The case you wrote about, Clostridium difficile infection aneurysm, is very rare. But rarity is not the point. The point is whether you have thoroughly understood this type of disease through this case."

Zaxi was stunned: "A type of disease?"

Yang Ping stood up, walked to the whiteboard, picked up a pen, and wrote a few words: Infectious aneurysm.

"The case you encountered this time was an infectious aneurysm caused by Clostridium difficile. But Clostridium difficile is not the only pathogen causing infectious aneurysms. Streptococcus, Staphylococcus, Salmonella, and Brucella can all cause them. What are the differences in their pathogenic mechanisms? What are the differences in their clinical manifestations? What are the differences in their diagnostic methods? What are their respective treatment plans? Will you be able to handle this kind of case with ease next time you encounter it?"

As he spoke, he drew a table on the whiteboard, which was filled with dense writing.

Zaxi stared at the chart, his mind buzzing. He had never imagined that a disease could be studied in this way.

Yang Ping turned around and looked at him: "From now on, this case will be your starting point. You need to use it as a starting point to learn all the relevant knowledge."

Yang Ping looked at Zaxi's surprised expression and smiled: "Scared?"

Tashi took a deep breath: "I'm not afraid."

Yang Ping nodded: "That's good. Remember, I'm not asking you to memorize all of this. I'm asking you to build a framework so that when you encounter any case in the future, you'll know where to start, how to learn, how to investigate, and how to think. This ability is more important than learning to perform a hundred surgeries."

Tashi nodded vigorously.

Yang Ping added, "Furthermore, I plan to start personalized training for your group of trainees this month. There are thirty of you from different places, with different backgrounds and needs. I can't use the same method to teach everyone."

Zaxi was taken aback: "Personalized training?"

Yang Ping said, “Yes, you come from a high-altitude area, where altitude sickness, spinal tuberculosis, and congenital malformations are common diseases. Ayi comes from Guizhou, which is a mountainous area, where there are many injuries, scoliosis, and rheumatism. Aili comes from Xinjiang, which is a vast area with many ethnic groups and many genetic diseases. Everyone’s training direction is different.”

He paused, looking at Zaxi: "I've already decided on your direction. When you go back, you'll face not only common illnesses, but also problems unique to the high-altitude region."

As he spoke, Yang Ping took out a study plan from the drawer and handed it to Zaxi.

He sat there, staring at the densely packed schedule, his mind completely blank.

Yang Ping looked at him, his tone suddenly softening: "Zaxi, do you know why I'm so strict with you?"

Zaxi shook his head.

Yang Ping said, "Because when you go back, you will be facing the people of an entire region. They have been waiting for you for many years, and you can't make them wait any longer."

Yang Ping continued, "When you return to the grassroots level, you will be doing the hardest work and helping those who need help the most."

He looked at Zaxi and said, "You, Ayi, Aili, Bilige... those of you who come from the grassroots are the ones I value most."

Zaxi stood up and bowed to Yang Ping. This time, Yang Ping did not stop him.

That evening, Zaxi sat in his dormitory, staring blankly at the study plan Yang Ping had given him. He read the plan three times, and each time he felt a chill run down his spine.

Complete the basic medical study of Clostridium difficile in a week? He spent a whole semester studying microbiology in medical school. But he knew Yang Ping wasn't making things difficult for him; Yang Ping was pushing him, forcing him to build his own knowledge system in the shortest amount of time.

He took a deep breath, turned on his computer, and began researching.

The first task of the first phase: microbiological knowledge of Clostridium difficile.

He found a review article and started reading it from the beginning. As he read, he realized a problem: he had forgotten many of the basic concepts. What is a spore? What is an exotoxin? What is a cytotoxin? He had memorized them in medical school, but forgot them after the exams.

He hesitated for a moment, then sent a message to Ali, who was on duty with him: "Do you have any textbooks on medical microbiology?"

Ali replied, "Yes, I have an electronic version. I'll send it to you."

Zaxi downloaded the textbook and started reading from the first chapter. He read slowly, taking notes as he went. He didn't finish the chapter on Clostridium difficile until 11 p.m. He filled more than ten pages in his notebook, drawing diagrams of the bacterial structure, pathogenic mechanisms, and toxin action mechanisms.

The next morning, he went to find Yang Ping.

Yang Ping was reading documents in his office when he saw him come in. He raised an eyebrow and said, "So fast?"

Zaxi handed over the notebook, which Yang Ping took, flipped through, and looked at for about ten minutes.

“It’s well drawn!” he said, “but there are a few things wrong.”

He circled a few times in his notebook with a red pen: "Here, you said that toxin A is an enterotoxin and toxin B is a cytotoxin. This statement is inaccurate. Toxin A also has cytotoxicity, and toxin B can also cause intestinal inflammation. They work synergistically, not separately."

Zaxi quickly wrote it down.

Yang Ping continued, "And here, you said Clostridium difficile is a Gram-positive bacillus. Yes, but you missed a crucial point: it exists in the intestines in spore form. Spores are resistant to alcohol, high temperatures, and many disinfectants. That's why this disease is easily transmitted in hospitals and why it's prone to recurrence. Go back and add that."

Zaxi wrote it down.

Yang Ping handed the notebook back to him: "Good, keep going, use a point to introduce a whole, we'll start learning about gut microbiota tomorrow."

Zaxi nodded and turned to leave. Yang Ping suddenly called out to him, "Zaxi."

Tashi turned around.

Yang Ping asked, "What time did you study last night?"

Zaxi hesitated for a moment: "Eleven o'clock."

Yang Ping frowned: "Studying until eleven o'clock, and then getting up at six in the morning? That's fine, but don't stay up so late!"

Tashi nodded.

Yang Ping said, "I've said it before, being good to yourself isn't selfish; it's being responsible to everyone. If you exhaust yourself, learning anything else is useless. Going to bed before 11 p.m. every day is an order. In medicine, without sleep, there is nothing. You should understand this principle."

Tashi nodded emphatically again.

That night, Zaxi turned off his computer at 11 p.m. He lay in bed, tossing and turning, unable to sleep. His mind was filled with images of Clostridium difficile spores, toxin A, and toxin B, swirling around in his head.

He picked up his notebook, read a few more pages, and then turned off the light.

The next day, he began to learn about gut microbiota.

This part is more difficult; he had never studied this area before. What are Firmicutes? What are Bacteroidetes? What is the relationship between the gut microbiota and the immune system? How do antibiotics disrupt the gut microbiota?
He spent two days studying the basics of gut microbiota, and then went to report to Yang Ping.

After listening, Yang Ping asked him a question: "Why is it that some people get Clostridium difficile infection while others don't, even though they all used antibiotics?"

Zaxi thought for a moment and said, "It might be because the composition of the gut microbiota is different; some people's gut microbiota are more resistant."

Yang Ping nodded: "Yes, so how do we predict it? How do we prevent it?"

Zaxi couldn't answer.

Yang Ping said, "Go and check the literature, especially the last five years, to see if there are any relevant prediction models or prevention strategies."

Zaxi went back to investigate and found a meta-analysis on probiotics for the prevention of antibiotic-associated diarrhea, as well as a review on fecal microbiota transplantation for the treatment of recurrent Clostridium difficile infection.

He spent a day reading both documents, and then went to find Yang Ping.

After listening, Yang Ping asked an even more challenging question: "For fecal microbiota transplantation, how is a donor selected? What are the screening criteria? What is the transplantation route? Which is more effective, oral capsules or colonoscopy-assisted instillation? What are the long-term safety profiles?"

Zaxi couldn't answer again.

But he didn't panic this time. He was used to it. Yang Ping's way of asking questions was like peeling an onion, peeling it layer by layer until you reached the part you really didn't understand.

He said, "I'll check."

Yang Ping smiled and said, "Go ahead! The Department of Gastroenterology at Sanbo Hospital is currently conducting intestinal flora inhibition. You can go and find out more about it."

A week later, Tashi completed the first phase of his studies. He wrote over a hundred pages in his notebook, drew dozens of diagrams, and read over a hundred articles.

When he went to report to Yang Ping, Yang Ping asked him a question: "How much do you know about Clostridium difficile now?"

Tashi thought for a moment and said, "About five percent."

Yang Ping laughed and said, "Not bad, you've made progress. At least you know that you only know five percent."

He paused, then took out a new schedule from the drawer: "This is the second phase. You have two weeks to learn the clinical medicine part of this disease. After two weeks, I want you to explain this case from beginning to end, to me and to the other trainees."

Zaxi was stunned: "Tell it to the other trainees?"

Yang Ping said, "Yes, the best way to learn is to teach others. Only when you teach others can you truly understand."

Zaxi took the schedule, his hands trembling slightly, but he was no longer afraid.