Sunday, 2 July 2017

The Good Doctor's Dilemma.

When face with a 20% cure of lung cancer (tumor) with surgery and a 55% shrinkage of the tumor with chemotherapy, as a patient at 55, with nary a background in such state-of-the-art medical knowledge, especially in such a highly specialised field, which option would you choose? 
Facing such options is like confronting Homer's mythological dilemma namely, Scylla and Charybdis. 
They are two symbolic sea monsters at opposite sides of the narrow Strait of Messina. 
Scylla (a six-headed sea monster) represents a "Rock" and Charybdis represents a "Whirlpool". 
For Odysseus, he chose the Rock instead of the Whirlpool. He figured that he would rather sacrifice a few sailors when his ship hits the Rock than lose the whole ship when it gets sucked into the Whirlpool. 
But when it comes to choosing a medical option to treat, cure or shrink a "large, fast-growing and aggressive tumour" in one's right lung, the stakes are much more than merely choosing between Scylla and Charybdis. 
The estimated percentage, whether it is 20% cure with surgery or 55% shrinkage with chemo, are both Whirlpool-like options when one's mortality hangs in the balance of fate, luck and limited human intervention, expert or otherwise.
In the papers today, this is Dr Ang's patient's Scylla and Charybdis. That was what his patient was asked to confront. 
But, the options given to her was different from the two options I had written about above (that is, between 20% cure for surgery and 55% shrinkage for chemo). 
Dr Ang neither mentioned nor discussed the surgery option with his patient. He only told her about the chemo option and he pitched the percentage not at 55% shrinkage, but a glowing (yet unrealistic) 70%. 
Why unrealistic? Because 70% response rate only applies to a certain type of tumour mutation and Dr Ang did not conduct any test to ascertain whether his patient suffered from that particular type of tumour mutation. 
Basically, you can say that Dr Ang was going on a lark and a prayer on a 70% shrinkage estimation with chemo treatment without ascertaining the mutation type. 
Secondly, his overly optimistic estimate was based on out-dated and limited studies published in the early-1990s, while the publications after mid-2000 showed that with chemo treatment, in general, the average response rate was "somewhere in the region of 40% to most...up to 55%, but very rarely...70%." 
So, in a nutshell, he was suspended for 8 months because, amongst other things, he had given his patient false hope which was not reasonably held by him or based on studies that did not move with the times and/or accepted practice.
Sadly, his patient passed away about six months after the chemotherapy treatment in October 2010. (I guess her unfortunate passing might just confirm that more likely her mutation was not of that particular type than that the odds were against her, that is, she falls within the unlikely 30% bracket?).
Alas, if his treatment had been successful, Dr Ang and his methods would have been hailed as a medical miracle. 
Lesson? Just one, and it has nothing to do with the above case.
In a rather new patient-centric medical environment, doctors will have to go back to the Hippocratic oath once again to examine more in details the duties and responsibilities they have sworn to their patient.
One part of the oath reads:- 
"I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow." 
Well, the sharing would have to be done with patients too. 
Doctors have to keep all viable options open to the patients, even if the chances of success or cure are slim at 20%, and let the patient have an affirmative say in how he or she would want to be treated or operated. 
Trust me, at most times, it is nevertheless still an agonising choice. 
Another part of the oath reads:- 
"I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism."
Somehow, everything looks neat and ironed-out on pulp paper. But the reality and application can be a mess at times. 
Alas, the twin traps of overtreatment and therapeutic nihilism (going rogue on medical asceticism or austerity) is like the Proverbial Scylla and Charybdis that doctors would have to navigate in choppy waters. 
Here is another part that reads:- 
"I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug."
Well, the raw truth is that when it comes to life and death decisions, you would rather be operated on by an aloof, distant and expressionless doctor but with an impressive string of successful record than one who is a people-charmer but just came out of med school and is still struggling to read scans. 
Of course, to have both temperament and expertise combined in a joyous hybrid would be most ideal. 
There's another part of the oath that goes like this:-
"If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help."
This is the celebrative ribbon on or the heavy duty chains tied around the profession (or all professions).
In this regards, and speaking generally, the raw truth is that we as experts are only as good as our last publicly disseminated worst case. 
And it takes just a spot of "rat-dropping" to stain the entire pan of rice. 
Somehow, our faults, especially for those riding high on past successes, are easily and sensationally magnified, while our successes are strangely side-lined. 
Finally, this concluding Hippocratic oath says it all about the profession:- 
"Most especially must I tread with care in matters of life and death. Above all, I must not play at God."
Alas, we are all looking for heroes. And for most of us, being elevated to the hallowed "demigod" status is as tempting as the siren wails of nymphs.
Now, I know that with power (or fame) comes great responsibility, but sometimes, the hero worship at the edifice of professionalism runs the risk of the masses forgetting that doctors are only human, and they wear their pants one leg at a time (just as the masses at large).
Yes, it is true that on matters of life and death, it rightfully rests in God's hands. 
But here on earth, it is in the hands of fallible humans that we all have to contend with. Cheerz.

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