Are you ready to "take on" your doctor?

In late February 2008, I met up with a senior management staff of a local hospital. In our meeting, she explored on the possibility on educating patients on being more pro-active and learning how to pose questions to their doctors. Indeed, I was taken aback by her thoughts. I shot the following question at her: "Are your doctors ready for it?"

I went on to share with her some cancer patients' and their caregivers' unpleasant experiences with their doctors. Being subsidized patients, they were just too afraid to "antagonize" their inhospitable doctors when things went wrong.

Therefore the greatest challenge is for those steely-cold doctors to behave more compassionately and cultivate patience to listen and address patients' queries and concerns with a human touch.

In addition, the present KPI-oriented public healthcare system should extend subsidized patients the privilege to have longer consultation sessions with their doctors. In view of the present shortage of healthcare professionals, especially senior oncologists in public hospitals, this will remain as wishful thinking on my part.

Generally patients have trust and confidence in their doctors' skills and competency. After all, they are laymen and rely on the medical experts to manage their illnesses diligently and professionally.

In reality, there are cases of medical negligence that kills lives. Therefore, it is important for pro-active patients and caregivers to understand how doctors think in order to achieve a desirable medical treatment, and amicable patient-doctor relationship.

At the close of our meeting, I was recommended the book - "How Doctors Think" by Jerome Groopman to read. This book is available at the National Library. Owing to my work commitments, I did not read it until May 2008. It is an insightful book even though some doctors gave it an unfavourable book review. In order to gain more insights into how doctors think, I will be reading another book - "How Doctors Think : Clinical Judgment and the Practice of Medicine" by Kathryn Montgomery when I receive it in August 2008.

In May 2008, one patient shared with me his recent traumatic experience with an alleged nasopharyngeal carcinoma(NPC) recurrence. I found his sharing informative and helpful to reinforce the message that patients must be pro-active and "take on" their doctors when the medical judgment is questionable.

I sought his consent to post his experience in this write-up.

"I consulted no less than 6 medical specialists at two different hospitals. The whole episode started when a CT scan detected an enhanced mass in the nasopharynx that was accompanied by skull base erosion. A subsequent PET scan found hyper metabolic activity that was indicative of a local recurrence. However, owing to the location of the lesion, no biopsy was possible. Cancer staging was raised from Stage 2 to Stage 4.

In the absence of histological confirmation, the consulting specialists had no alternative but to rely on imaging evidence for their diagnosis. All the physicians, with the exception of an ENT specialist, concluded that it was either NPC recurrence or post-radiation sarcoma. The ENT specialist, while agreeing in general with the verdict, raised the possibility that the findings of the CT and PET scans could also be indicative of radiation induced necrosis.

Owing to the proximity of the lesion to the brain stem, I was ordered to undergo chemotherapy to shrink the tissue mass before proceeding for re-irradiation. I had first undergone RT when NPC was first diagnosed in 1995. Following chemotherapy, a subsequent CT scan revealed a stable enhancing mass i.e. there was neither increase nor reduction in size of the lesion. Radiotherapy treatment was abandoned by the radiation oncologist in the light of unacceptable morbidity risks. I was told that the only viable option was oral chemotherapy which might extend lifespan by 3 years.

I had no choice but to proceed overseas for further treatment. However, before leaving Singapore, I decided on my own accord to undergo another PET scan to check if there was distant metastasis. This time, the scan came up with very surprising results. It showed not only no distant metastasis but also a total absence of cancer activity in the nasopharynx.

In a follow up session, a radiation oncologist, previously consulted for a second opinion, stood by his original diagnosis. In a separate consultation, the medical oncologist refused to accept the possibility of a more innocuous explanation for the purported presence of the "lesion". Perhaps, if he did, it would be tantamount to admitting that chemotherapy would have been quite unnecessary in the first instance.

After a nerve-wracking experience and a considerable amount of money spent, I was plagued by this highly disconcerting issue:

"A CT Scan showing a stable lesion and a PET scan showing a stable lesion but no metabolic activity would have been interpreted quite differently, each calling for a different response!"

Unfortunately, this didn't seem to bother both the radiation and medical oncologists.

But the other thing that pained me was a troubling "what if". What if the post chemo CT scan had showed some diminution in the size of the tissue mass? I would have undergone unnecessary re-irradiation with all its deleterious side effects. What if the lesion was not located close to the brain stem? Again, I would have undergone repeat RT. For what? To wallop a straw man? I am plagued by the thought that "the cure can be worse than the disease". Worse still if there was no disease to speak of in the first instance!"