High expectations

A fellow doctor muttered as he collected his coffee and joined a group of us at the breakfast table: ‘Once in 10 years! Once in 10 years!"

‘Once in 10 years, you meet a patient’s family like this one.’

The patient was a middle-aged man, whom the doctor had just met for the first time several days ago.

He had a cough and shortness of breath. A chest X-ray showed an area of opacity in the lungs, highly suggestive of lung cancer.

The doctor said: ‘I suggested a lung biopsy but his wife refused.’

Having a patient refuse a biopsy – removal of a piece of tissue to check for cancer cells – is by no means uncommon.

The myth is that one must not do any biopsy of the tumour because the procedure would ‘disturb’ the cancer cells and cause the cancer to grow faster.

Patients and their family often blame the spread of the disease on the biopsy.

There is, of course, no truth or basis for this fear. Cancer cells have the ability to invade surrounding tissue and metastasise via the lymphatic channels and bloodstream.

All too often, we see patients who already have metastatic cancer at the time of diagnosis.

The condition of this patient deteriorated rapidly.

The hapless doctor said: ‘He was already in a bad state the first day I met him. His breathlessness got worse from one day to the next. Within three days, he was breathless despite using a non-rebreather mask that delivers 100 per cent oxygen.

‘The wife refused everything I suggested. She refused to let me drain the water in the lungs, she refused to let me call her doctor in Indonesia, she even refused to let me give him antibiotics.’

Each day, the patient’s wife berated my friend.

Among the sarcastic comments: ‘I have spent a lot of money but you are not doing anything to help him.’

‘My friends tell me that another patient with stage four lung cancer was cured within days in another hospital in Singapore.’

In the ward, she scolded him loudly: ‘You’re a bad doctor and you are making his sickness worse.’

A lesser man would have given up, done the minimum that was required and stopped trying.

But in his usual quiet, unassuming and generous manner, this doctor did everything possible to help the patient and even went on to waive all his consultation and treatment charges.

‘Never mind, once in 10 years,’ he smiled with great relief, after the patient was flown back to Indonesia on an air ambulance.

Difficult patients are very rare, but the few that come into our lives inevitably leave scars.

Another colleague, a surgeon, actively discouraged his son from studying medicine, although the young man scored straight As in all subjects.

My colleague convinced his son that dentistry was an equally satisfying career with much less angst.

‘The practice of medicine is not what it used to be,’ he said.

‘It doesn’t matter how much you do for the patients. Once something goes wrong, and it doesn’t matter whether it was your mistake or not, they’ll gun for you.’

I recently received a request for the medical report of a patient in her 80s who passed away suddenly at home, as the family was ‘contemplating a claim for damages’.

This patient had liver cirrhosis (hardening) with liver cancer that was multifocal or occurring in several spots.

From the time of diagnosis, I looked after her and managed her cancer till her sudden unexplained death at home.

After diagnosis, the average survival period of a liver cancer patient with underlying cirrhosis is between six and 12 months.

Despite her condition and her advanced age, she lived beyond two years.

Patients and their families sometimes have overly high expectations.

Perhaps this is partly the doctors’ fault. Proclamations of the many advances in medical treatment, boasts of being the leading medical hub of the region and the high profile of some doctors have made human life seem indestructible.

But the truth remains the same. Despite progress in medicine and medical engineering, all doctors can do is to stave off the inevitable or make the end more bearable.

Despite all our fancy equipment and new drugs, there are times when we do not know what is wrong and why the patient is not responding.

It is frustrating and emotionally difficult for a patient or his family whenever this happens. Some take it out on doctors and nurses.

It worries me that my colleague’s sentiment is the prevailing concern among many in the medical profession.

As a result, some may have chosen to practise defensive medicine. Unnecessary blood tests and scans may have taken the place of sound clinical judgment.

I have three children who aspire to be doctors.

But unlike my colleague, I encourage them to pursue their dreams as long as they have an enthusiasm to serve and heal.

This spirit should not be dampened by the unrealistic expectations of a few difficult patients.

This article first appeared in "Mind Your Body", a Straits Times Supplement.