Hoping for the best

The wife of a patient wrote: “Let me tell you, doctor, in my view, you’re either a hypocrite or totally ignorant of reality”.

“My family consulted you on that fateful day (March 19, 2010), when we sought your opinion on options available to my husband.”

“Tragically, my husband passed away on 22 April of cardiac arrest, due to post-surgical complications.”

I first read the email when I was attending a cancer conference in Hong Kong this month.

I was initially stunned by the strong language. However after reading it three times, I sensed that she was still grieving over the loss of her husband, who was her “closest friend and lifetime partner”.

At that point, I had no clue who her husband was as I did not have access to his medical records. I wrote back to her immediately to express my condolences.

I asked if she would like to share with me what happened to her husband after the surgery and who the doctors involved in his care were.

She decided to write to me because of wide coverage on television of the public seminar on surgery in which I was one of the speakers. In the TV trailer, I was espousing the many advances in surgery and how surgery was safe.

“You appear on TV, reassuring the world at large that surgery is safe.” she had written.

I had not known, until her message, that her husband had died.

Once I returned home, I immediately drew out the medical records of her husband – a middle-aged man who had been seen by a urologist (a surgeon who specializes in kidney, ureter, bladder and prostate surgery). At that time, the investigations showed that he had stage two bladder cancer.

He was advised by the urologist to have surgery to remove the bladder.

Surgery remains the cornerstone of the management of many types of cancer when the disease is deemed to be localised, be it breast, colorectal, lung or stomach cancer.

When I had met the patient and his family, I reviewed all the reports provided. The patient had already undergone a cystoscopy (a fiber-optic scope inserted through the opening in the penis to allow direct visualization of the inner lining of the bladder wall).

A tumour was seen and biopsy taken. The specimen was reviewed by a pathologist and confirmed to be a cancer which had invaded into the muscle wall of the bladder.

Based on the information provided, I concurred with the surgeon’s opinion that surgery was the best option. I suggested that the patient come back and see me after the surgery as chemotherapy may be needed.

That was the only time I saw the patient. I did not know whether he took my advice. I was not informed when he was admitted for surgery.

Over the past week, I have been reflecting on this case.

Was I wrong to advise surgery?

The patient was a man in good health with no prior known medical conditions. Surgery is the standard treatment for patients with stage one and stage two bladder cancers.

I would probably give the same advice to the next patient who walks into my clinic with the same problem.

Is surgery really safe?

For the majority of patients, surgery is safe. In the absence of prior medical conditions, the risk of dying from bladder surgery and its complications is very low, probably in the region of 1 to 3 percent.

If the outcome is favorable, it is something we expect. However, when the patient dies, many unanswered questions remain.

Doctors, like patients, have to make decisions each day on what to do base on the available information.

Any unfavorable outcome does not make the initial decision wrong or worse hypocritical. It does not mean that I am ignorant of reality, for, indeed things can go wrong despite all our knowledge and experience.

I curse myself for every wrong decision, for each outcome that defies the odds, when the odds ought to be in my patient’s favour.

In these times, I forget the moments of gleeful triumph, when the odds turn out in our favour, when our team of doctors snatches a patient from the jaws of death.

As I don’t know how things will turn out, each day I labour in the hope that they will turn out for the best. Having said this, I remain ignorant of what “the best” – whether ailing life or peaceful death – may mean for each of us.

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