Medical Decisions - To Be or Not To Be

Prince Hamlet once asked an intriguing question in a play by William Shakespeare. In the opening phrase of the play, Hamlet bemoans the pain and unfairness that life dishes out, and with that contemplates suicide as an alternative to end the suffering. However, he acknowledges that the alternative might be worse. Thus he wondered, "to be or not to be, that is the question"

Doctors face these similar dilemma in modern times too. People come to us with illnesses and injuries. Life has thrown them a curveball, a spanner into the cogs that is powering their lives, and everything comes to a screeching halt. They then come looking for help, hoping that a visit to the doctor is going to turn that frown upside down. Now these doctors are left with a question to answer, multiple in fact. To treat or not to treat, that is the question for these modern day Hamlets.

A single patient may pose multiple questions to the treating doctor, and no one patient is ever the same, so these questions have to be individualised to each patient. Different types of conditions require different modes of treatment, and often times choosing not to do anything (or to treat it conservatively) may be the most difficult decision. I am often to the go to person amongst my family and friends for any niggling pain they may have in the joints or the back. My go to response is usually to just leave it alone and rest, as these things are usually self-limiting and will resolve. It's not an easy advice to accept though, as not prescribing treatment may not seem like a treatment at all. However, in some instances, the decision to not intervene maybe the best one.

The decision on which treatment method to employ are influenced by several factors. Alongside with clinical experience, there are guidelines that can be used. In certain cases, there are scores to be calculated, criteria to be adhered to and protocols to follow. Taking a person’s symptoms and combining them with investigation results can often yield a certain score, and these scores determines the appropriate treatment options. So, the next time you pay a visit to the doctor, and he goes quiet all of a sudden and have a blank stare, you now know that the doctor is processing the information at their disposal, running it through an algorithm and trying to come up with the best treatment plan.

Let me describe a case that I recently encountered, you could say it was rather humorous (pun intended) in a way. An elderly lady with an heart condition had a fall. In the aftermath of the fall, she endured a fracture of the arm bone (the humerus- you get the joke now). It was complicated with a wrist and finger where she was unable to extend her wrist and fingers. This is caused by a nerve damage which likely occurred during the fracture. The patient had initially visited a private medical centre and was advised for surgery. However, due to constrains, patient had decided to come to our hospital for the surgery.

This was where I first encountered her. Much to the patient's and her family's despair, I had informed them that she doesn't need the surgery. It was almost as if I had denied her right to proper medical care by not wanting to cut open her arm and stick some metals in there.  My first challenge was to convince them that the first doctor who advised them to have the surgery done might have jumped the gun, while also trying not to undermine a fellow colleague. My next challenge was to get the patient (and her family) to believe that she could get better without the surgery.  My reasoning was that the fracture configuration was acceptable and that nerve injury has around 90% chance of recovery.

Although doubtful in the beginning, with subsequent clinic follow up, the patient had started to notice changes. The pain in her arm had reduced (indicating the fracture is healing) and she was starting to be able to move her wrist again (indication the injured nerve is recovering too). Over the course of a few months, the fracture completely healed and she gained full motion of her wrist and fingers.  All that while avoiding the risks of surgery, which given her heart condition, would have placed her general wellbeing at risk.

As fresh medical graduates, doctors are required to recite the Hippocratic Oath. Honestly speaking, the only phrase that I vividly recall is this: First, do no harm. Modern medicine has greatly improved our living and medical standards. That being said, not everything condition requires an aggressive form of intervention. Often times, when the situation allows, the conservative path is the better one, because, as Hamlet once pondered, the alternative might not be.