By Foo Keog Tatt
Balance (as exemplified by the above Inle Lake leg rower) is the key, in nature, in life, in water colour painting as well as in our clinical practice as a medical Doctor.
Without balance, a patient may be over treated, or under treated. Over investigations and over treatment can do more harm than good. Though the main stream medicine (allopathic medicine) is said to be a science, we need to know the Anatomy, physiology and Pathology; the actual practice of clinical medicine in real life is more an Art than a Science. This is because, in real life we are treating patients not the disease. Treating the disease is the easier part, as it would be all in the books. However, when it comes to treat Patient, a person with the disease, it is a different scenario.
Often patients do not come with a ready diagnosis, they come with symptoms or combination of symptoms, and we need to sort out the important ones and make a diagnosis, and do various tests to confirm the diagnosis. After the diagnosis, we need to know the prognosis for the particular patient and to predict the natural course of the disease. Most of the time, nature is the best healer. The body has its own defences and healing power, and the Doctor just need to facilitate the healing process. Too much interference may make the patient more ill. The clinician need to balance the benefits and the harmful side effects of the treatment planned.
Just like a good Artist, the Doctor need to have the correct perspective to achieve balance and harmony in his work. Of course the Doctor work is made more difficult as he cannot afford to make mistakes. Unlike the Artist, who can just tear up his work and start all over again! To achieve good balance, like the Artist, the Doctor needs to know the basic fundamentals of clinical practice and when to intervene for the individual patient after making the diagnosis.
The first is whether the disease is life threatening, e.g. in patient with acute injury to the solid organs or obstruction to the airway. Also, whether there is cancer, however not all cancers are life threatening. Second, is the disease threatening any organs functions, e.g. the kidneys functions, the heart or liver functions. Then steps need to be taken to lessen the threat. For example, poorly control high blood pressure may lead to kidney failure or heart failure and also results in stroke. Third, is the disease causing any troublesome symptoms like pain or discomfort which would need relieve. If none of the above is present, then, it may be advisable to watch the situation. For example, a simple cyst in the kidney, which is not life threatening, not causing harmful effect to the kidney and has no symptoms can be left alone. Operating on the cyst may cause more harm than good. A less aggressive prostate cancer, especially in the older age group, is better observed than to treat, with its many side effects of treatment.
Thus when one is ill, getting a proper diagnosis is important as a first step. The next is decision making, and for that you would need an experienced Doctor to weigh the risks and benefits of various options for you. A Doctor whom you can trust, that whatever decision is done in your best interests.
The late Dr Earl Lu, a surgeon and an accomplished artist himself, well known for his painting of roses, once told us that, a good Artist goes through 3 phases in his life, very similar to the clinicians:
The first is “not the same”, (Bu Xiang 不像) whatever he draws is not up to the standard and not the same as the master. The second phase is “the same” (Xiang 像): he is able to copy the work of the master and may be able to reproduce the exact copies. The third phase is “not the same” again. (you bu xiang 又不像). But this time, he is now his own master artist, and produce original works which are not the same as any other, but is a class of his own.
Similarly, in clinical practice, the intern or junior resident work is not the same and need constant supervision from the seniors. Next, the senior residents or junior consultants would be practicing evidence based medicine and follow the latest clinical guidelines, treating patients more or less the same.
Hopefully with more experience, they would evolve to practising individualised medicine, for the particular patient in real life practise. He would be treating not just the disease but the individual with the disease, taking into account the patients’ age, anxiety and other co-existing conditions and his social economic background.
Every patient is different and he thus need to individualise his treatment and personalised his care. In this way he would be practising a more balanced medicine and improve the care of his patients.
Professor Foo Keong Tatt
Emeritus Consultant and Advisor, Department of Urology, Singapore General Hospital, Clinical Professor at the National University of Singapore, and Adjunct Professor at the Duke-NUS Medical School.
