Rosa is a mother whose young adult son is suffering from a terrible illness….and she has no money to support her son’s healthcare. Neither does he have health insurance. It’s a terrible situation to be in.  I feared for myself.

Even after she left, I couldn’t get her out of my mind.  Her image kept creeping back into my head.  I don’t want to suffer the same fate I said to myself.  A question then suddenly popped into my head “How can someone stay in the same job for more than 20 years that pays very little and has no health care benefits?”

At 43 years old, he was given 6 months to live.  He accepted his fate openly but he kept telling me to just relieve his pain because he has no money to support his treatment.  Eventually, he succumbed peacefully with no family of his own, very few loved ones and no properties of any sort to bequeath.

Lester grew up in a well-to-do family.  He was able to go to good schools through college and he lived a very comfortable life.  After graduation, he landed a job at a manufacturing company where he stayed up to the time of his illness.  Even while he was not earning a lot, he managed to live a comfortably because their family business somehow continued supporting him.  Unfortunately, the recent financial crisis really hit their business hard and it slowly declined until eventually, they had to close shop with some unpaid debts.  When he was diagnosed with illness, there was no more money left.  He has also consumed his health insurance but needed further treatment.

One of the benefits of being a doctor is getting to meet all sorts of people who have eye opening life stories.  My life has been led to a different path because of my insights from other people’s lives such as the people above.

Rosa and Lester are shining examples of those who have been lured into the comfort trap.

All of us tend to seek out the familiar, the known and the comfortable.  Most of us, given the choice, will opt for what is safe failing to take the risk even when we know that we are stuck and unable to move forward.  Being comfortable is a trap…..it nestles you in warmth, in the routine but it robs you of the fire in your soul.  It slowly and unbeknownst to you, eats you up until a big jolt hits you.  Hopefully that jolt is not yet too late.

As I write this article, one by one it dawned on me how profoundly the comfort trap has imprisoned me.  It occurred to me that all the excuses and rationalizations I’ve made are the ways that I keep myself snuggled in my comfort zone.  Are you also trapped?  I invite you to take a look too.

When I was a younger oncologist, I was very passionate about needing to tell everything about the condition to the patient and their relatives. I tell them that it is my job and responsibility to be straightforward and honest no matter how painful the truth is. I rationalized that the patient HAS to know in order that he may be prepared for the inevitable and be able to finish unfinished business. However, as I encounter more patients, I am noticing that there are some subsets of patients who are not quite ready to hear the bad news. There are patients who have left me because they were not ready to hear the truth no matter how compassionately it was delivered. They were just not yet ready for it.

Everyday I am faced with the dilemma to be straightforward and honest no matter what or should I play along and keep patients’ hope up. Perhaps one might say that it’s a simple question. The doctor must always keep the patient’s hope up. Not quite because there are implications of this action.

On one hand, there are patients who, when told of their prognosis, opt not to undergo active treatment. Even if I subscribe to the notion that it is the patient’s right to refuse treatment and this must be respected, there is always the voice that keeps on asking “What if?”. On the other hand, there are patients who would do anything and everything, even sell their last piece of property, for a slim chance of improvement. It’s like I’m always walking on a tightrope. I must carefully balance delivering the truth without shattering the patient’s hopes.

Which one would you prefer? Hope or Reality? I’d like to hear what you think.

Vomiting is an adverse effect of many chemotherapy drugs, but not all. It is very important to prevent chemotherapy-induced vomiting because it causes trauma to the patient physically and psychologically. If a patient vomits after the 1st chemotherapy, just the thought of going to the doctor can already trigger the response the next time around. It can then adversely affect patient’s compliance with treatment. Patients who experience vomiting may also feel averse to eating because of fear that this can trigger further vomiting. This can contribute to malnutrition which can further impair the patient’s already compromised immunity. Therefore, it is of utmost importance to prevent chemotherapy-associated vomiting.

Patients must be adequately covered with medicines to prevent vomiting and the drugs must be taken round-the-clock during the period when vomiting is expected (this period usually lasts for 3-5 days from the day the chemotherapy is given). It is always easier to prevent the condition than manage it when the patient is already vomiting. Uncontrolled vomiting may even lead to hospitalization due to inability to retain the oral medicines, dehydration and electrolyte imbalance.

Patients should discuss proper measures against vomiting with their physicians. They must be equipped with instructions regarding intake of additional medications and when to advise their physicians if the problem persists. Remember…….there is no reason to vomit.

This is a very common misconception among patients regarding the management of diabetes, especially when we see on television, some dietary supplements portraying the notion that people can eat and drink all they want as long as they take a certain health supplement or medicine. This creates a very bad impression in the minds of viewers that health can be swallowed in a pill. We’ve become a pill popping society accustomed to running to doctors to fix us.

Management of many lifestyle related diseases such as diabetes mellitus, hypertension, heart attack, stroke is never an “either-or” proposition. Control of blood sugar, for example, cannot be left to medicines alone. Diet is extremely important although by itself may not be sufficient for some patients especially when the diabetes has already existed for a long time.

Lifestyle and medicines always go hand in hand. They synergize when used in tandem. “Either- or” can prove lacking in efficacy and can be dangerous.

Disclaimer: The information above is not intended to substitute for appropriate consultation with your doctor.

Health supplements are a huge business. There is no end to the new products that business people will innovate especially when people are so sick and tired of the very expensive sickness care costs.

So what advice do I tell my patients about supplements?

1. Choose your supplements wisely.

Most advice about taking supplements come from celebrities, athletes, or salespeople. These people are being trained and paid to sell these supplements than about having a firm knowledge of the risks and benefits of taking these preparations. Learn more about the supplement that you are about to take not from the brochures handed out to you but from independent and credible sources. It’s about time that we take responsibility for our own health and not rely on other people to tell us what to do to our bodies.

2. Be cautious of the following terms: HERBAL, NATURAL, ORGANIC.

Many of my patients believe that taking anything characterized by any of those terms are safe and risk-free. Once they hear these words, they say to themselves: “I can take as much of it as I want, anytime I want it and with any food or medicine that I am taking”. Nothing can be farther from the truth. These are not magic words that will eliminate all our worries. I’ve seen patients whose kidneys and livers have been damaged by intake of these herbal and natural preparations.

3. Supplements are not meant as a substitute to your legitimate medicines.

This is especially true if your health condition is moderate to severe in intensity. For example, patients who have pre-diabetes or who have very mild diabetes can eliminate their diabetes or at least postpone it when they follow a plant-based diet, diminish the amount of processed starch and sugar from their diet and exercise for at least 30 minutes on most days of the week. However, these lifestyle modification alone will not be enough for patients who already have at least moderate diabetes or who have complications from their disease. These lifestyle changes will definitely help lessen the medicines that they are taking but will probably not completely eliminate them. If your supplement claims to help lower blood sugar, do not immediately substitute them for all your medicines without discussing thoroughly the risks and benefits with your doctor. If you are really bent on taking these supplements, introduce them slowly while at the same time gradually reducing your conventional medicines and be sure that you are being supervised properly while undertaking these changes.

4. Supplements will never undo all the abuse you put on your body.

There is a tv ad which shows people enjoying all the alcohol and fatty foods around and subsequently telling the audience to protect their liver from all those stuff by taking their health supplement. Health supplements will never protect us from our bad habits. Much as the advertisers would like to make us believe, but Health supplements will never ever surpass or at least be equal to the health benefits of eating a plant-based diet, minimal processed sugar and starches and being physically active. Neither can supplements undo the harm that smoking brings.

It is very very expensive and very difficult to be sick. I wouldn’t wish it to my worst enemy. We don’t have socialized medicine and most of the health insurance of patients I encounter are not enough to cover for life-threatening illnesses or complications of chronic diseases. A lot of the diseases affecting patients are self-inflicted, lifestyle-related and therefore preventable. Learn about proper nutrition, proper lifestyle and how to properly take care of ourselves and our family. We can prevent getting sick.

I have a personal bias towards telling…..telling the patient of the truth about his diagnosis. This is what I was taught in school.

Initially, I went around in circles when talking to patients that they sometimes perhaps wondered what I was really saying. But practice makes perfect. I learned the skill. Got rid of my own discomfort and became quite confident and proud that I can swing it.

Oops! Wrong Mistake!

However, I also noticed that telling the truth is not as simple as I thought it would be. What I have read in the books about the relationship being strictly between patient and doctor were only half as true.

When faced with an actual patient, I never dealt with a single person but almost always an entire community or entire family at the very least. I realized that if I insist on what I learned in school, I will be met with resistance in many different points. This resistance will swell-up and eventually explode into a war not between the doctor and the cancer but between the doctor and the family. The patient will never win in this kind of war. The doctor will never be therapeutic but a constant source of irritation and anger for the family. The doctor will only add to the already tense and anxious situation pervading the patient and family.

The Lesson: Respecting Variability is Key

I have learned that there are patients who want and patients who don’t want to know.

I have learned that there are families who are amenable to open discussion with the patient and there are families who must first be made to realize and convinced of its importance and there are families that who will insist on their wishes.

I have learned that I need to convince the relatives that we are allies, that we are on the same boat and that we have the same goals.

I have learned that the approach will never be one size fits all but must be customized for each patient.

Strategy: How To Tell Or Not To Tell

So, when faced with a patient, I often do not go directly to the patient. I discuss with relatives first and win them over to allow me to evaluate the readiness of the patient to discuss. The relatives also need to be assured that the amount of news to be delivered is only up to how much the patient wants, needs and can tolerate. I remind them that I am a friend and as such I will not impose harm on the patient. When I already have their go signal, I proceed to the next stage.

The next stage involves meeting the patient. When we are face to face, I determine first what the patient already knows. I listen intently and be sensitive for cues. In this way, I avoid the shock of delivering a bomb. Making the patient talk first somehow softens the impact because events are brought up to her consciousness at her own pace.

It is never easy to say when the right time has come. Given the weight of the news, there is never truly a right time. Often, we need to warm up to the patient. It might take a number of encounters before I can deliver. What is certain, however, is that when the patients asks for the truth, even when I have promised the relatives not to tell, it is a very clear sign that the promise has to be broken and the patient needs to know. There is no question about that.

Many studies have been done to investigate patients’ preferences about being told the truth about their diagnosis. Surprisingly, a significant proportion of patients wanted to be told the truth about their diagnosis. Studies have been done among Asian, European, Middle Eastern and American patients showing similar results.

It is the practice in Japan that the diagnosis is almost never told directly to the patient but to the family. However, a study conducted by Ruhnke GW, et al. among Japanese patients found that even in this conservative society, 42% of the patients agreed that they should be told of the diagnosis and should be asked whether the family should be told.

A study done by Al-Amri AM among patients in Saudi Arabia showed that 99% of the patients wanted to know their diagnosis.

In the Philippines, a study was done by Ngelangel, CA, et al found that 97% of patients indicated that they should be told directly of the cancer diagnosis.

Despite having found that many patients would like to be told the truth, we must realize that there exists a population of patients who do not want to be told and therefore, we cannot barge into a patient’s room insisting that the patient be told right away.

We must remember this: There are patients who want to know and there are patients who do not want to know.

So how do we go about it?………

When I was a student, we were taught that it is unethical to discuss a patient’s diagnosis with anyone other than with the patient himself. Doctors are expected to be straightforward with the patient. It was considered unacceptable to discuss the diagnosis first with the relatives.

When I became a doctor, I noticed exactly the opposite. Relatives often do not want the doctor to disclose the diagnosis to the patient. Relatives do not discuss the situation with nor around the patient. Health care workers are instructed to keep silent about the diagnosis. Everybody knows except the patient. So goes the conspiracy of silence.

What the relatives say

The most common reasons why relatives don’t want patients to know is because they are afraid that the patient will worry, become sad or depressed and they fear that this will contribute to hastening the patient’s deterioration or demise.

This reaction is very common not only in the Philippines but in every culture. This is more prominent, however, among Asians especially the Chinese and Japanese.

Factors That Influence Truth Telling

I have also observed that the degree of education plays some role. More educated patients tend to be more open about being told the truth and would demand such to give them the opportunity to prepare and participate in decision-making.

Other factors include family conflicts and our own inability to come to terms with the situation. A diagnosis of a life-changing illness affects not only the patient but the entire family. Family members also go through emotions such as denial, fear, anxiety and all sorts of emotions that patients go through. Sometimes, patients unknowingly project these emotions into the patient and we fail to distinguish our own thoughts and emotions from those of the patient.
(These are not meant to cast judgement but to simply point out my observations)

And of course, socio-cultural factors play a very crucial role. The family is seen as a cohesive unit that is charged with the authority to take care of the needs of its members.

A Doctor’s Perspective

In my experience, I have not encountered a patient whose condition literally deteriorated because of having been told his diagnosis and prognosis. It’s true that some patients tend to worry, become sad and others go into depression but these are normal emotions for patients to go through upon knowing that they are diagnosed with a potentially life-changing condition. These are normal human reactions to disease. Admittedly, there are patients who may get into severe depression but these cases are rare and can be managed.

Stages for Growth

There are stages of growth in being diagnosed with an illness. Patients must be allowed some time to be sad, to think, to worry, to be anxious. We must not deprive them of this opportunity because this is possibly a springboard to becoming stronger and a better human being.

We are like glass. Glass has to go through intense heat to be molded into a beautiful piece of art. Not allowing the patient to experience these emotions is like leaving the glass alone because we do not want it to go through the heat. Not allowing the patient to go through these emotions may hinder the patient from learning and thus growing in the process.