I have previously said that none of the interventions we employ in medicine come with absolute guarantee. Similarly, the laboratory tests that we do are also not 100% fail-safe. Not all diagnostic tests are as accurate as we hope them to be. There are many factors affecting the degree of validity and accuracy of these test results such as:

• Inter-laboratory variability – different labs can produce different results.

• Intra-laboratory variability – different results on different days due to factors such as different person performing the test, use of a different brand of chemical to carry out the same test, lack of calibration of machines

• Reader or interpretation variability – interpretation of results often depend on the reader’s experience such as reading of x-rays or CT scans. The same results can be interpreted differently by different persons.

• The quality of machines or reagents used – old machines (x-rays, CT scans, MRIs, ultrasounds) though cheap, can produce substandard results

• The inherent flaws of a test – not all tests, no matter how seemingly accurate, high-tech or done at reputable centers will give 100% correctness and accuracy. Some tests are bound to miss a positive diagnosis while others can detect problems that are not really there.

Tips to Minimize the Flaws and Maximize Laboratory Results

• Make sure that you are going to reputable laboratories instead of fly by night labs which offer lower prices to lure patients

• As much as possible, stick to the same laboratory to allow to minimize inter-laboratory variability.

• When doing specialized tests such as mammography, CT scans, MRIs, etc, better inquire from your doctor whether you can go ahead with a certain diagnostic center of your choice other than where your doctor wants to have it done. Patients often scout for cheaper prices (there is nothing wrong with this but let us take a lot of caution)and find them in small diagnostic centers not knowing that the cheaper cost is because they are using outdated machines which do not provide the same accuracy as the more expensive ones and hospital-based labs do. (I’ve had patients go for cheaper CT scans or MRI’s only to have them repeated at more reputable centers because the results did not give us the information that we needed)

• For tests that are done in series or annually such as xrays, CT scans, ultrasounds, mammography, MRI, request for the same reader to interpret your results.

When a patient is stricken with any kind of severe illness, it is never his journey alone. The entire family is afflicted as well. When a family member undergoes surgery, his entire family also feels like they are undergoing the treatment too. When a family member undergoes chemotherapy and experiences its effects, the entire family suffers with him.

Dealing With The Family

I recently delivered a lecture about “Breaking the Bad News” to medical students. I told them that when delivering the bad news, I almost always discuss first with the family before going directly to the patient. I do this not with the intent of hiding the truth from the patient but to educate the family and facilitate their understanding and approval of the necessity of letting the patient know and have him participate in decision-making. It is very comforting for the family to understand and know that they are being considered important too. There are some who might consider this unethical since we are not supposed to discuss the diagnosis with anybody except the patient. They claim that doing so will undermine the patient’s rights.

I am strongly opposed to withholding the diagnosis from the patient. Let that be very clear. However, my experience has taught me that in order to be a good doctor, I have other things to take care of aside from the physical well-being of the patient. I cannot separate that from his emotional, social, psychological and spiritual well-being and a significant part of this well-being is in relation to his family. Part of managing patients is not only dealing with what the patient is going through but also taking care of the well-being of the relatives. The doctor not only facilitates understanding and acceptance by the patient but the family as well. Taking care of the family too makes the patient happy and gives him a sense of peace and security.

As a doctor, I deal with patients. But I must always remind myself that I also need to deal with relatives and need to see everybody as human beings who have raw emotions. Theory is very nice, very interesting, very exciting but being strictly adherent to theory is not what doctors should do. Strictly adhering to theory puts us in danger of being unable to deal with the real world, real people and human emotions. Strictly adhering to theory puts us in danger of being devoid of compassion and makes us no different from machines. We can debate about theory for as long as we want but when it comes to patients, we need to be a little bit more respectful, compassionate and understanding. At the end of the day, the patient and relatives may not necessarily remember how long they survived or whether we were excellent in following the rules but in how they were dealt with as human beings. Expressing their sincere gratitude in the face of terrible loss lets me know that I am doing the right thing.

We see alternative forms of treatment everywhere. I see nothing wrong with that. What I practice is conventional/mainstream/Western medicine and I practically know nothing of alternative or Eastern forms of treatment.

What “the expert” Says

I do not claim to know all about diseases, specifically cancer, so I do not claim to be the only expert in this field and neither are my colleagues. If there is anyone who can offer my patients real alternatives, I am very much open to them and will gladly point my patients towards them if I see fit.

However, I think other forms of treatment are not being presented in a very truthful manner. I am specifically talking about treatments that claim themselves to provide “guarantee of cure” specifically those that claim to “cure all”; or any form of treatment, whether alternative or mainstream, that claims to eradicate all forms of disease or all forms of cancer. Those claims are not completely true. Some of them are malicious, deceitful and with the sole intention of luring patients and selling products.

Almost all forms of treatments, whether alternative or mainstream, have the potential to cause adverse effects. All medicines, whether synthetic or natural can alter the processes in the body.

The Other Side

I have seen patients whose kidneys and livers have been damaged by “natural” medicines. I have encountered patients who have experienced adverse effects from alternative forms of treatment in much the same way as patients who are given synthetic drugs have suffered side effects. I have had countless patients who went into alternative treatment only to come back to us with their diseases disseminated all over and sorry that they did not heed us.

I do not blame them nor tell them “I told you so” because that will be like rubbing salt on their wounds. However, I plead for them to take lots of caution.

Where I Stand

Am I against other treatments that I do not know of nor espouse? Definitely not. As a physician, I always take the side of the patient. I am for whatever will do the patient good even if I am not the one giving it or even if it proves that what I am saying is wrong.

What I am after is transparency and giving the patient the opportunity to choose by providing enough information.

At the end of the day, the patient is only answerable to himself. Only he can own up to what he chose. What he chooses is actually none of our business. But again, I plead for them to take lots of caution and go ahead for themselves and not for someone else.

The Final Word

None of us can claim that we are the best or that we know everything there is. True experts are always the first to admit to the fact that we know very little. If someone is offering you any form of treatment that “guarantees cure” or promises absolute certainty, better start running away for he is likely after your business not your well-being.

Modern medicine is riddled with so many laboratory tests. They have become an integral part of how we manage patients. It has enhanced our ability to diagnose diseases and improve patient’s outcomes. However, many tests have become invasive of patient’s bodies and cost a lot of money. Sad to say, some tests are also not judiciously used.

Should patients question doctors regarding the use of these tests? I believe so. Patients have to understand why they are undergoing them and how the results will affect the management of the disease and the overall outcome.

When the test is quite expensive or when it is very invasive and uncomfortable, I think the patient should discuss this thoroughly with the doctor. The following are tips as to what the patients should ask their doctor:

1. Will it improve the patient’s condition or overall outcome?

2. Will it affect or alter how the patient is managed?

3. What are the risks of the test to the patient?

4. Will the benefits outweigh the risks?

5. What will happen if the test were not carried out?

6. What will happen next whether the result is positive or negative?

7. If after the test, a patient needs to undergo surgery or other forms of treatment, will the patient tolerate that kind of treatment?

I asked the relative what they wanted to achieve in bringing the patient to me. I picked up that the relative, at this point in the status of the patient, was hoping to cure the patient from the disease. Apparently, he was not yet ready to throw in the towel and was looking for all possible avenues, despite the patient’s very very deteriorated condition.

I felt the intense emotions of this relative for the patient. My heart bled almost non-stop and found it hard to look for the right words to discuss the situation with the patient and relative.

A Time To Know

As a physician, I consider it my responsibility to give hope whenever I can. However, I need to make sure that the kind of hope that I give is that which is just enough and not cross the line into malicious falsity.

At some point in our treatment, I need to let the patient and relatives know that science will no longer help in the cure. The role of science has to change from one of might and power to cure to one of compassion and provision of comfort.

Discerning the Boundaries

I think “hope” has been over used and abused by many entities in our society. There are businesses that take advantage of the patient’s desire for hope by offering treatments that claim unfounded effects of cure. Many are malicious and take advantage of the patient’s sensitivity and vulnerability. We must always be careful and watch out for them.

What is also important is for us to examine ourselves and our own motives as to the path we choose. I always tell my patients that no option in cancer management is incorrect as long as that option has been carefully thought out and discerned to most suitably fit the person, his beliefs, his values and all that the person is about.

Are we really doing what is good for the patient or what is good for us? Doctors and relatives have to be extra-cautious of our recommendations to the patient because there is an extremely thin line between what is good for the patient and what we think is good for the patient. We need to be certain that what we recommend or choose is not a projection of our own wishes in the guise of choosing the best for the patient. We need to ask ourselves the very painful question of whether we are really protecting the patient and not ourselves.

The boundaries are so blurry but the boundaries do exist. We just need to be diligent and extremely careful.

Students who are studying to become doctor sometimes experience the symptoms that they read up on their textbooks. “You get what you read”….the power of the mind.

There was a point when I experienced the symptoms of having stones in my gallbladder. I felt some discomfort at the area of my right lower ribs which was radiating to my right shoulder. This condition creeped on and off to a point that I really got scared. I was scared of having to go under the knife. I thought of my classes, my exams, the impending internship…….I did not want to be delayed.

I finally decided to undergo an ultrasound because I was convinced that I had gallstones. Finally, the result of the ultrasound showed that my gallbladder is empty of any size of stone at all. It was only then that the discomfort went away completely.

The Placebo Effect

We’ve all heard of “Mind Over Matter” and “Positive thinking”. When studying new drugs or other forms of treatment, an intervention which is a sham or a tablet that does not contain any active ingredient is assigned to some patients to compare the effect of the active treatment. The purpose of this is to determine the “Placebo Effect”. Some patients have manifested improvement or side-effects when they believe that they are receiving treatment even when in reality they are not.

The Scientific Method

The scientific method is generally very suspicious when there is no hard evidence to prove its truthfulness. I adhere strictly to this method because I believe that this is one of the ways to minimize harmful effects on patients. However, I also believe very strongly in the power of belief and its ability to bring meaningful improvements upon patients.

Belief is very difficult to prove to bring cure to patients in a scientific manner. However, despite absence of overwhelming scientific data, I choose to believe it.

My Beliefs About BELIEF

I believe that we are destined to enjoy health in our lives.

I believe that our bodies have the capability to heal.

I believe that our minds can heal our bodies and OUR MINDS CAN ALSO MAKE US SICK.

I believe in the “Power of Belief” but I think we have mostly misconstrued what it really means. I do not yet know what it really is but I think I have some ideas what it is not.

True “belief” is nowhere near the kind of mind over matter and positive thinking that we know of. It stays beyond the realm of the superficial and lip service. It moves beyond the realm of make-believe faith. Neither should denial be falsely hidden under this title and labelled as strong belief. Belief is also not a means to deliver false hope.

True “Belief” is profound. It is present in the purest of heart and purest of thoughts. Hate, anger, anxiety, fear, sorrow, bitterness cannot coexist with belief. It is when we have purged ourselves of our ego, our need for control, our need for certainty can we be truly in a state of belief.

It is not only difficult to the patient and family but to the doctor as well. Having these patients in front of us stirs up our emotions as well. It brings to the forefront questions about life that perhaps we wouldn’t even consider during good times.

But most difficult of all is to be able to balance the need to bring hope and at the same time being in touch with reality.

The Good

Unlike in the past, a cancer diagnosis is no longer a death sentence all the time. There are patients who have survived more than the usual 5 years of monitoring after treatment. We have patients who have survived 10 years and still counting while there are also those who have succumbed to conditions entirely unrelated to the cancer. There are cancers where 60 to 80% of patients will be cured.

There are patients who have beaten all odds and have lived decades of productive and meaningful lives after treatment. There are patients who seemed to have lost all hope but are now a manifestation and evidence of what was once thought to be impossible.

The Not So Good

However, there are also patients who are not as fortunate. What is difficult on the part of the doctor is that there are few instances when our treatments are very specific and targeted. More often, we are like blind agents applying treatment to patients. Among 100 patients that we treat, there is the possibility that only 10 to 20 of these patients will respond yet we need to apply the treatment to these 100 patients to get that much response. There are still few cancers where we are more definite that we have already filtered those patients who have a very high likelihood of responding or not to treatment.

Moreover, even when we are able to pinpoint specifically those who are likely to respond, we have yet to deal with the potential side-effects and complications of treatment. There are milder forms of drugs available now. There are even oral forms of treatment that can eliminate the necessity of repeated hospital treatments but they are fewer than the conventional treatment. Sometimes, patients think that because their treatment is oral, it is just like taking any other drug.

Chemotherapy is chemotherapy whether intravenous (given through the veins) or oral (in tablet form). Although some are mild, they are not completely free of inconveniences and the same precautions, as in those taking the conventional drugs, must be taken.

Whether one sees cancer treatment as hype or hope, I must be careful not to push the line too much towards either side. I must as often as possible walk the tightrope as delicately and painstakingly as I can

The Paradigm Shift

When I became an oncologist, the phrase “the doctor as healer” was given a new meaning. At the beginning of my training, I almost quit. I thought that what I was doing did not quite fit into my concept of a doctor when patients would not turn out the way we wanted them to. I thought that what I was doing was futile and pointless.

Fortunately, I persisted. Along the way, I picked up a totally different but more meaningful definition of hope and healing.

My definition of Healing

Healing is not necessarily banishing physical illness but graciously accepting “what is”. Healing is about receiving and accepting the grace of finding peace and joy in the midst of very difficult and life-changing situations.

Healing is about choosing not to live in fear nor blame nor anger nor asking “why me, why now” but instead deciding to carry on despite the circumstances.

Healing is about making fond memories instead of leaving behind memories of pain and suffering especially during the last days.

Healing is about letting go of our need for control of our circumstances.

Healing is about holding on to the present not the past nor the future.

The Ultimate Hope

Hope lies not in changing people and circumstances but in changing our minds.

Hope lies in rediscovering “who we are” and living according to that person.

Hope lies not in fear of losing but in finding serenity in chaos and embracing the cycles of life.

Hope lies in going back to basics in how we live and unlearning those things that we have been led to believe.

Hope lies not in what will happen in the future but in living now and being present in the moment-to-moment choices that we make.

We are all capable of healing…..although not always in the manner that we want to.

Being an oncologist is perhaps one of the greatest miracles in my life. My dealings with patients have taught me so many important lessons that I probably would not have learned elsewhere.

Being an oncologist has provided my life so much meaning that it has altered the course of my life and made me realize. My patients have taught me so much.

Dying has never been a pleasant conversation piece. Nobody wants to talk about it. We don’t even want to think about it. It brings us so much sadness, fear, discomfort and anxiety. We avoid thinking about it and all of us hope that we will never get to deal with it. However, all of us, without any exception will deal with it with all certainty.

I intend not to sow fear but on the contrary help see the meaning in this process. Being an oncologist allowed me to come face to face with dying. It forced me to reflect upon it and reevaluate the way I want to live my life. I was placed in a situation where I had to ask myself whether I wanted to ignore it but know that the fear is lurking in my mind, continue pretending that it happens to other people but not me or to the people I love or discover what I can learn from it and contribute to my growth.

The options were agonizing.

I literally became paralyzed. I was able to perform my functions but I felt like I was on auto pilot. I had to do what I was supposed to do but found myself in an empty space. I questioned “what is the point when everything that will do will end in death anyway?”.

The answer did not come in an instant but through a process of searching that I’ve given a lot of effort to. The answer propelled me to move forward and explore new frontiers. It encouraged me to examine my beliefs and challenge them. It has infused my life with so much joy that made me realize there’s no need for drama and suffering in our lives. It has given me a sense of urgency and the audacity to do those things that I wish to do but never got down to doing. It minimized my whining about life but instead focus on all the other wonderful things that I take for granted. It made me choose to live in awe and gratitude. It made me realize that our lives are meant to be filled with peace, joy and happiness.

Has it all been effortless since then? Many of us think that living in this state will remove all the nuances of living and place one in a constant state of joy. The answer is no. It doesn’t eliminate the unpleasant but instead allows you to consciously choose to focus on the joy of living.

Reflecting about my own death has made me realize and value the things that are truly important. It has given me a sense of peace and joy that I never thought possible. Knowing that everything is borrowed allows me to savor every bit of everything. I extend to you this invitation and let us share our discoveries and joys.

Josephine is a 58 year-old lady diagnosed with Stage III colon cancer. She underwent surgery followed by chemotherapy. Two years later, she developed a recurrence in the liver (Stage IV). She underwent chemotherapy again then surgery. She is now cancer free and has since then gone back to work.

Annie

Annie is a 72 year-old patient diagnosed with advanced cancer of the ovaries. Initially, she was very reluctant to undergo chemotherapy because of her old age and because she took care of her sister who also had ovarian cancer. She said that she did not want to go through what her sister went through. However, her nieces were able to convince her to undergo treatment promising to always be by her side. She eventually underwent 4 cycles of chemotherapy. She has now been able to go back to ballroom dancing and she has been dancing for 3 years now without any disease recurrence.

Anthony

Anthony is a 65 year-old patient diagnosed with Stage II Lymphoma. He underwent 4 cycles of chemotherapy followed by radiation therapy. His tumor was completely eradicated by treatment. Three months later, his tumor recurred and he is now back to treatment again.

Manuel

Manuel is a 62 year-old patient diagnosed with Stage III Lymphoma twelve years ago. He underwent treatment is currently free of any form of disease.

Lea

Lea is a 28 year-old breast cancer patient. She was diagnosed when she was 21 years old and has since been free of disease.

Elena

Elena is a 23 year-old breast cancer patient who was immediately Stage IV when diagnosed. She was not a fortunate as Lea.

Fides

Fides is a 43 year-old patient with Stage II Breast cancer. She completed treatment but 2 years later developed recurrence in the lungs

Samuel

Samuel is a 55 year-old smoker with lung cancer. He had an advanced form of cancer when he was diagnosed. It has been 3 years now and he is still able to play tennis.

And of course, who doesn’t know Lance Armstrong.

As much as I wish I could explain to you why they differ as much as they do, I’m afraid that I have to humbly admit that I cannot. And neither can science overall provide you with an explanation that you will deem worthy and enough to erase your pain.

We have made some strides but not as much of a leap as we would hope for. We have given the gift of life to some but to others we have given less, not because we want to but because that is all that we have.

There are some whom we have raised their hopes only to tell them later that we are sorry that it’s not working. There are some to whom we have given nothing but anguish.

I wish science could be fair to all patients and all surprise them with the magnificent gift of life. But all I can do is admit to you that we have a great deal of shortcomings and be honest to you, my patient.

Note: All names of patients have been changed except Lance Armstrong