Doctor’s dilemma

The story below is the reason why doctors should always be nice to the patients. Ireland is just like any other western countries, the number of doctors being dragged into court by the patients are increasing by year. The best way to stay out of that is by treating patient as sincerely and do your possible best.

Treat patient with respect, as that respect will keep you away from having to stand in court defending yourself against a legal suit. Afterall, to err is human, to forgive is divine..

Doctor’s dilemma

Dr Ang Peng Tiam

Sun, Sep 28, 2008 The Straits Times

I was stunned when the patient calmly told me: ‘They said that I have no
cancer.” Mr Didik had been on palliative chemotherapy for several weeks for
metastatic pancreatic cancer when all of a sudden his son asked that the
pathology material, medical reports and radiology films be sent to one of
the top cancer centres in America.

After a week of thorough review, the American doctors had concluded that
there was no cancer.

The earlier diagnosis had been made in Singapore, when Mr Didik underwent
surgery for what appeared to be localised cancer of the pancreas. At the
time of surgery, we saw that he had multiple nodules on the surface of the
liver. These were not seen in the pre-operative computed tomogram (CT)

One of the nodules was taken for a biopsy and confirmed on frozen section
(this refers to rapid microscopic diagnosis of the specimen) to contain
cancer. As this meant that the cancer had metastasised to the liver, the
planned re-section of the pancreatic mass was abandoned. I was then called
in to discuss the role of palliative chemotherapy.

As this was stage four – or end-stage – cancer, the goal of the treatment
was to try and kill the cancer cells, control the disease and, hopefully,
allow him to live longer. After careful discussion, Mr Didik started on
chemotherapy. He was tolerating treatment well when this bombshell was
dropped on me.

If the pathologists from America were right, Mr Didik did not have cancer.
This meant that I was giving him chemotherapy that was unnecessary and
potentially harmful to his well-being!

Mr Didik is 59 and owns a wig factory in Indonesia. We have a good
relationship and he had given me one of his specimens for the lab.

As I sat there looking at a seemingly perfectly healthy man, three concerns
came to my mind.

The first was whether or not Mr Didik had cancer. In his presence, I called
up the pathologist who had done the earlier diagnosis in Singapore to
request an urgent review of the case. To my horror, he told me the entire
specimen (it was a very small biopsy), including the pathology blocks and
slides, had been sent to the American centre for review. There was no
remaining tissue for us to study or to send elsewhere for another
independent review.

When we contacted the American pathologist, he declined to release the
specimen as he needed to retain the tissue in the event that he needed to
defend his position. There was not enough tissue for two sets of slides.

My second concern was whether we should push on with the treatment or abort
it. As there was now doubt cast on the diagnosis, I suggested we stop the
treatment till we were sure. To my surprise, Mr Didik wanted to carry on and
was determined to complete the six months of chemotherapy as planned.

His logic was that he was tolerating treatment well and that one of the
cancer markers, elevated at diagnosis, was gradually coming down with

What if he really had cancer? His concern – a sensible one – was whether
stopping chemotherapy would increase the risk of drug resistance and
compromise his survival.

The third issue was whether he was going to sue us if there was indeed a
misdiagnosis. At that time, I really didn’t know how (or dare) to ask him if
he planned to take legal action or file a formal complaint against us. After
all, we gave him chemotherapy when he apparently did not have cancer.

The 2007 annual report from Singapore Medical Council (SMC) has just been
released. The number of complaints per 1,000 doctors has risen from 11.6 in
1997 to 15.6 last year. In total, there were 115 complaints received last
year, an increase of 42 per cent compared to 2006.

Our society is becoming more litigious. Siblings are suing each other, as
are children and parents. Patients are suing doctors.

For me, the practice of medicine is as much an art as it is a science. Each
day, doctors make judgment calls on how best to care for their patients.
They combine medical knowledge and experience with perspicacity in deciding
what is best for each patient.

If Mr Didik had decided to lodge a complaint, it would have been difficult
for us to defend ourselves at that time.

He completed his chemotherapy and remained well for a while. About a year
later, his cancer markers started rising and there was radiological evidence
of cancer progression. After an overseas review in Europe that confirmed
that he had metastatic pancreatic cancer, he is again on palliative
chemotherapy and responding well to treatment.

One day, I found the courage to ask him why he never complained or sought
legal redress for the alleged wrong diagnosis. He replied: ‘What for? All of
you are trying your best to help me. If there was a mistake, it was not

He is a truly magnanimous man. I wonder if he told the American doctors that
they were wrong.

– Dr Ang, the medical director of Parkway Cancer Centre, has been treating
cancer patients for nearly 20 years. In 1996, he was awarded Singapore’s
National Science Award for his outstanding contributions to medical


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