As physicians, our focus is on treating patients using the many options available. With today’s technology, we can easily access the latest information on health conditions and the effective treatments according to research.
By Prof Foo Keong Tatt
Emeritus Consultant, Department of Urology
Singapore General Hospital
As physicians, our focus is on treating patients using the many options available. With today’s technology, we can easily access the latest information on health conditions and the effective treatments according to research. Complementing these are workshops and simulators that enable us to continuously develop and sharpen our skills.
However, even as we have the best intentions for our patients when we prescribe certain treatments, there are sometimes side effects that can cause significant harm to them. By being sensitive to the fundamentals and basic pathophysiology, we can render the most optimal treatment to our patients. After all, the Hippocratic Oath dictates that we must, first, do no harm.
Therefore, the more important question we need to ask ourselves is not how to treat patients but when to treat them. To this end, prudence is key – we should always refrain from over-investigating or over-treating the patient.
Deciding when to treat a patient requires both a keen sense of clinical judgment and the ability to balance the risks and benefits; always with the patient’s best interests in mind.
We take the case of benign prostatic hyperplasia (BPH) as an example. BPH is a benign tumour affecting part of the prostate. The obstruction caused by the tumour may not be due to the size, but rather, the location. As medications for BPH can be expensive and have harmful side effects such as giddiness and sexual dysfunction, BPH patients who do not experience significant obstruction may be better off just managing their condition conservatively by adjusting their fluid intake and exercising more.
"The more important question we need to ask ourselves is not how to treat patients but when to treat them. To this end, prudence is key – we should always refrain from over-investigating or over-treating the patient."
Advising patients against going for further investigations or treatment is a difficult task for surgeons, including urologists. Telling patients not to have a biopsy or an operation in their best interests is sometimes more difficult than going ahead with a procedure.
In another example, a patient with an elevated prostate specific antigen (PSA)—a tumor marker— is usually advised to undergo a biopsy of his prostate. However the complication rate of the biopsy is high, with 6.5% of patients developing bleeding, fever and urine retention. There is also a small chance of infection. By weighing the relatively high risk of complication for a diagnostic procedure against the inversely low rate of accurate detection for prostate cancer (30%), urologists need to take a more balanced approach when recommending biopsy. This includes taking into account other risk factors for prostate cancer other than the PSA readings.
In Urology, we hope to improve the reliability of prostate cancer diagnosis through research, especially with recent advances in magnetic resonance imaging (MRI). Along with clinical experience, an experienced urologist can then better to advise each patient accordingly. For patients where biopsies may not be necessary, the urologist would be able to suggest ways to manage their condition.
More experienced urologists should also continue to share their knowledge – both the successes and the mistakes to avoid – and mentor junior doctors so that, collectively, we strengthen the culture of adopting a more balanced approach in managing our patients’ conditions.
The fundamental premise to achieving a more holistic process of decision-making is to have a core understanding of the basic pathophysiology of diseases. Beyond evidence-based medicine, we also need to consider a patient’s age, his preferences and existing health conditions while making the right decision to recommend the next steps. In this way, we can ensure that our patients can enjoy the best quality of life.
This is an abridged version of the article titled “Towards Zero Harm in Urology Clinical Practice” by the same author which was published in the Asian Urology, Newsletter of the Urological Association of Asia, July 2016 edition, available at www.uaanet.org
