Hippocratic advice: To do nothing can be good remedy

Shin Sang-won Korea University Medical Center professor

By Shin Sang-won

Regarding the case of a thyroid cancer patient in the “On the couch with Dr. P” in the Dec. 29 edition of our healthcare section, professor Shin Sang-won at Korea University Medical Center’s Anam Hospital sent his opinion. — E.D.

Hippocrates, the father of western medicine, said “To do nothing can be a good remedy." Derived from these instructions, “watchful waiting” is an approach to various medical problems where time is allowed to pass before medical intervention or therapy is used. During this time, close observation may be needed even though what most consider as medical treatment — drug prescriptions, expensive tests such as blood tests or x-rays, or surgical intervention — is not given to the patient. In medical school, “watchful waiting” is taught as an important therapeutic strategy.

Watchful waiting can be used for a very broad range of medical problems, the most typical of which is the common cold. If a patient presents a runny nose, mild cough and fever, he or she can be recommended to rest, drink plenty of fluids and wait until the symptoms resolve themselves. Not a single medical textbook supports doctors prescribing antibiotics for a common cold. In addition, this strategy can be applied to many typical medical conditions, such as gastritis and diarrhea, and abdominal, joint, muscle, and back pain.

Surprisingly, even in a much more serious ailment like cancer, such as early stage thyroid cancer or prostate cancer in the elderly, the watchful waiting strategy compares favorably to active anticancer therapies like chemotherapy, radiotherapy and surgery. For example, elderly patients diagnosed with prostate cancer using PSA (prostate specific antigen) testing are often better served by “watchful waiting” than by aggressive treatment with radiation and surgery, which are likely to leave patients with erectile dysfunction and/or urinary difficulties, not to mention the money and worries which accompany anticancer treatment.

Many elderly patients with early stage prostate cancer never become symptomatic, and chemotherapy and surgical “cures” serve only to diminish their quality of life. Some medical experts currently claim, and have research to support their claims, that some types of cancer are over diagnosed, leading to overtreatment. One study showed that one in three women with breast cancer are over diagnosed and receive surgery and/or chemotherapy which was unnecessary, not to mention potentially harmful.

I am not saying that for all diseases and symptoms physicians should wait until a patient’s condition becomes serious. On the contrary, every symptom and disease should be considered serious until it is resolved completely. However, doctors and patients must recognize and accept that as human beings, we will suffer from minor aches and pains, most of which are very natural phenomena and thus unavoidable.

Doctors and patients must also be actively aware that no medicine or medical procedure, or even test, is free from side effects, which while may usually be mild but sometimes turn out to be fatal. Medical science has yet to discover a magic bullet without side effects, so doctors must carefully weigh the benefits and the harm in every medical intervention seriously.

Certainly, watchful waiting is not an easy decision. In some ways it is the most difficult decision in medicine, especially with a serious disease like cancer. It needs a clear understanding of not only medical technology but also a holistic understanding of the patient’s status, including physical and mental aspects.

In the real world, the watchful waiting strategy is seldom used because it is very difficult to apply. First of all, it is an uphill battle with patients, suffering from pain or distress, who expect to be tested and treated, either with drugs or surgery. Consequently, for physicians, it is a time consuming and challenging task to persuade patients to accept “watchful waiting.” Doctors have an old saying, “To write prescriptions is easy, but to come to an understanding with patients is hard.”

Additionally, when doctors do not offer treatment, they may lose their patients’ trust. Doctors may be considered lazy, or may even be sued when the results are negative. Alternatively, patients may seek a second opinion in hopes of finding some new medicine or high tech surgery to eradicate their disease once and all. Such hopes are often highly unrealistic.

Most of all, it’s about money. In Korea and many other countries like the United States, and even in Europe with its socialized medicine, doctors are paid by what they do, creating a “do more, bill more” mindset. In capitalist society, even doctors, though they have jobs most envy, are not free from money concerns.

Thus, from a common sense point of view, it is better for doctors to offer some kind of treatment, whether truly necessary or not, than to offer nothing. Moreover, in Korea, doctors cannot bill for their services, no matter how much time they spend examining and talking with a patient, if they do not write a prescription or order some type of treatment, which is antithetical to good medical practice.

It is not the high technology drugs or state of the art expensive medical devices or high rise luxurious hospitals which save people’s lives and relieve their suffering. Good medicine depends much more on good communication between patients and doctors and their reasonable decisions.

We need a medical system that fully supports “watchful waiting,” that knows what any good mechanic knows: “If it ain’t broke, don’t fix it.” However, such a sea change won’t happen overnight. Until then, individuals, both doctors and patients, must take responsibility for medical decisions that put the patient’s health first, even if that means doing nothing.