This case is modified from a real case for simulation and educational purposes only. It is meant to facilitate learning. Study this case and ask yourself the following questions.

1 Why did the surgeries did not meet Tom's expectation? How can this problem be handled?

2. Why did Tom prefer herbal medication?

3. What additional training does the surgeon need?

4. What are the goals of palliative intervention?

Tom Tan is a Malaysian Chinese. He is a 49 year old male, who was diagnosed colon cancer. He underwent a surgery in March 2006. Unfortunately, things did not work out well. After being discharged from the hospital Tom had severe hiccups and he had to undergo another corrective surgery. According to the surgeon, his intestine had to be “rearranged”. After the second surgery, Tom was unable to move his bowels for some days and the surgeon suggested a third operation! The surgeon said: “Because within five days you have not moved your bowels or did not pass out gas, you need another surgery.” Tom asked: “Did you ever come across a similar problem like mine with your other patients? What is the longest time such patients take to be able to pass out gas?” The surgeon replied: “Ten days.” To this Johnny said: “But, in my case, it is just five days – why are you so worried about it? Give me two more days.” Tom declined further surgery.

In December 2006, about nine months after his surgery, Tom related in great detail the “agony and frustration” about his cancer experience. The transcript of this simulated case conversation is as below.

Q: Before you had cancer, did you know anything about cancer?

Tom: No, not in the sense of medical knowledge. But I know of many people who had cancer, like my former boss. He was only 41 years old and he died of colon cancer. He went to our hospital here and then went to Singapore for chemotherapy. After that he went to China for more treatment. Within two years he was dead. Since his death (three years ago) I began to realize that cancer was serious – no joke, it could kill people. I began to wonder what the cause of cancer was although I knew I could do nothing about it. I also noted that seven or eight of my friends also died of cancer. After chemotherapy and radiotherapy, they did not live long. At most they survived for two years and they died. A week after my discharge from the hospital after my operation, my sister-in-law also died of cancer. She had six cycles of chemotherapy and she died.

Q: Why do you have to undergo a second operation?

Tom: After the first operation I felt okay and was subsequently discharged from the hospital. Then something went wrong. I could not eat and had severe hiccups – in one minute I hiccupped 30 to 40 times until I could not even breathe. I was discharged at about 2 p.m. and by 4 or 5 p.m. the hiccup problem became serious. The next morning, I was brought back to the hospital again. Four days later, I had my second operation. Then I stayed for another two weeks before I was discharged.

Q: The surgeon who operated on you. How did you feel about him?

Tom: In the first instance I have high confidence in the surgeon who operated on me. But after the second operation, I totally lost confidence in him. When he came to tell me that I had to go for a third operation I was very upset. Until today I have not seen him again. In terms of percentage, I gave him 50%. I am not happy at all. To me he did not really look at the problem. I was like an experimental animal – the first operation did not work out, I was cut up again the second time and the second time seemed to have problem he wanted to cut me up the third time. I am a human being but that was the way I was treated. He even had the guts to tell me that I need to go for the third operation! Imagine me undergoing three surgeries within a month?

As a person I knew that he is a good man. He was unable to sleep because of my case. He visited me a few times in the middle of the night – at 3 a.m. He came with uncombed hair, wearing inside out shirt, etc.

Q: Why did he come and see you?

Tom: He told me: “I really cannot sleep because of you. My shoulder is feeling heavier. I think you need to go for a third operation.”

Q: After the surgery, did you suffer any side effects?

Tom: No, except that at one point along the operation scar, there is a bulge or protrusion (doctors called this hernia). I think it was not properly done. That is the only problem I have now. I went back to see the surgeon again for my first review. The surgeon arranged for me to go for chemotherapy.

Q: After you have your surgery, you decided not to go for chemotherapy. Did you know that there are other options?

Tom: Yes. I know of alternatives but I did not know where to go. I knew that if I was not going for chemotherapy, I can take herbs. I knew there must be another way but I did not know where to go for this. So I stopped at that until I found someone whom I could trust. I am not the sort of person who would pick up any information here and there and then start trying them out. So for two months (after the surgery) I did nothing but was hoping to “find” a way out.

One week after I went to see the oncologist at the cancer hospital I came to see you. When I came here I felt that this was the way to go.

Q: Do you know that surgery may be done for palliation purposes only? If so, do you know what is the goal of palliation?

Tom: I have no idea.

Q: You took the herbs. Did you benefit from them?

Tom: After I took the herbs for one, two and three weeks I felt more comfortable and felt like everything was going back to normal. I felt I was getting better and my body was coping well. After taking the herbs for less than a month I went back to work (on 18 June 2006). At that time I was still quite weak but with time I became better and better. I told my friends: “Herbs helped me a lot. I don’t care if it is Chinese or Indian herbs – for as long as they help me. Herbs really helped me.”

Q: Before you started taking the herbs, did you believe in herbs in the first place?

Tom: I believe in herbs. After I came here, there were many other people who told me the same thing.

Q: Our last question: do you have anything else to share with cancer patients?

Tom: There is nothing we can do once we are diagnosed with cancer. Just accept it and learn how to live with it. But there is a way out. In my case, I would not go for chemotherapy. I have seen many of my friends suffered with chemotherapy. I would not want to suffer like them.

Q: Chemotherapy and irradiation therapy are two methods of clinical intervention introduced by modern medicine during the technological era. What are the setbacks of these two methods.

Tom: I do not know.

Tom  need to change your lifestyle. That is Tom's number one priority. Those who don’t change have a slim chance to survive. If Tom don’t take this challenge, how are Tom going to survive.

After you attempt to answer the above five questions you will see that the missing link can  actually be solved by introducing the role of palliative medicine. Both the surgeons and patients would benefit from appreciating the principles and practices of palliative medicine. This is a little difficult to understand but worth attempting to understand. It is the foundation of all "medicine" since time immemorial.