The surgical confusion

An elegant family of five walked into my office The patient was the 80yearold matriarch letrsquos call her Auntyji She was dressed in a bespoke white and gold salwar kameez with her hair tied back in a school teachery bun She sat upright in the chair in front of me while her two daughters probably in their 50s planted themselves on either side The two dutifullooking sonsinlaw accompanying them plonked themselves on the examining bed ldquoWersquore two brothers married to two sistersrdquo one of them spoke up introducing the fam jamldquoHowrsquos that going for the four of yourdquo I digressed even before trying to find out what was wrong with Auntyji in a bid to calm the nerves that were palpable in the room ldquoWell letrsquos just say everything has its pros and consrdquo one daughter replied ldquoBut there are more pros for surerdquo the men jumped in to save the dayldquoSo what brings you hererdquo I asked finally turning to Auntyji ldquoIrsquove been forgetting stuffrdquo she said taking charge of the conversation ldquoSometimes I feel giddy and sometimes I have some imbalance while walkingrdquo she continued ldquoWersquove discussed it and we donrsquot feel therersquos anything wrong as far as her memory goesrdquo one of the daughters provided her perspective ldquoBut I feel something is not right with merdquo Auntyji assertedI examined her in detail and ascertained that her strength and coordination were good ldquoWersquove done an MRIrdquo a soninlaw pulled out the films and I raised them against the beaming light of the October sun peering through my window which I often prefer to the boring white light of an Xray box ldquoYou have a 3 cm tumour in your left temporal loberdquo I said pointing at it ldquobut itrsquos mostly arising from the covering of the brain called the dura and not from the substance of the brain itself making it not malignantrdquo I went on to explain It was a meningiomamdasharising from the meninges or the outer covering of the brainldquoHowever the swelling around it is a little more than normalrdquo I cautioned I wanted to give all the details while I tried figuring out in my head what the best advice would beldquoWe know all thisrdquo the other soninlaw interjected ldquoWersquove come here for a second opinion or rather a thirdrdquo ldquoBecause we are very confusedrdquo his wife added ldquoLet me explain the conundrumrdquo the soninlaw went on ldquoWe went to a senior doctor in one hospital and he said we could leave this alone lsquoIt grows at 12 mm a year and shersquoll pass away from natural causes before the tumour can do anything to herrsquo were the doctorrsquos exact wordsrdquo They were then forced to take a second opinion by their extended family from another equally senior and renowned neurosurgeon in another hospital ldquoHe said lsquoThis needs to be operated upon at the earliest because she could have a seizure and the brain swelling could have deleterious side effects Itrsquos better to remove it while shersquos well rather than when she has more problemsrsquordquo reiterating verbatim what the second doctor had said ldquoThatrsquos why we are so flummoxedrdquo the daughter added while Auntyji patiently waited for the verdict of someone with 25 years less experience than the other two stalwarts in the fieldAlso read Mumbai Killer RPF cop was a repeat offenderStrange as it may sound this is an ageold occurrence in medicinemdashthat doctors just like people will have differing opinions on how to proceed regarding something I have seen it time and time again in my field and beyond that medical professionals with identical qualifications and extremely similar levels of experience will often present diverse views on what to do next for a patient We call this clinical equipoisemdasha state of genuine uncertainty I have seen it with back pain Some doctors will prescribe bed rest while others completely denounce it Cardiac procedures present the same battle Some doctors prefer to stent while others simply give you blood thinners In obstetrics certain doctors are caesareanhappy while others will have you labour it outLike in many aspects of life and living these seemingly contradictory suggestions are neither right nor wrong they are simply honest but varying perspectives I began to realise for the umpteenth time how hard it is for the common man to make decisions about their health when such conflicting opinions are presented ldquoUse your intuitionmdashnot your logical mindmdashwhen making important choicesrdquo my wife always tells meldquoThere is a grey zone in medicinerdquo I clarified to Auntyji and family ldquoWhen there is no conclusive evidence toward one treatment paradigm over the other surgeons tend to use their clinical judgement and experience to give you a recommendation Unfortunately sometimes the true nature of the disease is only revealed in due course of timerdquo I explained Just like some people I wanted to add but refrainedI could either agree with one of the two eminent doctors or present my own version and hope that I did not leave them even more confused than when they arrived The Buddha in me decided to take the middle path staying away from the indulgence of jumping into surgery and the selfdenial of leaving this alone ldquoLetrsquos do some gait and balance physiotherapy for three months and see if shersquos clinically betterrdquo I suggested ldquoI want her to be as physically and mentally active as possible and also to take a walk every day and get some sunrdquo I added the standard cures of many of lifersquos problems ldquoWersquoll also repeat an MRI then to see if anything has changed in that timerdquo I decreedThe only commonality between the Buddha and me is that even though I am younger I feel just as old Unfortunately in the field of medicine simply feeling old does not count as experience Nevertheless adopting the Buddharsquos teachings that day brought with it a certain degree of peace I stayed nonattached from either extrememdashsurgery and doing nothingmdashand assumed the eightfold path with mindfulnessThe family looked reassured and immensely relieved with the middle path too which in my opinion was the right thing to do This is what most therapists also endorse When in doubt wait it out It is still too early to say if this was right or wrong but the decision to wait comes from a good place and the urge to do what is best for the patient persists What happens to Auntyji whether she or her MRI worsen in three monthsrsquo time or stay the same and the decisions we take subsequently will be revealed with timeAuntyji folded her arms with grace and dignity to thank me As she left with all her children one of them said ldquoThank you for allowing us to find a middle wayrdquo I couldnrsquot help myself ldquoTwo brothers marrying two sisters is rather extreme so it was time for something milderrdquo I joked as we all had a bit of a laughThe writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals