By Dr Albert Lim Kok Hooi

"JUST do it" is the clarion call of the young and trendy. The "movers and shakers" rule the roost and are praised. The nay-sayers are disdained and denigrated. Progress is measured in movement, in action, in numbers. The more, the better.

It is difficult to say "No" in today's world. And so it is in medicine. We see a doctor, expecting some pills or therapeutic measures to make us feel better, to live longer or to save our lives. We do not expect to go home from the clinic empty-handed.

Mr A came to see me last week expecting more pills and X-rays. Let him tell his story.

"I was treated for nasopharyngeal cancer in 1997. I had 32 sessions of radiotherapy to the back of my nose/ throat as well as to my neck. Five extra treatments were given to my left neck as the lymph glands there were very enlarged. A CT scan four months after treatment showed that the cancer was gone. My mouth became dry but that was about it.

"Ten years on, I noticed two other problems. I began to have difficulty rolling my tongue to pronounce 'R's. Also, if I squeezed the left side of my neck, I would experience an electrical sensation running down my left arm. It is like 'a thousand ants crawling all over'. I have seen several doctors (six, I think) and all of them ordered scans and prescribed pills. I am not better for all that. Could you help me? Is there any other scan I should undergo? What about more specialised scans? I would also like a new set of pills!"

Mr A, now 60, is very fortunate. He has been cured of cancer. (Kudos to my colleagues in Hospital Kuala Lumpur who treated him). He leads an active social and family life. He is a financially-secure retiree and has a loving and supportive wife who was with him throughout the consultation.

I reviewed the scans and X-rays that he brought along with him. The last available magnetic resonance imaging (MRI) scan of the neck (done about six months ago) showed mild radiation-induced fibrosis in his neck and inlet to his chest but no recurrence. The "ants crawling on his skin" sensation is what we call formication (a word I would advise you to pronounce and spell with caution). This can happen after partial damage to sensory nerves.

In his case, it was caused by radiotherapy. His dry mouth is a nuisance and I advised him to drink lots of water whenever he eats. I also told him to keep his bedroom well-hydrated whenever he sleeps. A large thoroughly-drenched (and squeezed dry) towel hung up next to the bed will do.

Of course, Mr A (A for "well done", "cured", "alpha" as he is doing just fine) does not need more scans. The set of scans done three years ago (10 years after his cancer was first treated) were already sufficient. He also does not need more pills and bills. He had already gone through the whole list of "nerve-repair" and "nerve-enhancing" pills without any improvement. In fact, he had to endure the side-effects of such pills which included dizziness, headache, and double vision.

I counseled him at length and he was happy to accept the fact that he has to live with the treatment-induced side effects and adjust his life and activities accordingly. I prescribed masterly inactivity.

So much of what we do in medical practice is unnecessary. Some of it (I hope a small part) is motivated by profit. Some of it is a result of ignorance. Most of it is a conditioning that inaction is an admission of defeat. Doctors are trained and wired to act.

We, on cue and almost on instinct, order blood tests, X-rays, scans, pills and injections, and surgery each and every time we encounter a human with a medical problem. This is detrimental to our patients at times. Unnecessary scans, especially CT scans and positron emission tomography (PET) scans, means unnecessary exposure to harmful X-rays which may result in an increased incidence of cancer.

Unnecessary treatment is even worse. At times, side-effects of treatment can be troublesome. Occasionally they can be fatal.

Thinking and caring spinal and orthopaedic surgeons tell me about unnecessary operations on the spine. Many an eye lens is extracted without an established cataract. Antibiotics are prescribed for almost every runny nose, sore throat, and fever. Women have their wombs taken out just because they have prolonged menses and are about to attain their menopause. Pancreatic, liver, kidney and liver cysts (seen on scans) are mostly benign.

Many patients subject themselves to surgery because they are told there is a 1% chance of such cysts becoming cancer. Some patients needlessly undergo a thoracotomy (surgery of the chest) for so-called "early lung cancer" without a PET/ CT scan done to confirm that the lung cancer has not spread. Once the lung cancer has spread, surgery is not warranted and may be detrimental.

Oncologists are not blameless either. Patients who have undergone treatment for cancer who are well and asymptomatic are subjected to unnecessary blood tests and scans. Almost all internationally accepted protocols and guidelines will tell you it makes no difference if scans or blood tests are done in such patients. All it needs from a cancer survivor is a detailed history and complete physical examination. Blood tests and scans only follow if there is a suspicion of recurrence.

There is often undue pressure from the patient with advanced incurable cancer and also from the patient's relatives to do something, anything, everything. They insist on mostly ineffective third, fourth, or even fifth line chemotherapy because death is not acceptable. Sometimes they demand a course of prolonged, high dose radical radiotherapy in such a situation. Sadly, some oncologists cave in.

Masterly inactivity. I love the sound and rhyme of it. It is an act not borne out of inertia or impotence. It is an artful and thought through decision. It speaks of the knowing thirty year silence of the Zen masters on the slopes of the Tibetan Highlands. The wise and watchful eyes of the owl in repose. The enlightened doctor who sometimes holds back because he knows "less is more".

Dr Albert Lim Kok Hooi Is a consultant oncologist. For further information, e-mail starhealth@thestar.com.my. The views expressed are those of the writer and readers are advised to always consult expert advice before undertaking any changes to their lifestyles.

-The Star/Asia News Network