The three questions easy to ask but difficult to answer

Over years of my experience as a doctor, I have learnt one simple truth. Questions with a clear medical response are usually the easiest to handle. If someone asks about a blood pressure reading, a cholesterol value, or the result of an angiogram, medical knowledge offers reasonably firm information to respond quickly and specifically. Guidelines, clinical trials, and numbers, they all come to our rescue. Both a doctor and patient find comfort in objectivity. The real challenge lies in answering a question that sits uncomfortably at the crossroads of medicine, society, beliefs, personal experience, and expectation. These are the questions for which textbooks offer little guidance and experience matters more than evidence. When confronted with these questions, doctors often pause and ponder — not because they lack knowledge, but because they recognise uncertainty. That pause, however, can be unsettling for patients. A carefully worded explanation may sound evasive, while an honest admission of ambiguity may be mistaken for incompetence. Ironically, the very effort to give a balanced answer can leave the patient more confused and unconvinced than before. Over the years, I have realised that three questions recur in almost every cardiology clinic. They sound simple, even reasonable, yet answering them in a way that truly reassures patients, is remarkably difficult.

The first question which a patient often asks with a mix of surprise, confusion, and a quiet resentment is “doctor, why did I get this disease?” It is the most human of all medical questions, and yet one with no straight answer. Each of us is the end product of two powerful forces—nature and nurture. Nature refers to our genetic makeup, inherited traits, family history, and the way certain diseases behave within families. Nurture includes how we live our lives, what we eat, how active or sedentary we are, whether we smoke or drink, how we handle stress, how well we sleep, and even the environment we live in.

Development of most diseases requires an interaction between these two forces, often over decades. The difficulty is that we cannot accurately measure the individual contribution of each factor in a given person. Adding to this uncertainty is what can be loosely described as the “iceberg phenomenon” of risk factors as well as disease. Just as most of an iceberg stays hidden under the surface of sea water with only a small portion visible above the surface, similarly many contributors to disease remain invisible or poorly understood. Subtle genetic variations, early-life influences, hormonal factors, and random biological events all play a role. This is why some lifelong smokers never develop heart disease, while others with seemingly perfect lifestyles suffer heart attacks. Despite advances in risk calculators and prediction models, medicine is still far from answering the “why me” question with confidence.

The second question, which often leads to delay in starting treatment and poor long-term compliance, is “doctor, will I need to take this medicine for life?” This question is usually asked with a quiet hope that the answer will be no. Unfortunately, most lifestyle-related conditions such as high blood pressure, diabetes, and high cholesterol are chronic disorders. While claims of permanent reversal are often made—both within modern medicine and traditional systems—these claims are largely unsubstantiated and rarely verified in the long term. The uncomfortable truth is that many chronic diseases require long-term, and often lifelong, treatment.

Yes, medication doses may change. With weight loss, regular exercise, stress reduction, and dietary discipline, drugs may be reduced or occasionally stopped under supervision. But such changes are often temporary and require constant monitoring.

The idea of lifelong medication feels burdensome, but denial of the chronic nature of disease does not alter its biology. What worries doctors most is not lifelong treatment, but intermittent treatment—starting, stopping, and restarting medicines based on convenience or fear. The third question is perhaps the most intriguing and the most revealing. “Doctor, I hope this medicine will have no side effects?”

Notice that the emphasis is on “no” side effects. Not minimal or acceptable ones. I usually respond by drawing parallels with everyday life.

Almost every meaningful decision we make—marriage, choosing a career, buying a house, or owning a car—comes with benefits as well as inconveniences. In medicine, an unwanted or undesirable effect of treatment is labelled as a side effect. Sometimes, it is simply an exaggerated form of the desired effect of the drug itself, such as minor bleeding with blood thinners or a lowering of blood pressure below normal when medicines are given for the condition.

The real question, therefore, is not whether a medicine has side effects, but what is the frequency of these side effects and whether those side effects are acceptable, manageable, and outweighed by the benefits. All medical treatments, remarkably similar to life decisions, are exercises in balancing reward with limitations. When the benefits clearly and substantially outweigh the potential harm, the decision becomes rational and justified.

In the war against disease, a doctor and a patient must fight on the same side, with illness as the common enemy. Fear should be reserved for disease, not for its treatment. Allowing misconceptions, half-truths, or prejudices to delay or deny scientifically proven therapy, often causes far more harm than the medicines themselves.

While asking questions from your health care provider is not only healthy but also essential, it must be understood that some answers in medicine will remain imperfect. When one recognises this fact, it might be the first step of a true partnership between a doctor and his patient towards rendering ideal healthcare.

Prof Hemant Madan is an Interventional Cardiologist and Programme Head, Cardiac Sciences for Narayana Health.