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Table of Contents
COMMENTARY
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 111-112

Zugzwang moments in medicine


Department of Neurosurgery, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram, Kerala, India

Date of Web Publication02-Nov-2021

Correspondence Address:
Dr. George C Vilanilam
Department of Neurosurgery, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJNO.IJNO_416_21

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How to cite this article:
Vilanilam GC. Zugzwang moments in medicine. Int J Neurooncol 2021;4, Suppl S1:111-2

How to cite this URL:
Vilanilam GC. Zugzwang moments in medicine. Int J Neurooncol [serial online] 2021 [cited 2021 Nov 27];4, Suppl S1:111-2. Available from: https://www.Internationaljneurooncology.com/text.asp?2021/4/3/111/329811



Men of medicine aren't familiar with the word “zugzwang.” Their patients too, aren't. Chess enthusiasts and bibliophiles, however, love this tongue-twister word. Lexicographers, the people who compile dictionaries, dare not miss this fascinating word. An etymological investigation suggests that the word has a German origin. It simply means, being compelled to make a move and that move may often be disadvantageous. That move may further weaken your position, but move, you must. Letting it pass or giving up is not an option. That would spell doom or a sure defeat. It is not uncommon for men and women in medical practice to get into such “zugzwang moments [Figure 1].”
Figure 1: There are moments in the life of a doctor where one has to make a proactive decision against all odds, where a certain defeat is looming over victory. At that moment, there is a fine line between success and failure, between everlasting glory and abject disappointment…and yet, no matter what the cost, one has to take action…the zugzwang moment in one's life

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Malignant tumors most often strike people unexpectedly. Some are discovered well beyond the point of cure. Still, others are at a threshold of cure, critically poised and poignantly positioned at the brink of a cure. A risky yet successful outcome lies on one side and just beyond is the point of no hope, doom, and incurability. These are precisely the zugzwang moments that challenge the limits of medical care. Doing nothing may seem the easier way out. But surely, that spells disaster. Doing something could be daunting but the only ray of hope and succor.

Stretch your imagination a bit and you will come across several such moments in clinical decision-making. Take the case of a young man with a skull base tumor encasing the major cerebral vasculature. Or that of a little boy with a large fusiform abdominal aortic aneurysm ticking away like a deadly time bomb. Almost every specialty of clinical medicine and surgery has these moments of uncertainty. Moments where being stagnant may be a deadlier option. “Masterly inactivity” sounds like a fashionable word. But, it could kill in a ruthless manner. Nevertheless, reckless action and bravado could also kill. The scalpel that cures is double-edged. It could tear a life apart or skillfully cut the deadly tumor away.

Risk–benefit ratios are statistics that help to choose a difficult treatment option. When the benefit outweighs the risks, the balance tilts in favor of the surgical procedure, and vice versa. Breakthroughs in medicine, however, were always achieved by the risk-takers. Those who braved the chance took medical and surgical sciences to greater heights. The risk of inaction versus the perils of bravado is surely a tough choice.

”Conservative management” sounds very technically appealing, but the risks of inaction are often too many. You have to make a move, passing the move by inaction is not an option. Action is wrought with risk too, but it may be well worth it. If Joseph Murray in 1954 hadn't taken the risk of doing the first renal transplant in history, many more lives would have been lost due to end-stage renal disease. If Harvey Cushing had shied away from deadly and humongous brain tumors in the early part of the 20th century, many more might have been maimed or ended up being dead. Doing nothing at all, perhaps, wasn't an option for these pioneers, despite the many perils of doing something.

So when faced with a young man having a monstrous, life-threatening skull base tumor, encasing the major vessels and cranial nerves, it is often a zugzwang moment. Do nothing and surely the tumor would kill. Do something and it could still kill. In this situation, doing something seems to be the only way out. So do something, if you must. Muster all the courage, sharpen the swords, and go for the battle. Defeat may seem imminent, either way, even if you do not don the battle gear and go for war. History is replete with moments of triumph, even when the odds were heavily against the underdog. Bleak though it may seem, if there is a slightest chance for triumph, let us go for it.

When the odds aren't favorable, when the risks are glaring, when defeat seems certain, there may still be a ray of hope. A last straw of expectation. Go for it, you may not just save a life. You may rewrite history. So seize the zugzwang moments and swing it to your advantage.




    Figures

  [Figure 1]



 

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