When a tincture of time is better than a prescription
How often have you finished off a medical consultation by agreeing with your doctor to do nothing? Probably not very often; there is usually a high-tech test to try or some new treatment that is causing excitement in the media or on the web to tempt you.
In any case, you have brought a problem to the doctor and as part of the modern pace of life you naturally expect them to come up with at least one potential solution. Doctors feel this pressure too: to write prescriptions, to order more tests or to refer patients to yet another specialist for an opinion.
The art of “doing nothing” as part of good medical care is under threat. How often do today’s medical students hear the advice to “Don’t just do something; stand there” from their teachers? And even if they do, it’s getting harder to adhere to because so much of 21st century medicine is about “doing something”.
But the age-old advice is a reminder of the need for doctors to stop and think before they act. Despite medicine’s many advances there are still times when doing nothing is far superior to doing something.
For example adding another drug to an already complex cocktail of medication, especially in older people, may trigger a serious drug interaction. Or in the case of children, the dose of radiation from a single CT scan is known to cause health issues later in the person’s life.
The problem for some doctors is that doing nothing is often seen by their peers as a negative attribute. “Clinical inertia” is a term that features in the medical literature – but its an expression loaded with negativity.
However medical author Danielle Ofri has suggested that doctors who tend towards inertia may actually be doing their patients a favour.
Many chronic medical conditions are governed by “numbers” – the lower your cholesterol or the more tightly controlled your blood sugar, the better the patient is doing. As Dr Ofri notes, “while ‘lower is better’ is probably true for large populations, that is not always the case for individual patients. In fact, there are some clinical trials in which aggressively lowered blood sugar or blood pressure have been associated with higher rates of dying”.
This argument is clearly not applicable to medical emergencies. But for chronic conditions there is usually time for deliberation while options are weighed up – including the option of doing nothing.
What’s in a name?
I wonder would this option be more readily accepted if we changed its nomenclature? I’ve seen it referred to as a “tincture of time”, which has a nice ring to it.
And of course there is the well accepted practice of “watchful waiting”, which is regularly used with men who have an elevated PSA, the blood test which, when raised, may indicate the presence of prostate cancer.
Essentially this is a deliberate form of “doing nothing” for a defined period of time before rechecking the PSA blood levels and re -examining the patient.
There is a risk that must be acknowledged: to refrain from performing a therapeutic procedure can appear to the patient or their relatives as not giving enough attention to a specific complaint. It may even be seen as outright carelessness or negligence.
This is because medicine, in its modern technological form, encourages the myth of the medical doctor exclusively as an activist, hurrying to perform an urgent operation or implant a vital device.
Doing nothing: therapeutic nihilism or an important part of clinical practice?
There is a need for doctors and patients to revalue the art of reassurance.