Doing nothing - but doing it right

It’s always easier to do something than to do nothing. Doctors often offer treatments for things they know are what we call ‘self-limited’ meaning that they will clear up all by themselves.  I think this form of unnecessary treatment reflects an awareness that although many things resolve without intervention, both doctors and patients are driven to DO SOMETHING. Though it is usually tempered by the wish to do something as benign as possible, sometimes doing nothing is the best choice. The trick is knowing how to do nothing properly.

Saying ‘It’s just a cold so there’s nothing I can do’ or ‘we don’t treat bronchitis because it is viral’ may be technically accurate but is poor care, as it carries the meta-message that the patient is wasting the doctor’s time and should have known better. Good care requires a combination of caring and education. 

In residency, I had a faculty member who was very explicit about this, teaching us to use four steps. He was primarily a pediatrician, a field arguably dominated by self-limiting conditions, but his approach applies in all age groups. His steps were:

  1. Explain to the patient that the problem is not an immediate threat. The patient is likely concerned about one of two things: fear that it is serious, or wanting relief from some form of misery. Start with addressing the fear issue. Despite how miserable a three year old can seem with a viral URI or otitis media, these are not dangerous illnesses. Despite how disruptive a viral bronchitis is for an adult, it is not a threat to health. Despite how irritating poison ivy or bug bites are, they rarely cause harm. Explain what is happening with the illness, what is causing the symptoms, and why you are confident that there is no danger.
  2. Reassure the patient that the problem will most likely resolve without treatment beyond ToT (tincture of time). Most viral URIs will resolve in 7 days with treatment and a week without treatment. Three quarters of ear infections in otherwise healthy children will resolve without complications without treatment. Viral bronchitis means at least 3-4 weeks of cough, but does not improve faster with antibiotics. Poison ivy and bug bites clear up quite nicely without medical interventions. Be certain to give accurate and reasonable expectations and do not belittle or minimize the degree of misery. Make sure the patient knows what defense mechanisms are hard at work protecting them.
  3. Make sure the patient knows how long to safely wait and what to watch for.The three year old who, on day 5 of a URI suddenly is worse with fever and poor appetite should be seen. The child with otitis not improving after 48 hours will probably benefit from antibiotics. A cough that has lasted 4 weeks, or is associated with prolonged fever, shortness of breath is probably no longer a simple bronchitis. Bug bites or poison ivy that are developing honey-crusting and spreading or are associated with fever are probably infected. The patient needs to know when she can return to work, or resume running. He may want to know if he is a risk to his 2 week old grand child.
  4. Only after doing steps 1, 2 and 3, should one explain that there are some safe but not necessarily effective things that the patient might want to try if they are uncomfortable just watching and waiting. (This should be carefully framed to make it clear that the treatment is optional, may have risks or side effects, and is not essential to a good outcome.) This can include both prescription medications, over the counter medication, and home remedies. One can minimize cough that disrupts sleep, help control itch, treat pain, maintain hydration and activity. The patient may find it useful to know that both fever and inflammation play a role in healing and do not necessarily have to be treated with medication.

Thanks to Marc Hansen, this has become the foundation of my approach to self-limited illnesses - of which there are many. I adjust it as needed based on the individual patient and the problem we are addressing. I find it both effective and well accepted.


 

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