Wednesday, October 26, 2011

DON’T JUST DO SOMETHING; STAND THERE.

Please excuse the hiatus in posting. I’ve been putting my time into untwisting this blog into a book. I’ll keep you posted on progress.

The NY Times Well Blog, a reliable source of stimulating issues, ran a sparkling post October 20, http://well.blogs.nytimes.com/2011/10/20/when-doing-nothing-is-the-best-medicine/#more-62303

In that post, Dr. Danielle Ofri discusses “clinical inertia,” the medical name for doctors doing nothing instead of doing something. She notes that the term is negative, and I agree. It conjures an image of a hypothyroid physician moving slo-mo, as though wading through Vaseline, despite the indication for immediate action. I wonder what Hippocrates would think of “clinical inertia,” having advised, “When it comes to the sick, do the least.”

We docs are trained in doing, and our culture teaches patients to expect us to do, no matter what. God forbid a patient leave the doc without something in her hand—a prescription, a sheaf of test orders, a packet of sample pills, anything to indicate that a medical transaction has actually occurred. An anthropologist would call her departure baggage a “fetish,” a symbol of conferred power.

The issue’s more complex than that, though. If it’s true—and I believe it is—that the bulk of medical visits are for illnesses generated in lifestyle, then less treatment might actually be therapeutic. Emphysema begins with smoking, cirrhosis with drinking, most type two diabetes from overeating, much hypertension from hypertense lives, and so on. Simply patching those symptoms with medical technology can bring relief and is a kind service, but also enables pathogenic behavior. I’m not for firing patients who live self-torturous lifestyles, but on the other hand I need to recognize that my intervention frankly enables that behavior without diminishing it. A more effective strategy would be to attenuate my intervention while requiring more involvement by the patient. Instead of calling that “clinical inertia,” call it plain old restraint.

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