The art of fighting without fighting

At a recent ethics conference, where we were debating whether or not to treat a particular patient (medically indicated and life-saving, but against their wishes) a concept came up as one argument to treat. I’m paraphrasing but it went something like this:

“We’re Doctors, and we’ve been trained to treat, so surely we have to do something?”

Now I’m someone who generally abhors people who don’t do their job (or worse, make me do it for them). One of my mantras is JFDI – Just Frickin’ Do It. But this concept was to me a little extreme, and maybe went to the core of several issues in modern medicine. I think it also gives an insight into how Docs think about what they do.

We HAVE been trained to treat. We learn about a disease, how to diagnose it, how to treat it. Wash, rinse and repeat. Graduate. But that is only one part of medicine. As with many things in life, the real art is in knowing when NOT to do anything.

Tsukahara Bokuden was a great Japanese sword master who was challenged to a fight by a drunken youth while on a ferry ride. When asked, the old warrior said that his style was the “No Fight Style”, and when pushed to demonstrate his style he suggested they go to an island to fight, so as not to injure the other passengers. Both men jumped into a boat and rowed over to the island, but when the youth leapt out to fight, Tsukahara rowed the boat back to the ferry, leaving the irate young man on the beach – and in the process saving him from certain death at the hands of the superior swordsman.

Bruce Lee reenacted this scene in his immortal film “Enter the Dragon”. To those mindful enough to appreciate it, this scene was not one of humor, but a deliberate attempt to show that avoidance of conflict is better than beating someone by force.

In medicine the same concept can be applied. “Primum non nocere” – first do no harm – is the idea that a medical intervention may hurt the patient, and we should at the beginning (first) consider whether an intervention may be harmful. We do harm all the time of course, chemotherapy for cancer is the best example where the benefits usually outweigh the cost, but we should always be aware of that premise. In one of my medical exams the marking was such that an incorrect answer cost you marks, whereas doing nothing didn’t affect the score either way. This penalized students who acted without fully knowing what was going on – the same idea.

Of course the decision to not intervene is just that – still a decision – and not always one to be taken lightly. It is different from simply doing nothing. Often the decision to not intervene involves a calculated risk that nothing will go wrong, and one argument for excessive testing and treatment is defensive medicine. Another feature is that patients often expect, either implicitly or explicitly, that something will get done. But that something doesn’t always have to mean a prescription or a lab test. Actually performing a test may do harm – radiation from CT scans may cause future cancer for example, colonoscopy can cause perforation, the discovery of “incidentalomas” (a incidental finding on a scan used to look for something else) can lead to additional testing just to rule out cancer or something else. In addition the psychological impact of an “abnormal” result should not be underestimated. In the US we spend twice as much per capita on healthcare than other Developed countries and yet have worse health outcomes (US Life expectancy is 38th in the world, slightly worse than Cuba). Excessive testing is one part of that overspending.

It may well be that patients ask for tests for some of the same reasons that Docs do – they may not trust their clinical skills of history taking or physical exam. Truth be told, a good H&P will give you the answer (either a diagnosis or reassurance) the vast majority of the time. And if that information is properly communicated to the patient they may well be happy with fewer interventions. A recent study from Israel supports the idea that CT scans are only helpful in a third of cases when they are used, and physicians were accurate without them 80-85% of the time. This supports the notion that clinical skills are impressively accurate even for hidden injuries, and that better guidelines are needed for when to scan people’s heads! One study from a family practice clinic showed that if better communication skills were used, the patients had fewer tests and referrals.

A key point of this is the effort one must put into convincing someone that a test isn’t needed. Even with “obvious” examples, performing a thorough physical examination will not only cement your own thoughts as a medic but will also demonstrate to the patient or parent that you are thorough! Show a little empathy or concern, make sure you explain everything and have a backup plan or safety net for them (eg a followup visit or phone call). When a patient trusts a machine or lab test above their physician there’s a problem…and these are skills and behaviors that can help build trust. Clearly this is a lot different than just “doing nothing”. The English medics have a phrase for this – MICO. Masterly Inactivity and Catlike Observation. It nicely sums up the concept of knowing what you’re doing, non-intervention, and keeping an eye out for changes. (If someone is sick you always have the option of MICOS – Masterly Inactivity, Catlike Observation, and Steroids.)

I do wonder sometimes, as I watch the techs and phlebotomists scurry about the hospital, if the doctors actually had to DO these additional tests themselves would they order them so much? In that setting, investing a few minutes of your time to talk might be preferable to doing the test.

Then there are the drugs and treatments we use – misuse of antibiotics for viral infections, medications to treat the side effects of medications, quantity of life sometimes is considered more valuable than quality of life. Even in the ICU setting, I have often seen kids on the ventilator who just need to be extubated so we can “get out of their way”, and let them breathe on their own. Sometimes an “information prescription”, some good advice, reassurance, is just what the patient is after rather than a pill. The “quick-fix” mentality is the enemy here, and we have to be wary of believing that a magic pill exists to fix a problem that good old fashioned hard work could help far more easily. Direct to consumer advertising doesn’t help…but that’s a rant for another time.

It seems to me that practicing medicine without doing tests all the time, or prescribing treatments all the time, is a perfectly valid way to go. Test when you need to, treat when you need to – but more judicious practice will, in the end, serve us all well. I don’t think it’s a coincidence that when I took my Pediatric board exams I kept feeling as if the questions were pushing me towards non-intervention/reassurance a lot of the time. I guess I was mostly right when I chose those answers since I passed the boards 🙂

The bottom line is that when discussing treatment options with your patient (you DO discuss the options, right?) non-intervention is often an option even if it’s not recommended or the best course of action, it’s still an option. Remember that.

  1. #1 by Judy Stone, MD on August 22, 2011 - 08:07

    Excellent post, Nick. I have a similar approach and often prefer “watchful waiting,” warm soaks, etc. There are problems with this, however. Patients are often upset that I don’t give them antibiotics. Referring physicians are occasionally upset when I prescribe Penicillin or Amoxil or similar, rather than the latest Cepha-kill-it-all, accusing me of not being up to date. The explanation and discussions take time, and the realities of medical practice today makes this difficult, if not, at times, impossible. Some practice settings insist on a certain “productivity.” Nice to see that someone younger than I still tries, however, like I do.

    Judy Stone, MD

    Author, “Conducting Clinical Research: A Practical Guide for
    Physicians, Nurses, Study Coordinators, and Investigators”

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