The lost art of standing still
Even when waiting is the best approach, GPs can find it difficult to justify doing nothing, says Margaret McCartney
Watchful waiting, expectant management or – my favourite – masterly inactivity.
Not doing something requires description, reassurance, and, if I am honest, a bit of justification. The training of a doctor often emphasises action – when to prescribe, when to operate, when to biopsy. But the art of standing still is a tough one to learn, and tougher still to do.
I find this even when the evidence stacks up to convince us. There is now copious evidence that avoiding intervention can be useful in many circumstances.
For example, recent data showed that palliative care for metastatic lung cancer, rather than ongoing aggressive chemotherapy, led to an equal length of life – but a higher quality of life.
Turning off chemotherapy may seem like a risky business, but keeping it going was shown to be detrimental.
Yet even with the evidence, there are still times when making a rational, informed, collaborative decision not to do something can feel riskier than more aggressive action. Inaction, or less activity, can feel harder to justify – hence the nomenclature medicine has created in trying to frame not doing something as a positive declaration.
But all GPs know the value of time as a diagnostic tool. And, of course, there is the futility of too much of the wrong kind of medicine, used with good intention but to no benefit, at the end of life.
The need to ‘do something' has become so embedded in our guidelines and protocols that making a thoughtful decision to dissent feels like an uphill struggle.
The boxes in the QOF seem to push for more – we have to justify each request that we decline to comply with.
And yet the process of beginning medication calls for far less justification – it has become automatic, and I am not sure that the resulting polypharmacy is capable of doing as much good as the extrapolated evidence would have us believe.
What I'm looking for, among all the advice to start medication at an earlier and earlier stage in the disease – or worse, pre-disease – is evidence-based, pragmatic, wise guidance about stopping medication and interventions.
The contract dupes me into thinking that the largest risk is not complying with it. Yet the reality is the misery of iatrogenesis.
I worry that preventive medications simply exchange one cause of death for another, with little time to gain between them – and worse, were we to account for side-effects, little or no quality of life achieved for all the effort of swallowing down the tablets.
This is not about rationing or ageism. Not doing some activities – like prescribing – does not necessarily mean that we are doing less. The effort expended in proper joint decision making and attention to evidence for an individual patient is far, far more.
It would be much better if every guideline supporting some kind of medical activity also explained the limits of evidence and who, reasonably and rationally, we should encourage to step firmly off the protocol.
There are small letters somewhere on most guidelines that say that they are only that – a guide. I'd love to see that printed in massive red letters on the front.
Dr Margaret McCartney is a GP in Glasgow