It's the hardest thing in the world for a doctor to do.
After all, doctors are do-ers. That is how they have managed to achieve their degrees: hard work, discipline, perseverence. Who else would be willing to memorize all those organic chemistry equations long enough to vomit them back on paper? Who else would tolerate long nights and weekends on a constant basis? But they do it because it's the right thing to do. They do it because someone has to. People don't get sick nine to five. They get sick at 2 am. And so, by it's very nature over the years, medical education becomes a sort of natural selection: only the strong survive.
Historically, doctors endure the system because they know that there are rewards for this hard work personally, professionally, socially, and financially. So throughout their training, doctors learn to perfect the art of doing. That's what people come to expect. Oh my God, doctor, he's choking: do something! He's turning blue: do something! But he fainted, doctor! Do something!
One of the best parts of medical school is learning the answers to these mysteries of medicine and how to fix them. In the past, this gave doctors a aura of deity: they could be trusted to fix just about any ailment that befell man. It was awesome. With time, a sense of invincibility and omnipotence set in.
And like flies to a flame, we bought it. Lock. Stock. Barrel.
In fact, our entire Greater Medical Complex has grown to support and promote the mystique. Doctors are the omnipotent, the all powerful, the experts, the purveyors of a great Center of Excellence, the Great and Powerful Oz's centered in the Crystal City. We have read the great CheckList Manifesto and installed the Electronic Medical Record. We believe! How much does that cost? Who cares! Just DO SOMETHING!
So imagine when a doctor says that doing nothing is the right thing to do. Man, what a Debbie Downer. There is no checkbox for nothing.
Everyone gets upset.
The patient is confused. The administration gets upset. And yes, even the doctor gets upset. But the doctor gets upset for reasons that most don't think of. The doctor gets upset because there is little incentive to do nothing. That's how he's paid. He must do something or people might sue him. It's not okay to do nothing in medicine any longer. Just like it's not okay to stop working at Walmart. We must stay busy little beavers. That's the way it is.
See Jane run. Work, Dick, work! No tickey, no laundry.
That's because doing nothing doesn't pay the bills and ancillary staff, or turn on the lights, or pay the cleaning crew, or groundskeepers. Doing nothing isn't acceptable when millions more need health care.
So imagine this scenario: a patient presents to you after a sudden self-limited, but nonetheless significant stroke. A million-dollar workup shows nothing after a week in the hospital with a normal EKG, ultrasounds, CT scans and full cardiovascular workup except an abnormal MRI that looks for all the world like a blood vessel was plugged in her brain for a period of time. She mentioned to the doctors, though, that she was told she once had atrial fibrillation so she's placed on anticoagulants and discharged. Several weeks later, she walks blissfully into her primary care doctor's office feeling fine but is noted to have an irregular pulse and EKG confirms atrial fibrillation which she didn't feel at all.
Quick doctor! Do something!
So she is sent to me to do something. I look, listen, poke, prod, review, then review some more. The patient is asymptomatic, has rate-controlled atrial fibrillation, is on an appropriate anticoagulant and medical therapy, yet there they sit, expectantly.
It would be easy to do something. If fact, it's hard not to. After all, they're not a 100 years old. They lead productive lives. We are trained to help. We are paid to do stuff. To order. There simply is no tangible incentive to do otherwise.
And yet, sometimes, despite the powers that be, the best thing to do is nothing. Just stand there. Take the medicine. Breath deep. Move on. No need for more studies or repeat studies. No need for catheter ablation or additional medications to control the rhythm. Really.
But you'd better be damn good at explaining why, lest the legal world come back to bite you where it hurts. So minutes upon un-billable minutes are spent explaining the options and the reasons why, all for a small "thank you for taking the time." They seem grateful leaving, but you wonder, are they? Or will they seek the answer they want to hear somewhere else?
Truth be known, in our system is is always easier and more lucrative to do something, but the best doctors I know are the ones who are willing when it's appropriate to place their necks on the line to say enough is enough.