When doing nothing makes the most sense and is the least risky option

Even doctors must become patients eventually, and often challenging patients at that.  We know enough to be dangerous but not enough to be in charge.  We want to question everything but try not to.  We can tend to be catastrophic thinkers because that is how we are trained to be, but fear being alarmists.  We want our care providers to actually like us, when we know they inwardly cringe knowing they are dealing with another physician.  We wouldn’t want to take care of us either.

Due to intermittent changes in vision in one eye, I have recently been getting some practice at trying to be a model patient.  Unfortunately, I have become an “interesting” patient, something no patient really wants to be.  That means the symptoms are not classic, the diagnostic tests not straight forward, the exam findings not clear cut, the differential diagnosis list very long.   It also usually means a visit to a tertiary care center for a visit with a sub-subspecialist to try to pick the brain of one of the handful of living physicians who thoroughly understands one aspect of complex human physiology and anatomy.  As a primary care physician who always sees an entire forest when I approach a patient, it is a unique experience to watch a colleague at work who truly concentrates on understanding one leaf on one tree.

A public academic training institution’s subspecialty care outpatient clinic is a fascinating place to spend a few hours.  The waiting room was packed to capacity with people from all walks of life sharing our afternoon together because of a shared concern about one small but crucial part of our bodies — our retinas.  We were all told the average time spent in clinic could be three hours or more and we all knew it was worth the wait so didn’t mind a bit.   Despite the long wait, not one of us would have thought to object when a couple of sheriff deputies accompanying a shackled county jail inmate dressed in his orange jumpsuit were escorted right into an exam room, rather than taking the only empty seats in the waiting room next to several elderly ladies.   We figured he was more than welcome to jump to the head of the line.

Finally my turn came to be seen first by a technician, and then a resident physician, then more testing with more technicians, and finally by the subspecialist attending physician himself.  I appreciated his gracious greeting acknowledging me as a colleague, but also his unhesitating willingness to be my doctor so I could be his patient.  His assessment after his exam  and review of everything that had been done:  there was no clear cause for my symptoms,  so my diagnosis would carry an “undifferentiated” label rather than the currently less preferred “idiopathic” label.   In other words, he didn’t know for sure what was up with my retina and as an expert he didn’t like to admit that, but there it was.

He then smiled and said “so for now we’ll treat you with MICCO.”

MICCO?  I knew there are many new unique pharmaceutical names that I have not been able to keep up with, but this was a brand new one to me that I figured only a sub-subspecialist would know about and be able to prescribe.

So he explained: Masterful Inactivity Coupled with Cat-like Observation.

In other words, do nothing for the moment but keep a close eye on it and be ready to pounce the minute something changes.

I am relieved to only be under watchful surveillance for now even though my diagnosis, its etiology and prognosis is unclear.  I realize it is a treatment strategy I need to use more in my own clinical practice.    It helps solidify that doctor/patient partnership, especially when the patient is a doctor;  I am content to do nothing but watch for now,  knowing I’m being watched.

It was an afternoon well spent in the sub-subspecialty world, as I come away with a commonsense piece of advice very appropriate for some patients in my own primary care practice:

Right now it might appear I’m doing nothing, but doing nothing makes the most sense and is the least risky option.  In reality I’m keeping my unblinking eye on you, ready to spring into action if warranted.

Treatment plan: MICCO prn

Emily Gibson is a family physician who blogs at Barnstorming.

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  • Suzi Q 38

    Makes sense to me.

  • http://twitter.com/BenGreenMD Ben Green

    Love it. Similarly, I was a patient recently and was given a diagnosis of SIDK: “Blank I Don’t Know”

    • Suzi Q 38

      My surgeon said that to me the other day, and I appreciated his honest answer.

  • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

    Reminds me of one of those law of medicine.

    Our main job is to keep the patient busy while their body heals itself.

    • Suzi Q 38

      Yes, two of my doctors got this idea about me, but it turned out that my neuropathies were symptoms of a far bigger problem.
      Spinal stenosis in my C-spine. Unfortunately, I was almost paralyzed in both legs before they finally took the full MRI that I had been asking for for several months. My chief complaint for a year and a half was: inner thigh weakness, unsteady standing after sitting or sleeping. After awhile, they just ordered PT and called it a day.
      Sometimes, you have to also look at the education level, the past history, and sincerity of the patient.

      • NewMexicoRam

        Of course, “not always.”
        The idea behind the EXPERIENCE of the practitioner is to sort out the chances of something being bad, or whether one can wait and follow the clinical course with low risk.
        Will risk ever be “0″ (as you seem to like in another post of yours)? NO, NO, NO. But can it be lowered by looking at the information at hand, combine it with experience, and salt it with the broad medical experience available to us? YES.

  • http://twitter.com/FerkhamPasha Ferkham pasha

    Everyone has to be a patient at some point in their life

  • http://twitter.com/mkashinsky Marc Kashinsky

    It’s worked for me for the past 11 years!

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