Sometimes doing no harm means doing nothing


A couple of years ago, I took care of a 12-month-old boy with a cough. He had been seen by three other doctors over the last two days. Initially, he was seen by his pediatrician, who told his mother that it was “just a virus” and that his symptoms would go away on their own. Unsatisfied with this answer, she left the pediatrician’s office and drove immediately to an urgent care facility, where they told her that her son had pneumonia, and he started on an antibiotic. The next day, he was coughing more. So his mother took him to a different urgent care facility, where a second antibiotic was started.

On the third day, she brought the child to the pediatric emergency room where I worked. She was very concerned that his cough was worsening, despite the two antibiotics he was on. She was worried that he had now developed diarrhea, in addition to his primary symptoms. And more than anything, she was irate that his pediatrician had done “nothing.”

Everything about his history and physical exam screamed: “bronchiolitis” (a common viral respiratory infection in young children that does, in fact, go away on its own). Worsening over the first three to four days is precisely what I would expect from this illness. And more than likely, his diarrhea was a result of the antibiotics he was on.

As far as bronchiolitis cases go, his was mild. He was eating well and breathing comfortably — just coughing a lot and dripping snot everywhere. According to the most current treatment guidelines, he truly needed nothing but nasal suction — and maybe a humidifier. Eventually, I was able to explain all of this to his mother, convince her that he would be OK (better, even) without the antibiotics, and arrange follow-up with his pediatrician the following day. But it took time. Doing “nothing” — and doing it well — isn’t easy.

In reality, doing “nothing” involves quite a bit of work. Choosing to do “nothing” presumably involves the doctor listening to the patient’s symptoms, gathering relevant details, performing a physical exam and reaching the conclusion that no further testing or treatment is warranted. In many cases, doing “nothing” is the most appropriate course of action. And in these cases, doing more would place the patient at risk for harm from unnecessary tests or treatments (like my patient’s diarrhea — or worse, a life-threatening allergic reaction to a medication).

At the risk of trivializing my profession, the majority of patients seen by pediatricians would be just fine without us. When I first discovered this, I was somewhat disappointed. But then, I realized this doesn’t mean that pediatricians are irrelevant. On the contrary, one of a pediatrician’s primary responsibilities is reassuring parents about normal or mildly abnormal conditions.

But providing this reassurance requires a great deal of knowledge about those things that would be more concerning. Vomiting could be due to a viral illness, a head injury, a bowel obstruction or new-onset diabetes (among many other possibilities). A fever could be caused by a self-limited illness or an overwhelming infection. Doing “nothing” involves discerning the sometimes subtle differences between the common and the complex, sorting out the few who really need us from the many who don’t. And it requires a level of confidence sufficient to send the patient home, knowing that being wrong could have disastrous results.

Most people who seek medical care for themselves or their children — especially in urgent care or emergency room settings — expect testing or treatment. After all, if they thought that doing nothing would be sufficient, many of them would have stayed home. Convincing them that they don’t need these things, and effectively explaining why can require far more time than simply writing the prescription. Many physicians today, due to a shortage of time or concerns about low patient satisfaction scores, over-diagnose and over-prescribe to avoid this situation altogether. But a doctor who always gives patients what they want either has remarkably well-informed patients, or practices poor medicine.

“Doing no harm” frequently means doing nothing at all. But doing “nothing” well is more than saying “it’s just a virus.” It requires expertise, confidence, and communication — and it’s much easier if the doctor has already developed a relationship of trust with the patient or family. The doctor must know enough to make an accurate diagnosis (or at least rule out the scary ones) — when working with children, this means having sufficient training and experience with childhood illnesses. The diagnosis should be explained to the family in a way that they can understand. The family should know what to expect, what changes would be truly concerning, and what to do if one of those concerning things happens. They should leave the visit understanding why “nothing” was done — and ideally, being grateful for a doctor that cares enough to do nothing.

Chad Hayes is a pediatrician who blogs at his self-titled site, Chad Hayes, MD.

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