A guest column by the American College of Physicians, exclusive to KevinMD.com.
I distinctly recall during residency a much older and well-respected clinical teacher periodically opining that what was needed in a particular patient case was “a dose of the tincture of time.”
For those less familiar with more historic terminology, a tincture is an alcoholic extract or solution of a plant or other chemical substance (such as iodine or opium) for medical use, although uncommonly used these days given advances in pharmaceutical preparation.
But what he meant was that perhaps the best thing to do was to simply follow the trajectory of that individual’s symptoms or clinical course without pursuing specific testing or treatment, and that with time the next best step would become clear. Or, in other words, administering time itself as a diagnostic or therapeutic intervention.
Being young, excited, and (at least in our perception) knowledgeable clinicians-in-training with a vast array of diagnostic and therapeutic options available to us, this advice seemed to most of us to be both antiquated and somewhat naïve. Why in heaven’s name wouldn’t we immediately apply the best that medical science has to offer to find the cause of the patient’s complaints and attempt to relieve them of their suffering?
However, over the years and with lots of clinical experience, I’ve come to fully appreciate what this seasoned and wise clinician was trying to teach us, and at the risk of potentially being seen as antiquated and naïve myself, have attempted to emulate this approach in my own practice.
When caring for patients, it doesn’t take long to realize that aggressively pursuing many symptoms or complaints brought forth by patients can often lead us in directions we don’t necessarily want to go – a cascade of diagnostic tests and consultations that result in discovering (often incidental) findings that are usually unrelated to the primary complaint while failing to uncover what we were looking for. And an aggressive therapeutic approach may also lead to treatment of symptoms and findings in ways that likely provide little or no benefit to the patient and in some cases may actually cause harm. And this doesn’t even begin to factor in patient anxiety and resource costs to the individual and healthcare system.
What underlies this seems to be that physicians across all specialties are taught that doing more is almost invariably better than doing less. After all, diagnosis and treatment are what we’ve been trained to do. And patient worries and expectations certainly play a large role. Many equate the quantity of intervention with the quality of care, and to not aggressively pursue evaluation and treatment might be seen as not caring or not taking their complaints or symptoms seriously. This sets up the clinical struggle we all encounter – balancing what our clinical experience tells us with the more aggressive diagnostic and therapeutic approach we’ve been taught, patient expectations, and the eternal anxiety associated with the risk of “missing” something important and the implications this holds for the patient and us as physicians.
However, masterful clinicians learn how to effectively incorporate the use of time and patience into both the diagnostic and therapeutic process, and seem both confident and comfortable in doing so.
This is derived from what most experienced clinicians know – and data support – that many if not most symptoms experienced by patients are self-limited, with 75% to 80% of them improving over 4 to 12 weeks if we don’t do anything. Many medical problems just get better over time and don’t necessarily require immediate or aggressive care – low back pain and non-specific gastrointestinal complaints are good examples.
Additionally, incorporating time into the management of potentially serious diseases previously approached aggressively has not only become acceptable but in many cases a standard of care. Watchful waiting, or closely monitoring a patient’s condition but withholding therapy until symptoms and signs appear or change, is now a viable and sometimes preferred option in a number of clinical conditions such as low-risk prostate cancer, breast cancer surveillance, certain leukemias, and small renal tumors. And many primary care physicians take a similar approach when managing problems such as mild depression.
Taking a more thoughtful and intentional approach by no means represents a diagnostic or therapeutic “nihilism” – the successes of modern medicine that sometimes require extremely aggressive and invasive intervention and often lead to remarkable outcomes are something to be celebrated. But we also need to factor in that not immediately establishing a diagnosis or implementing treatment sometimes isn’t necessarily a bad thing and in many cases may be beneficial to patients.
The trick is knowing when it is OK to wait and watch.
It requires confidence in your own understanding of disease, its presentation and natural course, and your personal comfort level with clinical uncertainty. It also requires a trusting relationship with patients. They need to have confidence in their physician’s skill and clinical judgment. And doctors need to incorporate patients into the process in a way that is transparent and empowers them as active partners in making clinical decisions so they feel supported and comfortable with not having a specific diagnosis or waiting to treat a particular problem.
I believe that what develops with experience is the ability to integrate and synthesize all of the factors of an individual patient’s circumstances into medical decision making, the wisdom of knowing what needs to be pursued aggressively and what does not, and the courage to not always do everything that could potentially be indicated or justified.
This is the art of medicine.
In this day when sometimes older and seemingly outdated medical treatments are found to be highly effective in many current clinical situations, perhaps now is when we should reconsider our use of “the tincture of time.”
Philip A. Masters is vice-president, Membership and International Programs, American College of Physicians. His statements do not necessarily reflect official policies of ACP.
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