She catches me staring at the window. I can’t see out any more because of the obscuring film of plastic on all the panes. I should be doing something: signing prescriptions, checking emails or letters or lab results, perhaps even reviewing our progress against the myriad of targets that distort our tendency to action. I am a little embarrassed to have been caught out like this. Breaks are largely a thing of the past.
‘What do you think of this?’ It is an ECG. Not one I have asked for.
‘Mind if …?’ Regaining focus, I take it gently into my own grasp, cradling its ticker-tape length on my forearm like a newborn.
The nurse watches like an anxious midwife. I can see why: there is a machine-derived report printed there, an acute heart attack diagnosed.
‘What’s the story?’ Anxiety levels rising, I am scrutinising the fine black wiggles as I ask.
‘Chest pain, radiating down her right arm. Twice in the last 24 hours. Once going upstairs, second time was last night, watching TV.’ She is experienced and her tone conveys the doubt contained in her description. It was in the wrong arm.
I grimace. ‘It’s a rubbish tracing!’ I report.
‘Yes, sorry,’ she apologises, ‘it was the best I could get: I tried three times.’
I hadn’t meant to imply criticism of her. I look up. ‘No!’ I say hurriedly. ‘I was blaming the machine, not you!’
We both peer back at the paper, like the baby just gurgled.
‘It’s fine!’ I tell her. ‘I don’t believe the machine at all.’ Was it a good idea to do the test in the first place given the clinical doubt?
‘I didn’t either,’ she replies. I sigh. I wouldn’t have stared so long if I’d known that.
She reminds me who the patient in question is. That contextual information is enough to convince us both further. She goes off to reassure the patient in the way she had always intended to.
I gaze back at the window, pondering how another patient’s atypical chest pain has avoided the full may of medical intervention. We do it rather a lot, that sort of thing: assessing, reassuring, downgrading symptoms from possible medical crisis to something-or-nothing. Some of us do it rather more often than others. Confidence, perceptions of being in control, happiness, and stuff like that make us more likely to.
It is hard to teach though. There are always actions that may have been justifiable. In discussing options, doing nothing is only one option, and often bottom of the list. How well do exams test for it? I suspect ‘appropriate use of resources’ is not quite the same thing. Or at least, it is not usually interpreted in that way. It was embodied in the idea of using time as a diagnostic tool until the notion came along that doing tests and trying treatments would get us to the same point only quicker and without the risks.
There are lots of examples of our tendency to be over-zealous: witness the levels of prescribing for those with low mood or borderline hypertension; and the varied use of statins and aspirin for primary prevention.
Patients often make me feel bad if I succeed, mind. How often has an apparently satisfied patient, leaving the room without test or prescription, departed with an apology for ‘wasting the doctor’s time’?
No matter. As a skill, it deserves a higher profile. Posh folk call it masterful inactivity. Up here it’s probably better labelled as doin’ nowt.
With a start I realise I am still gazing at the view. What should I be doing?
- © British Journal of General Practice 2012