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Logo of bmjThis ArticleThe BMJ
 
BMJ. 2007 November 17; 335(7628): 1048.
PMCID: PMC2078625
From the Frontline

Itchy fingers

Des Spence, general practitioner, Glasgow

The period between school and university was spent cutting grass at £1.80 an hour, and many a university night and any brief holiday were spent working in a bar or restaurant kitchen. But now I was on a medical career break, wandering the world. I gazed over the volcanic lake in Java. It was wonderful just to do nothing. I straddled the equator, a white emulsion line painted on broken jungle tarmac, dodged orang-utan urine, and looked nervously on to Krakatoa. I learnt what it was to be a visible minority—my hairy arms were stroked by groups of laughing Indonesians, and my wife smiled as she was told that blonde was considered a sign of intelligence.

But doing nothing is not easy. Current medical protocols have a non-negotiation policy with patients' symptoms. We immediately blast off the doors with investigations, releasing clouds of clinically irrelevant biological variations, and then indiscriminately empty a magazine of interventions. These interventions are all in the name of “best practice” and the “patient.” But little attempt is made to understand the patient's culture, setting, or previous health seeking behavior. This is a policy of absolute total medicine; there is no art and no reflection. Outside the perimeter of our medical compound the alternative therapy militia are increasing in influence and controlling many of the streets.

Illness can be divided into self limiting conditions or an unstoppable biological cascade of degeneration or proliferation. In reality, our power to intervene in either of these scenarios is limited, and any delay in diagnosis has little impact on any eventual outcome. So it would make sense to adopt a policy of “wait and see.” But this would involve doctors putting the safety catches on the weapons of mass investigations and would involve a significant change in our aggressive medical culture. Rather than focusing on all the investigations we can do, undergraduate and postgraduate training should highlight all the investigations we shouldn't do—the forgotten craft of non-intervention. Perhaps then accepting clinical uncertainty—the core skill of a doctor—might come more easily to us and help us to free patients from unnecessary anxiety.

Meandering through Asia should be compulsory part of NHS training for all those stressed-out and battle-weary consultants and general practitioners. Let them return home with sun bleached hair, friendship bands, and yin-yang tattoos. We need to restore the ancient balance between the art and science of medicine and recognise the power of doing nothing.


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