The art (Tao) of doctoring without doctoring

There is a scene near the beginning of Enter the Dragon where Bruce Lee, when asked as to his style of fighting responds, ‘the style of fighting without fighting.’ (see here).

He tricks that South African toughie into boarding a rowing boat tethered behind them as they travel to Han’s Island.

The art of doing without doing.

Non-doing.

Very Zen.

You might say.

One of the forms of doctoring I practice is just this, it is, you could say, doctoring without doctoring.

Some might argue, ‘That is doctoring,’ let’s see.

Yesterday, I spoke with one of my patients.

His liver tests had become abnormal a few months ago.

I explained to him my suspicion that the abnormality was related to liver (hepatic) congestion caused by his fluid retention (heart failure) and, if we treat the fluid, his liver should recover.

I also have him the option of a trip to the hospital for an ultrasound. It could be gallstones, infection, or cancer.

He opted for the more conservative approach. Waiting and watching.

Fast forward and his heart failure has improved as have his liver tests.

We talked yesterday and he was pleased with the situation.

An ultrasound is considered within the gamut of clinical investigations, ‘non-invasive’ (you don’t require the inner cavities of your body to be prodded or visualised), it is also relatively cheap, as compared to a CT or MRI scan. The argument usually being (if you are the doctor), ‘Why not?’

After all, this approach accepts the principle of primum non-nocere, first do no harm.

And yet, arranging an ultrasound or any other test, is a form of action, it is a doing and with this doing comes consequences, for example the patient’s anxious waiting for the appointment, the six am out of bed wait for the hospital transport (arrives at 10), the waiting in the hospital, the uncertainty, lift home and waiting for result; there are potential the unintended outcomes of scan reports that add to uncertainty, ‘The liver’s heterogenous appearance could relate to heart failure or could be minor metastases,’ and so, the ultrasound is followed by a CT and if still uncertain a biopsy and so on.

There are some interesting principles here:

1. Patient preference and autonomy – a patient should be allowed, when provided with the information in a form understandable to them, make an informed decision about what they want for their body. It is, after all, their body. The old concept of ‘doctor knows best’ is becoming passé with a greater realisation that although the doctor might be the expert in the blood test, the patient is the expert in the patient. As the power-balance shifts, we learn that many patients prefer waiting and watching, they are inherently less gung-ho than clinicians.
2. Unintended consequences – it is always easy of a doctor to bamboozle a patient with science, using jargon and long sentences to scare the bejesus out of them to get what they want, for example, even though the risk of cancer is equivalent, if you use words that carry threatening connotations, you can get people to do anything, ‘If you don’t agree to the ultrasound, you might die, cancer might be missed, all hell will break loose.’ I find this phrasing particularly common when doctors are working with older people, they are, it seems, easy to scare. (And the scan is uncertain, next a CT, then biopsy, then…)
3. Sense of urgency – in healthcare there are some time-critical events, for example, if you have a stroke, it is essential that you receive a scan and potential treatment as quickly as possible – within hours, the same applies to heart attacks. The longer the delay the more brain or heart dies and the greater the likelihood of death or disability.

You can’t mess-around during cardiac arrests and many cancers require prompt treatment to reduce the likelihood of spread.

All this haste creates a pressure that damages intelligence (going back to the original almondemotion – Amygdala, primitive fear response) – when we are stressed, ‘Four hours to admit the patient,’ we don’t necessarily make the best decisions. If the procedure is routine and well-rehearsed, for example, the cardiac arrest, muscle memory takes over and there is capacity to work out what is happening, if not, it is a mess (stramash).

Not all areas of medicine require this urgency – sometimes a little bit of time and space is needed; in the support of people living with dementia, for example in a crisis, providing time and space can lead to a spontaneous resolution of what might seem urgent (leave Colin for now, we can offer him the medicine/treatment/injection later vs ‘intramuscular Lorazepam’.)

If I pressurise my patient with time-critical decisions, ‘You need to have the scan now!’ they are less likely to weigh what matters to them, the pros and cons and comply.

4. Defensive practice – doctors fear missing something awful. Missing cancer or a pulmonary embolism or heart attack are amongst our most deeply rooted fears. And so, we say to ourselves, ‘I might not sleep tonight if my patient doesn’t have scan/test x, y, or z, let me use my professional muscle to get them to have it’ (this sometimes entails manipulating the truth, inventing falsely elevated temperatures or symptoms to get the radiographer, or receiving doctor to take-over responsibility).

Defensive practice is a scourge of modern medicine and really a misunderstanding of causality, of the process of events, of what patients and regulators want.

To say, ‘I don’t know what is wrong,’ is better than inventing a possible rare condition and passing the buck.

Doctors can imagine all sorts of rare conditions, ignoring the common things are common maxim for, ‘it could be Von-Heffeltopfer’s disease!’ Best send you to hospital.

I doctored without doctoring, or rather, I doctored. This is shared decision making, working in collaboration with the patient to determine the best outcome.

And, just as in Enter the Dragon, although Bruce Lee in not fighting, was playing a joke on the South African, he was exemplifying the essence of his art. Yes, punch if a punch is required, if you punch when a punch is not needed, you risk hurting yourself, you risk escalation, wating energy or causing unnecessary harm.

When in doubt, act, goes the saying.

Sometimes acting is waiting.

Sometimes acting is nothing at all.

Have a good day.