Don’t Do Something; Just Sit There

Educational opportunities abound in medicine. But it turns out there is exactly nowhere to learn the single hardest skill of all.

I had been taking care of Shannon for a decade before it dawned on me that if I didn’t get up to speed in this particular area fast, I might actually kill her. I looked in all the usual places. I found nothing and no one to help me learn how to sit across from miserable, suffering Shannon and do absolutely nothing at all.

That meant not treating her terrible sinus attacks, not investigating her continuing abdominal pain, not medicating her headaches and her crampy hands, not addressing her depression, her itch, her nausea. I had, I blush to say, done all of this and much, much more, many times over, to the tune of several hundred separate prescriptions, scans and referrals. And at the end of all that frenetic activity nothing much had changed: Shannon and I were 10 years older; she was weeping in distress and I was desperately looking up new nasal inhalers.

Suddenly I knew that it was time to stop doing anything for Shannon for a while but pass her the tissues.

Doing nothing is different from doing no harm, that endlessly advertised professional goal. You can do a lot of things and still do no harm — and often not much good either, each effort accomplishing little enough that the sum total remains at zero. Often by that time the leg or the back or the virus has taken care of itself.

Doing nothing is also different from handing out placebo medications, an ethically complex activity featuring doctor as shaman. To really do nothing, all shamanic trappings must be abandoned: stethoscope, prescription pad, weighty pronouncements, the works. And yet — and this is key — doing nothing is also quite different from saying, “There’s nothing I can do for you; goodbye.” Most doctors are masters of this final nothing. But keeping a therapeutic relationship afloat without the usual tools, tricks or enticements — that is a rare achievement, and surely harder than the hardest microsurgery.

There are no courses in the art of doing nothing, no fellowships. Who would sponsor them? In fact, one might hazard that doing nothing is the most subversive activity in all of modern medicine, undermining as it does the agendas of all doctors, all patients and all interested corporate parties. Doing nothing has no billing code.

Among more than 22 million cataloged medical articles I found exactly one that seemed likely to help. Published in The Rhode Island Journal of Medicine in 1986, “The Art of ‘Doing Nothing’ ” cannot be read online and took a week to arrive via interlibrary loan. It proved to be well worth the wait.

“Physicians have been trained to expect the worst of every symptom,” wrote the author, Dr. David F. Wehlage, an Indiana psychiatrist. They “ ‘do everything’ to diagnose and treat it without regard for the destructive aspects of doing too much.” In fact, Dr. Wehlage pointed out, even such simple bromides as “take my advice and don’t worry” can be harmful, casting patients in a passive, dependent role that undermines their natural problem-solving capabilities.

“The art of doing nothing is learning to help by not doing or advising,” he wrote. “The evaluation is the treatment.”

The doctor should avoid asking, “What can I do?” The patient should leave the office empty-handed. “Do not presuppose that people want something done. Do not do something for people they can do themselves. Do not presuppose there is something to offer.”

Instead, find out what is really going on.

Shannon was initially not too taken with do-nothing medical care. Understandably, she lost no time finding another source for her nasal inhalers and antibiotics.

And yet, month after month, she kept coming by. Our discussions slowly moved away from the nose and the stomach I had grown to detest. (Doctors who feel they must do something predictably become discouraged, confused and angry when their efforts fail, Dr. Wehlage wrote.) We talked about other things.

“You know,” Shannon said after a few months, “I think I should see a psychiatrist.”

It’s not as if I hadn’t tried to send to her to a psychiatrist half a dozen times. She had broken every appointment. This time, though, she kept the appointment, and the next one, and the one after that. Each was a tiny step in a better direction. I stopped feeling guilty when I billed do-nothing visits as if something had actually happened.

And then I called Dr. Wehlage in Indianapolis to thank him. He is retired now, and was most surprised to hear from a new reader of the old article. It turns out that a missing punctuation mark in the title still bothers him. “It’s not ‘doing nothing,’ ” he said. “It’s ‘doing no-thing.’ They left out the hyphen I wanted in there. You do no tangible thing. But you can still do a lot of something.”