Can't we just sit tight sometimes?

March 1, 2019
Mike Paul, DVM
Mike Paul, DVM

Dr. Paul is the former executive director of the Companion Animal Parasite Council and a former president of the American Animal Hospital Association. He is currently the principal of MAGPIE Veterinary Consulting. He is retired from practice and lives in Anguilla, British West Indies.

dvm360, dvm360 April 2019, Volume 50, Issue 4

When it comes to providing optimal care for veterinary patients, sometimes the best action is no action at all.

Most of the time if we don't make a situation worse it will improve on its own. When presented with a problem, it's human nature to want to take action. For medical and veterinary healthcare providers, the urge to “do something” when a patient's health seems out of sync is compelling. All too often patients and pet owners also expect something to be done any time they or their pet experiences the slightest symptom or sign. Illness and pain are frightening and surely something must be done, right? Nobody wants to hear, “Let's wait and see what happens.”

Hurry up and slow down

No action is taken in a vacuum. Every intervention we undertake has clinical consequences with potential negative effects on the course of a case, and we must weigh those consequences against the potential benefits of our actions. Instead of rushing to take action, I invite you to consider the following admonishments: “Don't just do something, stand there” and “Hurry up and slow down.”

I have always believed that sometimes the best thing to do is nothing. Of course, I am not recommending ignoring clinical signs and client complaints but rather keeping them in perspective. Observe, monitor and respond instead of taking immediate action. Every illness is important, but not every illness is urgent. All disease has an initial moment of onset-the first cough or missed meal or gastrointestinal upset-but we have all been presented with patients so early in the course of an illness that a real diagnosis was neither possible nor indicated. Yet we tend to react to client expectations and do something right away.

The downside of frantic doing

Intrigued by this idea? Australian physicians call it “masterly inactivity” in a recent article in Emergency Medicine Australasia. You can read it here.

Blood tests are an indication of health at one moment in time, but is it the relevant moment? Radiographs often lag behind the course of a condition. Will radiographs obtained on day 3 reveal more than they did on day 1? The rapidly out-of-control cost of care is a direct result of our sometimes unbridled urgency to gather diagnostics, ordering batteries of tests as a matter of course before initial results are even available.

While some caregivers are reflex doers, for others doing nothing initially is the primary way of thinking. If the patient is doing fine right now, why rock the boat? Given appropriate support, many conditions will resolve without the possible-and even likely-chance that we will do more harm than good. I recently learned a phrase for this approach termed “clinical inertia” that refers to “right care.”

Primum non nocere

First, do no harm. It's the most basic tenet of medicine. At a close second is preventing clinical harm. In veterinary medicine today our first instinct is often to submit blood or perform some other diagnostic test. Don't get me wrong, there are clearly indications-sometimes urgent-for invasive and noninvasive procedures to be conducted when a sick patient is presented. But there is a “time to every purpose.” Eighteenth-century French philosopher Voltaire said, “The art of medicine consists of amusing the patient while nature cures the disease.”

Early in my veterinary education I was told by one of my professors that we have far less impact on clinical outcomes than we think. Most of the time if we don't make a situation worse it will improve on its own. Sometimes there is nothing we can do that will help. And other times, I think far less than 50 percent, we have a definitive positive effect and the patient truly responds because of our actions rather than in spite of them. In other words, if you don't screw it up it probably will be fine. The challenge is in knowing which group your patient falls into.

Some years ago a chiropractor told me he saw his primary role in patient care as supervising the recovery of patients who were going to get better if they didn't get worse. By “adjusting” them every few days he could remind them to give it time. “If it hurts when you do that, don't do that,” he told them. Maybe he was onto something.

Dr. Paul is the former executive director of the Companion Animal Parasite Council and a former president of the American Animal Hospital Association. He is currently the principal of MAGPIE Veterinary Consulting. He is retired from practice and lives in Anguilla, British West Indies.

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