Watchful Waiting #illumedati


Hey guys, it’s Medicine Mondays again. To be honest I wasn’t sure what I was going to write about today. However, I recalled in my prior posts about the importance of “doing nothing”. So for today’s post, I’m going to talk about Watchful Waiting. This should be a short post.

Watchful Waiting

Stock Photo from: Pexels

So it’s mid August now…

All of the new interns have cut their teeth now and have a bunch of patients under their belts. Their experience has grown exponentially in the last 6 weeks. The same can be said for the residents and the young attendings. However, I think now is the appropriate time to review an important part of medicine.

Doing nothing.


!!!!!???? – Doing nothing is important?

Yes. Intrinsically, we know this just by being human.

Let me tell a little story:

My daughter was at a birthday party yesterday. The birthday boy and his family were going to be moving to the East Coast, so his birthday was kind of a birthday/Bon Voyage party. There was probably around 70 or so people there total (adults and kids). It was a great party with all the stuff kids want: Bounce House, Moana and Maui, Shave Ice Machine, Taco Stand, etc.

As you would expect, Kylie was having a lot of fun in the Bounce House. However, she went down the slide of the Bounce House and then when she was running back to the front she must have tripped on a little tree branch and cut her foot. As you would expect, she looked around for my wife and I, but didn’t see us immediately, so she ran to Moana instead. Moana picked her up and comforted her while I walked over.

She was ok don’t worry.

She had cut her foot right at the nail and there were a few drops of blood. The cut itself wasn’t deep, but because of the way the cut was angled it lifted some of the skin up. As you would expect my wife and I cleaned it out with some water and one of the other parents have a bandaid handy. So a few minutes later, she was all patched up and ready to play again.

I think the above story is a common one. However, the first instinct in this scenario is that nothing intense really needs to be done. For example, I wasn’t going to rush her over to urgent care and demand antiobiotics or get an MRI of her foot. To be honest, we probably didn’t need to do anything at all. The cut had already stopped bleeding.


Well, that makes sense, I guess.

However, we, as physicians don’t want to miss anything and are always compelled to “do something”. Remember the quote “don’t just stand there, do something!”? It’s kind of like that.

One of my OB attendings when I was a 3rd year medical student let me deliver my first baby. I was nervous, of course, and I guess he must have noticed.

Here is our conversation:

“Why are you nervous? What are you afraid of?”

“What if I make a mistake?”

“Childbirth is the most natural thing in the world. The baby will come whether you’re here or not. Your job is to do nothing, unless needed.

This has the effect of immediately calming me down. My first delivery went well, and I delivered a lot more babies during my OB rotation.


I see, so doing nothing is important?

Well yes, but it’s actually more than that.

I think we need to remember that when we choose to “doing nothing” it is actually “doing something”. It’s a conscious decision that comes after carefully evaluating the patient, that nothing needs to be done or needs to be changed. The term most commonly used for this is “watchful waiting”.

Apparently, there are related terms which are, (From Wikipedia):

  • expectant management,[1] active surveillance and masterly inactivity.[2] The term masterly inactivity is also used in nonmedical contexts.[3]

I have heard the term expectant management before, but not active surveillance or masterly inactivity.

Of those terms, I really like “masterful inactivity“. I think it really describes what is being done.

“It’s not ‘doing nothing’, it’s ‘masterful inactivity.” — masterful. Not just inactivity, but masterful inactivity.


Masterful inactivity huh?

Yes!

So, remember this the next time your team comes together and is trying to figure out the plan for Mr. Smith over in Room 423.

If, after carefully evaluating the patient and his current treatment plan, you don’t think there is any need to change anything, then have the team consider “Masterful Inactivity”.

Quick side note:

Whenever I hear the word: “Master” I always remember this scene from “The Last Dragon“, a really great 80’s movie.

If you guys haven’t watched the movie before and want some 80’s nostalgia, I’d recommend watching it:

As of this post 8-14-2017, you can rent it for $3.99 from Amazon Video, or just buy the physical DVD for $5.99. I don’t think the Blu-Ray version adds much, although it does come with an Ultraviolet code for those who like to keep all their movies in a digital library.


How do I know when to use “Masterful Inactivity”?

I think a lot of this will come with experience and your comfort with patient management. But it all comes down to one very simple question:

“How’s the patient doing?”

This is how physicians talk to each other. It used to confuse me when I was a medical student whenever the attendings would ask me this question after I went to do examine one. I used to say “Um, he’s doing ok I guess.” I never understood how to answer it until I figured out what they really wanted.

The answer to this question is not a simple “fine”, “ok”, or not good”. This question is meant to give you the opportunity to provide everyone with the important information you were able to gather from examining the patient and then provide your evaluation. From this you provide your treatment plan.

The purpose of this post is to keep “Watchful Waiting” (or “Masterful Inactivity”) in the back of your mind when formulating a treatment plan.

Sometimes “doing nothing” will help the patient a lot more than making sweeping changes to the treatment plan.


TL;DR

“Doing nothing” is still “Doing something”.

“The baby will come whether you’re here or not. Your job is to do nothing unless needed.”

Always keep “Watchful Waiting” / “Masterful Inactivity” in the back of your mind.

“Who’s the Master?” You are. (The Last Dragon is a great movie.)

Also: Yay! Kind of a short post today!

Medicine Mondays Sensei

-Sensei

Agree? Disagree? Questions, Comments and Suggestions are welcome.

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