The right upper quadrant

July 2013

Professional

A is for aphorism

‘Nothing is sometimes a good remedy’

Volume 42, No.7, July 2013 Pages 507-508

Benjamin Mitchell

Georga Cooke

We live in a different era of medicine than that of the great Hippocrates. Our patients are better informed, with ready access to a plethora of medical information, and enter the consultation with expectations of being offered therapies for all their ailments. But is it still true, over 2000 years after Hippocrates, that ‘nothing is sometimes a good remedy’?

To investigate if Hippocrates was onto something, we each undertook a ‘straw poll’ in our respective university departments. While straw polls are not a commonly published methodology, our personal experience would suggest that this is the most common research method used by general practitioners in daily practice. Interestingly, a MEDLINE search for ‘straw poll’ resulted in five hits.

In our straw polls, staff members were asked to cite examples of where doing ‘nothing’ is a good remedy:

  • routine single session individual psychological debriefing for the prevention of post-traumatic stress disorder after traumatic incidents1
  • feeding tubes for advanced dementia patients2
  • over-the-counter cough medicines for acute cough3
  • antibiotics for the common cold and acute purulent rhinitis4
  • routine episiotomy in vaginal births5
  • flecainide in post-myocardial infarction patients6 (perhaps the most famous example)
  • abstinence-only teen sex education programs7
  • eye patching for corneal abrasions8
  • corticosteroids for tennis elbow.9

In all the examples, doing nothing (such as not patching an eye for a corneal abrasion) is the better remedy.

It seems the drive we feel to do something has influenced doctors to continue to use all types of treatments that do not work.10 Sometimes knowing if treatments work is not always clear, but the risk of harm is minimal. For example, the evidence for the routine use of alcohol swabs before administration of intramuscular injections is weak, but a lack of evidence doesn’t necessarily suggest a lack of effect, and the cost and risk of harm is small.11

Of course, if treatments and investigations can cause harm, then doing nothing can become a good remedy. Considering the examples listed, it is important to define explicitly what Hippocrates meant by ‘nothing’.

Doing nothing would not involve ordering expensive tests or instituting active treatment. In deciding to do ‘nothing’, doctors will greet the patient, take a history, and perform an examination. ‘Nothing’ will also involve discussing with a patient what you think is going on, listening to their concerns and providing further explanation, reassurance and safety-netting advice. ‘Nothing’ is comprised of the therapeutic relationship we create in a consultation or across a series of consultations. Similarly, ‘nothing’ is the education, communication skills and any generic benefits that patients receive from simply visiting their GP. So when we think of it like this, ‘nothing’ is clearly ‘something’. 

However, with a growing list of clinical situations where doing nothing is proving superior to doing something, the challenge becomes one of deciding how to do nothing. How do we explain to patients we will do ‘nothing’? Calling bronchitis a ‘chest cold’ improves patients’ satisfaction when they don’t receive antibiotics,12 and doctors’ understanding that patients want pain relief more so than antibiotics for sore throats13 are two examples where, through skillful consultation, doctors can practise the art of doing nothing. Here, the doctor is the treatment, and the clinician’s reassuring thorough consultation is probably more effective than looking for investigations to do the same.14

Evidenced based medicine can help us champion new therapies, temper our use of existing ones, and help us to decide when to leave something behind and move forward. We let go of therapies where the harm outweighs the benefits, as doing nothing becomes superior. Doing nothing in the face of a child with acute viral cough, despite our in-built desire to do something, demonstrates simultaneously modern medicine’s ineffectiveness for curing the common cold; the recognition that cough medications and mixtures simply do not work3 and may be harmful;15 and the ethical obligation to our patients to prescribe the correct treatment, even if that means not prescribing antibiotics or other therapies. Here, nothing, albeit not truly nothing, is not only a good remedy, but the best remedy.

Competing interests: None.
Provenance and peer review: Commissioned; not peer reviewed.

References

  1. Rose SC, Bisson J, Churchill R, Wessely S. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database Syst Rev 2002;(2):CD000560.
  2. Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev 2009;(2):CD007209.
  3. Smith SM, Schroeder K, Fahey T. Over-the-counter (OTC) medications for acute cough in children and adults in ambulatory settings. Cochrane Database Syst Rev 2012;(8):CD001831.
  4. Kenealy T, Arroll B. Antibiotics for the common cold and acute purulent rhinitis. Cochrane Database Syst Rev 2013;(6):CD000247.
  5. Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev 2009;(1):CD000081.
  6. Preliminary Report: Effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial Infarction. N Engl J Med 1989;321:406–12.
  7. Stanger-Hall KF, Hall DW. Abstinence-only education and teen pregnancy rates: why we need comprehensive sex education in the U.S. PLoS ONE 2011;6:e24658.
  8. Turner A, Rabiu M. Patching for corneal abrasion. Cochrane Database Syst Rev 2006;(2):CD004764.
  9. Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA 2013;309:461–9.
  10. Doust J, Del Mar CD. Why do doctors use treatments that do not work? BMJ 2004;328:474–5.
  11. Pratt RJ, Hoffman PN, Robb FF. The need for skin preparation prior to injection: point – counterpoint. J Infect Prev 2005;6:18–20.
  12. Phillips TG, Hickner J. Calling acute bronchitis a chest cold may improve patient satisfaction with appropriate antibiotic Use. J Am Board Fam Pract 2005;18:459–63.
  13. van Driel ML, De Sutter A, Deveugele M, et al. Are sore throat patients who hope for antibiotics actually asking for pain relief? Ann Fam Med 2006;4:494–9.
  14. Rolfe A, Burton C. Reassurance after diagnostic testing with a low pretest probability of serious disease: systematic review and meta-analysis. JAMA Intern Med 2013;173:407–16.
  15. Therapeutic Goods Administration, Australian Government, 2009. TGA internal panel report on the safety, efficacy and use of cough and cold medicines in the treatment of children aged 2–12 years.  Available at www.tga.gov.au/pdf/ archive/consult-labelling-cough-cold-091022-panel-report.pdf [Accessed 10 June 2013].

Correspondence afp@racgp.org.au

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Article Series

Medical aphorisms

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Professional