The Art of Doing “Nothing” Well

A couple years ago, I took care of a 12-month-old boy with a cough. He had been seen by three other doctors over the last two days. Initially, he was seen by his pediatrician, who told his mother that it was “just a virus” and that his symptoms would go away on their own. Unsatisfied with this answer, she left the pediatrician’s office and drove immediately to an urgent care facility, where she was told that her son had pneumonia, and he was started on an antibiotic. The next day, he was coughing more. So his mother took him to a different urgent care facility, where a second antibiotic was started.

On the third day, she brought the child to the pediatric emergency room where I was working. She was very concerned that his cough was worsening, despite the two antibiotics he was on. She was worried that he had now developed diarrhea, in addition to his original symptoms. And more than anything, she was irate that his pediatrician had done “nothing.”

Everything about his history and physical exam screamed “bronchiolitis” (a common viral respiratory infection in young children that does, in fact, go away on its own). Worsening over the first three to four days is exactly what I would expect from this illness. And more than likely, his diarrhea was a result of the antibiotics he was on.

As far as bronchiolitis cases go, his was mild. He was eating well and breathing comfortably—just coughing a lot and dripping snot everywhere. According to the most current treatment guidelines, he truly needed nothing but nasal suction—and maybe a humidifier. Eventually, I was able to explain all of this to his mother, convince her that he would be ok (better, even) without the antibiotics, and arrange follow-up with his pediatrician the following day. But it took time. Doing “nothing”—and doing it well—isn’t easy.

In reality, doing “nothing” involves quite a bit of work. Choosing to do “nothing” presumably involves the doctor listening to the patient’s symptoms, gathering relevant details, performing a physical exam, and reaching the conclusion that no further testing or treatment is warranted. In many cases, doing “nothing” is the most appropriate course of action. And in these cases, doing more would place the patient at risk for harm from unnecessary tests or treatments (like my patient’s diarrhea—or worse, a life-threatening allergic reaction to a medication).

At the risk of trivializing my profession, the majority of patients seen by pediatricians would be just fine without us. When I first discovered this, I was somewhat disappointed. But then I realized this doesn’t mean that pediatricians are irrelevant. On the contrary, one of a pediatrician’s primary responsibilities is reassuring parents about normal or mildly abnormal conditions.

But providing this reassurance requires a great deal of knowledge about those things that would be more concerning. Vomiting could be due to a viral illness, a head injury, a bowel obstruction, or new-onset diabetes (among many other possibilities). A fever could be caused by a self-limited illness or an overwhelming infection. Doing “nothing” involves discerning the sometimes subtle differences between the common and the complex, sorting out the few who really need us from the many who don’t. And it requires a level of confidence sufficient to send the patient home, knowing that being wrong could have disastrous results.

Most people who seek medical care for themselves or their children—especially in urgent care or emergency room settings—expect testing or treatment. After all, if they thought that doing nothing would be sufficient, many of them would have stayed home. Convincing them that they don’t need these things, and effectively explaining why, can require far more time than simply writing the prescription. Many physicians today, due to a shortage of time or concerns about low patient satisfaction scores, over-diagnose and over-prescribe to avoid this situation altogether. But a doctor who always gives patients what they want either has remarkably well-informed patients, or practices poor medicine.

“Doing no harm” frequently means doing nothing at all. But doing “nothing” well is more than saying “it’s just a virus.” It requires expertise, confidence, and communication—and it’s much easier if the doctor has already developed a relationship of trust with the patient or family. The doctor must know enough to make an accurate diagnosis (or at least rule out the scary ones)–when working with children, this means having sufficient training and experience with childhood illnesses. The diagnosis should be explained to the family in a way that they can understand. The family should know what to expect, what changes would be truly concerning, and what to do if one of those concerning things happens. They should leave the visit understanding why “nothing” was done–and ideally, being grateful for a doctor that cares enough to do nothing.

As always, your comments are welcomed (even if you happen to disagree). I'll get back to you as soon as I can. Please try to keep it civil--I reserve the right to delete comments that are offensive or off-topic.

7 thoughts on “The Art of Doing “Nothing” Well

  1. Even though, as a parent, I know this, and will mostly wait out most sicknesses, it is so tricky! Most recently, my whole family had a bout of strep throat (Me and three children ages 4-7 mos.). With the 2 yr old and 7 mo old, they just had a low fever (under 101, which is the typical threshold of “worry”). My 4 yr old, the only one who could really voice his discomfort, only complained of a headache (which turned out to be a concurrent ear infection). Had I not gone to the dr. first and gotten tested, there is no way, with the minor and typical symptoms they all presented, that I would have even taken them to the doctor! It has me rethinking all of my wait-and-see tactics!

    • Jena–that’s why your doctor is there. When you’re worried enough that you need help (even if that help turns out to be nothing more than reassurance), it’s the right time to take them in. Hope everyone is feeling better!

    • Here’s something that may surprise you: There’s debate about whether ear infections, or even strep throat, need antibiotics at all. The British joke that Americans are the only docs that treat your ear infection by giving you diarrhea (side effect of the antibiotics). Wait-and-see (and symptomatic treatment) may have been a perfectly fine tactic anyway.

  2. ok, but the doctors at the ******** did “nothing” for my daughter’s leg cramp and pain, said it was a pulled muscle. They did this not one time, not two times, but rather, Three or Four times over approximately a one year period. A simple ultra sound would and did reveal a tumor, Synovial Sarcoma which after a Year of “doing nothing” was stage four cancer with little or no hope of cure. While I agree with the assessment of a virus, in your case, other factors should be considered when appropriate.

    • Mark–sorry to hear about your daughter. That’s a terrible situation. And you are exactly right–while the majority of pediatric illnesses will go away on their own, there are some things that are worth investigating. Deciding which cases are which isn’t always straightforward. Thanks for sharing your experience and insight.

  3. This was really useful read. I’ve just been through my daughter’s first bout of rsv, at her five months, and I think this effectively describes all the underlying thoughts and reasoning involved in my ped’s visit. However, I wish our doctor would have been able to explain this in person, I found the visit super unhelpful at the time and reading this helped me make peace with it.

  4. Hi Dr. Hayes – I would so appreciate your comment on how a doctor determines definitively that a 6 year child has bacterial pneumonia as opposed to viral pneumonia (or other condition). My child who complained of a sore throat on Thursday and then ran a fever of 103 on Saturday. Her sore throat improved by Monday but she developed a cough and still ran an intermittent low grade fever by Tuesday. She said she felt fine and wanted to return to school. We took her to the doctor who diagnosed her with bacterial pneumonia based on hearing crackling or popping in a “focused” area of the lungs (opposed to general blockage which would have indicated “viral” to her). She also had 101 degree temperature. My child’s breathing / oxygen was in an ok range evidently but also improved with a nebulizer. No other testing was performed. She was prescribed a 10 day course of amoxicillin and a nebulizer with albuterol. This is a relatively new doctor for me and so I dont have a sense of her approach to antibiotics. My child has already been unnecessarily treated with antibiotics for “ear infections” before theAPA guidelines were revised. AmI under-reacting? We are using the nebulizer today but should I get a second opinion before having her take the augmentin?

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