Introduction

Reviews

Sometimes The Best Treatment Is No Treatment

Timothy B. McCall, M.D.

According to the proverb “The three greatest physicians are nature, time and patience,” many problems are what doctors call self-limiting, meaning that if they are left alone they will improve by themselves.

Sometimes, as in an emergency situation, an intervention must be performed without delay. When the situation is not urgent, watchful waiting or “tincture of time” may be a better course of action. Many people who decide against back surgery, for instance, get better anyway. If their symptoms don’t improve or worsen, they can often still have the surgery. If their symptoms go away, they have saved themselves the money, hassle and risk of surgery.

Consider cardiac catheterization, a test in which dye is injected into the heart’s arteries, which is the most accurate method to look for blockages. It’s also often a step on the road that leads to bypass surgery. A group of Harvard cardiologists studied patients who came to them for a second opinion on catheterization, to determine how often the test was really needed. In their report, which was published in the Journal of the American Medical Association, they judged that 80 percent of the patients didn’t need the test, that 4 percent should have it and that the remaining 16 percent needed further, less-invasive testing before the decision could be made. The authors conclude that half the catheterizations performed in the U.S. are either unnecessary or could be safely delayed.

If your doctor proposes an intervention that you are not sure you need, you might ask Why now? What would happen if I waited a month? A year? If the problem is acute appendicitis, you can’t afford to wait a few hours. If it’s a small hernia, you might be able to wait years.

As we have seen in past columns, an incorrect diagnosis can lead to inappropriate intervention. If the doctor has misdiagnosed your condition, an intervention carries all its usual risks without any commensurate benefits. There is little chance that you’d benefit from an intervention aimed at something you don’t have. Proper diagnosis is based on the doctor’s performing a thorough interview and physical examination and confirming or ruling out hypotheses with a judicious use of diagnostic tests. As time goes on, the physician needs to continually reassess your condition, making sure the initial diagnosis was correct and that nothing new has cropped up.

Remember, too, that just because an intervention is appropriate and effective for one medical condition does not insure that it will help others. Antibiotics are appropriate for certain pneumonias but not for the common cold. Likewise, doctors perform C-sections for both appropriate and inappropriate reasons. Before you sign on, be sure you know your diagnosis and the track record of the proposed intervention for your specific problem.

Next: Tough Treatment Decisions

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