Wednesday, 14 November 2012

Virtues of doing nothing

In article titled 'Buffet succeeds at nothing'  Buffet fan and investor Mohnish Pabrai writes about the need to avoid reacting to every little flicker of the ticker, enjoy long periods of relative quiet and inactivity. Sitting on their butts as they put it. Apparently it is beneficial, well of course it is, it made them very rich.

I love it when Pabrai says 'Eventually the nerds got fidgety....'. High intelligence and high skills can sometimes be an high intensity problem - people want to use their intelligence and skills often. They want to prove it often to themselves - a need to pamper our egos. They want to show off to lesser mortals around them - the feeling of superiority gives us a true 'high'.  This leads to the cleverer ones doing things when the better option would be to actually do nothing.

Masterly inactivity is well known to doctors especially who are obstetricians. Anaesthetists achieve excellent safety in the administration of general anaesthesia and we know very well that for most general anaesthetics there are brief periods of intense activity followed by long periods of studious and judicious inactivity. However for many other doctors there is the desire to do something. That sometimes actually achieves good results for patients. However, this urge to do something also results in unnecessary investigations, overdiagnosis, un-indicated procedures, too many follow up appointments, wasted education programmes, mere activity replacing achievement, medicalising normality, therapeutics for the false positives, narrower sub-specialisations,.............. Do I need to go on?

In quality improvement theory, to intervene when not indicated is actually called tampering, which is inevitably a waste of time and could be seriously harmful. The term inactivity is actually used with caution here, it does not mean completely switching off and going to bed, it means that we need to observe the effects of action. Once an action is initiated, it takes time to see its effects, it takes time to gather data, it takes time to analyse the data, it takes time for trends to develop, it takes even more time to understand trends and it takes a lot longer to decide on how to respond to the trend analysis. The frame of time of course varies depending on the activity; seconds, minutes, hours, days, weeks, months, years, etc

Most of us have no respect for this line of thought and would react to individual events rather than proper trends. Anyone who has studied some decent management would have learned that the cost of indecision is higher than the cost of a decision. This is taken as a call for action, often hasty, often unindicated. The decision not to act before it was necessary is a wise decision, this is often mistaken by fools as indecision. I would say the cost of unindicated action is higher than the cost of indecision. 

The importance of doing nothing is especially acute in clinical medicine and healthcare. We have in Clinical Wrongology already touched briefly on the lack of evidence for most of the activity we do in clinical care, the high rate of errors in clinical care delivery processes, our inability to agree with our colleagues and our lack of acceptance of these issues. Logic demands that under these conditions we should often do nothing, since doing something is more likely to be wrong. To act hastily under these conditions and to react to every point rather than proper trends is indeed a recipe for disaster and adds to the wrongness in healthcare.

Whenever there is a choice between action and inaction the cleverer ones chose action. We all know for every action there is an equal and opposite reaction. That reaction may neutralise the effect of the action or worse cause harm. To do or not to do, becomes a very relevant question for clinicians. To do something when doing nothing would be better requires a higher level of maturity and judgement apart from better operational evidence. 

Do be very discerning in understanding this blog, I am not saying we should not act when the situation demands it. I am asking you to think if we act even when the situation does not demand it, if we do, then I am arguing that there may be virtue in doing nothing.
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