When I first read “The art of doing nothing” by Iona Heath some time ago, I was smitten by it. A real doctor talking about listening to me, taking the time to consider. Wonderful! Over the last few months, I have changed my mind. As you listen and notice, the only thing I’d like to tell you is: For pity’s sake, do something, my body’s on fire. I’ve been ill, you see.
In this post I want to offer my (new and ill) perspective on the essay. It still is very good and thoughtful. After all, who would disagree with listening with an open mind, not medicalising my experience or not using ineffective treatments? And yet, I don’t think this essay is about me. It’s one doctor talking to another doctor, as I, your (almost) average patient, can only watch as you iron out the finer points of medicine, philosophy, and poetry. Sorry, I don’t care.
So, yes, of course, I agree with listening and being open. But do I care about the problem of the ‘diagnostic label’? No, it’s your problem – my body’s on fire, remember? So as you keep considering whether to give me a label, please consider also that I just don’t care (yes, I understand that diagnostic labels are not innocent, particularly in psychiatry; I also think diagnostic labels are not only ‘for me’, they are also for you). While I appreciate the question about the right care, putting it on a par with the diagnostic label worries me. This hierarchy of issues has nothing to do with mine.
And this is where I come to the crucial sentence in the essay:
Doing nothing but having the courage sometimes to wait – to use time as both a diagnostic and a therapeutic tool – to see what nature does – to wait and see.
Is it really courageous to wait? Really? As doctors congratulate themselves, I’d like them to, please, spare a thought or two about me. When I come to see you again and again, and again, you tell me that we must wait, I actually would like my courage to be, shall I say, noticed. Why courage? Because I know that you will tell me more about waiting, but I simply cannot face more waiting, watchful or not. It’s also courageous because sometimes, when it gets really hard, I want to do and say things that I am not allowed to (and I probably should not write about them explicitly – but you get the picture, I think). In a nutshell, you clearly have no idea how courageous it is to show the restraint I am showing
And believe me, there is nothing therapeutic about waiting, especially for a doctor to be ready to ‘do something’, after their decision, in their own time (of course, it’s about power!). And every visit after which we wait some more, your assurances of listening and noticing, let alone of my health, sound ever more hollow. And as my restraint requires more courage, I really, like: really, don’t care for another quote from another philosopher or poet.
Also, please do spare me being present for the entirety of 10 minutes (unless I start shouting), as I go home and face my pain, my illness, my despair on my own. Gosh, how lucky you are to be able to do all this waiting, yes, at my expense. Any ‘empathic witnessing’ (I do love Kleinman, but has he ever been ill?), I think, must very quickly turn into not much more than a source of irritation, anger, and feeling of being left to my own devices at a time when I need you more than ever.
But then, I’m just a patient, forgive me, so what do I know about overdiagnosis, the futile and ineffective treatments? But let me tell you that if ever I could choose between an ineffective treatment and waiting for a doctor to do something, I would always take the former. Yes, of course, there are caveats to be made, no one wants a treatment that does serious harm, but at the end of the day, at least I would know that you do something, that you focus on me, you’re trying to help me. Believe me, as warranted as ‘watchful waiting’ might be both ‘objectively’ and for the doctor, I mostly read it as ignorance, attempts to save money, ideological posturing.
So, I really cannot see doing nothing as art, let alone as courage. In fact, I detest it.
That’s my rant. As rants go, it is as sincere as I dare make it. But it comes from me speaking as a patient. Now comes the academic. What Iona Heath wrote is great, really. In fact, I recently wrote that the core of medicine is listening, acknowledging and understanding. I would not presume to say that we, i.e. Dr Heath and I, agree, but there is synergy between the views (I’m not actually entirely certain I am allowed to have such views). The problem is that I wrote it as an academic. Intellectually, what the article proposes is unchallengeable in my view. In real life, however, as a patient, I would always choose the obnoxious Dr House who makes me feel better than a doctor who practices the art of doing nothing.
The academic in me also understands that the article makes a certain intellectual positon clear. This position can then be developed in various social, medical, institutional and ethical contexts. I also understand that Dr Heath’s article is not really directed at me as a patient, it’s doctors speaking to each other, almost outside any experiential context. I am probably not even invited to listen.
Understanding this, I still would like to make three points.
1. I reject the notion of ‘courageous waiting’. No, it’s not. If it makes sense to talk about courage, please do not take the high moral ground just because you do nothing, even if your doing nothing makes perfect medical sense. Medicine is not the only context here.
2. I think doctors should not only help, but also be seen to help. When they ‘watchfully wait’, I would encourage them to think about patients looking at them, I would venture a guess, with bewilderment, as they see inaction.
3. The third point is somewhat more complex. All the listening and noticing is predicated on one assumption: that there is this wonderful, skilful, good listening that you can do (though I am yet to see it described in some practical detail and in a context, but maybe I don’t know the literature well enough). I understand that I am not entirely ‘your average patient’, still, I am yet to be ‘really listened to’ and acknowledged. I mean, apart from doctors puling their ‘listening faces’, which are funny and irritating in equal measure.
Moreover, listening is also constructed as giving that wonderful and holistic access to the ‘real me’, including my real needs, wants, desires. Let me put it gently: No, it bloody doesn’t. Just as I am not going to tell you, what matters to me, no, you will not get this wonderful clarity through which you will decide about ‘the right care’. So, a sentence such as:
What sort of care would be right for them – at this time and in this place?
is as much underpinned by your decision, by the exercise of your power, as any other. Except it’s hidden better.
And here we come back to the issue (almost) everything in medicine starts and ends with. Power. As you decide to listen, not to put the label, or leap to conclusions, no matter what you do, all those things are about the doctor and the power s/he wields and granting us the favour of doing it in some particular way. I also wonder, however, whether this is not the point from which to start. How about:
The art of being powerful….