The art of doing something

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….

    1. Dariusz Galasinski

      Yes. I agree with you, but this is why I said it was so difficult to make a judgement. For me, especially at the beginning, it was the inaction, the waiting, which was the source of most suffering. I am in pain and they do nothing. But I understand how it can change

      Thank you for the link! I will read and respond.

  1. I think sometimes, the courageous thing for a patient to do is to walk away, even though we can’t be entirely sure that we are walking towards something better.

    Not all doctors are the same; your current GP sounds like a dick, if I may say so. Sometimes, doctors simply cannot give us what we need, no matter what “should” be the case.

    Frankly, not all qualitative researchers are the same, are they? I’m not expecting a direct response, but I don’t have the same responsibility as you to be coy about the matter: I’m just hoping that you know that regardless of whether you ever come to feel perfectly “fluent” in the English language, you are a delightful wordsmith and your writing pisses on the chips of so many of your UK peers. 🙂

    GPs are no different in their variability but even the really good ones are not going to be able to show a great deal of public solidarity with you on this, because of their own sensitivities and perceived responsibilities to their peers.

    I know it’s hard making changes in the middle of any kind of crisis, when the stakes seem high either way, but as an “expert by experience” in the art of dealing with dick doctors I think your GP is doing it all wrong. There are better, more empathic and emotionally-intelligent people in the profession who will be able to give you the understanding and respect that you need and deserve.

    Take as good care of yourself as you can, whatever happens with the doctor. 🙂

  2. I agree it’s a power relationship. That’s inescapable (not anyone’s fault, just a fact). But what if inaction is made transparent and agreed? For example, deferred prescription of antibiotics – probably the commonest example – where the doctor seeks consent to the *watchful waiting” you dislike? It would be far easier, and an abuse of power, for the doctor just a write a prescription. Or is all patient consent an illusion?

    1. Dariusz Galasinski

      I agree – it’s a spectrum of situations, from unilateral inaction to one which is agreed upon. The extremes of such a spectrum are very very different. And if ever a medic is to watchfully wait, s/he should negotiate and agree this with the patient.

      No, not all patient consent is an illusion, though I’d suggest consent is far more complicated than is, I think, commonly assumend.

  3. Although it’s a while since I read it, I think Iona’s essay assumes a context: one where a GP might see 50 or 60 patients and day, and by far the easiest thing to do is to create the illusion of doing something (a glib diagnosis, a pointless test, a futile treatment) simply in order to give patients transient satisfaction and get them out of the door as quickly as possible. Given that context, I can’t see the problem with framing inaction as courage. In pragmatic terms, medical conditions often only become apparent over time, and reacting to a snapshot each time can make things far worse than committing to watching how things evolve over time.

    1. Dariusz Galasinski

      John, this time we disagree. I sympathise with GPs, I actually really wouldn’t like to be one. The range of issue, the breadth of knowledge required – it’s breath-taking. Inaction still is not courageous. It’s just part of a decision process in which the decision is made by one person. It might be uncomfortable, but no, it is not courageous.

      This is because when you are in a relationship in which you call the shots, you are the powerful one, nothing you do requires courage. It’s to be nuanced, but that’s the bottom line, in my view.

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