Thread by @TheRealDoctorT

(The following thread refers to a specific situation and isn’t always broadly applicable. I am by no means saying that doing nothing is always the right decision.)

“They muddy the water, to make it seem deep.”
- Nietzsche

“Muddy water, let stand, becomes clear.”
-Lao Tzu. 1/

The patient lying before me in the hospital bed has presented a clinical problem for which a solution is not readily apparent to me.

Wildly fluctuating blood pressures, tenuous kidney function, and abnormal electrolytes.

She is frustrated.

And scared. 2/

I am the fifth specialist to see her.

Numerous medications have been started, then discarded.

A dizzying array of tests and diagnostic exams have been ordered.

The results have been confusing and the picture has gotten murkier, not clearer. 3/

I decide to go back to the drawing board, and stop all the numerous blood pressure medications that have been heaped on board by numerous other doctors.

The consulting physician asks me what I want to do instead.

My answer seems to surprise him.

“Nothing. Just wait.” 4/

There is a distinct bias in modern Western medicine towards the intervention.

Take the medication, have the procedure done, get the answer.

Do something.

Do. Something. 5/

Every day on rounds in hospitals across America, case managers ask, “So what are we doing for patient X today?”

The unspoken (and sometimes spoken) question is, “And why is the patient still in the hospital?”

If there’s no intervention planned, a hospital day is “wasted.” 6/

The human body has a remarkable ability to regenerate and heal. It has numerous homeostatic mechanisms.

Sometimes all that’s needed is... time, and careful observation.

Our attempts to accelerate a natural process artificially can potentially backfire in terrible ways. 7/

Antibiotics for self-limiting (or viral) infections is a common example of an unnecessary attempt to speed up a natural process.

So is giving someone heavy doses of diuretics when their kidneys are already “auto-diuresing,” or removing excess fluid by themselves. 8/

Blood pressure med management is often a pinball machine of wildly varying and reactively adjusted medications with little underlying mechanistic synergy, coherent strategy, or understanding of drug interactions.

There are often too many cooks who aren’t communicating. 9/

Sometimes we need a day or two (or more) to just “equilibrate” and let the body find its homeostasis. It’s what it has evolved to do, on a systemic level.

Feedback loops upon feedback loops, nudging us constantly back towards the center point, the balance. 10/

Of course this isn’t always the case, and often an intervention is needed, sometimes urgently.

But it’s also important to understand that deciding to do nothing is not the same as making no decision at all. 11/

The “tincture of time” is a therapy as old as medicine itself, and shouldn’t be discounted.

I’m not saying don’t take your meds, or don’t get procedures done, or don’t listen to your doctors.

I’m also not saying that doing nothing is always right. It can be a big mistake. 12/

I’m just saying that if your doctor decides not to do anything but wait, it can be a therapeutic decision also.

After stopping all my patient’s blood pressure meds and waiting for 24 hours, the electrolyte abnormalities become clear, and the blood pressure is stably high. 13/

I am now able to run a few tests to diagnose the underlying issue, and am able to start correcting it with two medications instead of six.

The patient is discharged home to follow up with me in clinic.

Eventually she only needs one medication.

Her pressures are fine. 14/

This doesn’t always happen this way.

Not all pauses result in clarity.

But every now and then, if you’re searching for something in muddied water, standing still is your best bet.