Iona Heath

The art of doing age is remarkably preoccupied with sure to DO and it takes many forms and
Signa al

the vision of continually improving these are just some of them:

nothing means rather than saving ourselves
trouble by reflecting on ends.2 Listening, noticing
Op het WONCA-congres ‘The Art & Science Thinking
of General Practice and Family Medicine’ in Ours has become the age of unthinking Waiting
Wenen hield op 5 juli 2012 dr. Iona Heath,
voormalig President of the Royal College of
doing – keep doing, don’t stop to think Witnessing
General Practitioners, een indrukwekkende – there’s no time! And there’s no time Preventing harm
keynote lecture met de titel ‘The art of because we are too busy doing.
doing nothing’. In dit signaal geven wij u de
The American poet William Carlos Each is an art in its own right – re-
tekst die zij bij die gelegenheid uitsprak.
Williams who was also a general prac- quiring judgment, wisdom and even a
titioner understood very clearly how sense of beauty.
The wisdom of others easy it is for doctors to succumb to this
In his 1994 book Alone again: ethics after particular vicious circle. In his 1932 Listening and noticing
uncertainty, the sociologist Zygmunt short story about ‘Old Doc Rivers’ he Doing nothing – but instead – listening
Bauman quotes the German psychia- wrote – and noticing. It is impossible to do and
trist and philosopher Karl Jaspers: to listen intently and accurately at the
With this pressure upon us, we same time. Anyone who has tried to lis-
Our time thinks in terms of ‘knowing eventually do what all herded things ten to their children while also trying
how to do it,’ even where there is do; we begin to hurry to escape it, to cook a dinner knows this to be true.
nothing to be done.1 then we break into a trot, finally into William Carlos Williams describes the
a mad run (watches in our hands), intensity of listening in general prac-
In her 2001 book Science and Poetry, the having no idea where we are going tice:
British philosopher Mary Midgley ex- and having no time to find out.3
panded on this point: It is actually there, in the life
I suspect that everyone who has worked before us, every minute that we are
Out of this fascination with new in general practice recognises this phe- listening, a rarest element - not in
power there arises our current huge nomenon. Rushing around all day – no our imaginations but there, there in
expansion of technology, much of it time to stop, to listen, to think, to no- fact. It is that essence which is hidden
useful, much not, and the sheer size of tice – or even – to go to the toilet! in the very words which are going
it dangerously wasteful of resources. The Austrian Nobel Prize winning in at our ears and from which we
It is hard for us to break out of this physicist Erwin Schrödinger, most fa- must recover underlying meaning as
circle of increasing needs because our mous for his cat, seems to have under- realistically as we recover metal out
stood the importance and the power of of ore.5
the art of doing nothing:
He describes this essence as the nearest
In an honest search for knowledge most patients come to the poetry of
you quite often have to abide by their lives as they struggle to give ex-
ignorance for an indefinite period. The pression to their deepest feelings and
steadfastness in standing up to [this fears in the quiet privacy of the doctor’s
requirement], nay in appreciating it as consulting room.
a stimulus and a signpost to further The Scottish poet Kathleen Jamie
quest, is a natural and indispensable thinks that the necessary commitment
disposition in the mind of a scientist.4 and concentration of listening and no-
ticing come close to the idea of prayer
He seems to me to be describing the
importance of the pause for thought Isn’t that a kind of prayer? The care
– especially in the conditions of igno- and maintenance of the web of our
rance and uncertainty so common in noticing, the paying heed.6
general practice.
Taking all this wisdom into account, And when she describes her experience
my conclusion is that, perhaps coun- of bird-watching – it sounds so close to
ter intuitively, in medicine, the art of the kind of receptiveness that we need
doing nothing is active, considered, and in general practice:
deliberate. It is an antidote to the pres-

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This is what I want to learn: to notice, nes which were designed to provide strong magnets.
but not to analyse. To still the part guidance but, abetted by a multitude By the characteristics of sweat.
of the brain that’s yammering, ‘My of subtle pressures and the indiscrimi- By listening carefully to the directions
god, what’s that? A stork, a crane, an nate, and distinctly unsubtle, incen- of blood.
ibis? – don’t be silly, it’s just a weird tives of performance-related pay, have By waiting to see what happens next.9
heron.’ Sometimes we have to hush been slowly transmogrified into tablets
the frantic inner voice that says ‘Don’t of law that make it all too easy to DO Waiting to see what happens next is
be stupid,’ and learn again to look, without pausing to think. indeed the most sophisticated method
to listen. You can do the organising of diagnosis and, in the face of the ever
and redrafting, the diagnosing and Waiting increasing availability of expensive and
identifying later, but right now, just Doing nothing but having the courage intimidating technology; we would do
be open to it, see how it’s tilting sometimes to wait – to use time as both well to remember this.
nervously into the wind, try to see the a diagnostic and a therapeutic tool – to
colour, the unchancy shape – hold it in see what nature does – to wait and Being present
your head, bring it home intact. see. These are essential skills of the art Doing nothing but simply being present
of doing nothing that are profoundly – there with the patient – and bearing
Right now – do nothing – just be open important if we are not to fall into the witness so that the old adage is reversed
to the patient – notice them and hold seductive traps of overdiagnosis and and becomes: ’Don’t just do something,
them in your head. Don’t start to ana- overtreatment. stand there.’
lyse – to diagnose – too soon. The importance of waiting is captu- In A fortunate man, which is for me
And it is Zbigniew Herbert, the red in one of the poems by the New Ze- the best book ever written about gen-
great Polish poet who reminds us of our aland doctor and poet Glen Colquhoun: eral practice, John Berger writes:
responsibility to those who are some-
times the most difficult to pay atten- Increasingly sophisticated methods He does more than treat them when
tion to – to listen to – to notice: of divination used in the practice of they are ill; he is the objective witness
medicine of their lives.10
His only weapon was abuse, the
rebellion of the helpless – without By observing a rooster pecking grain. And John and Bogdana Carpenter, re-
hope but precisely because of that, By the various behaviours of birds. sponsible for the English translations
deserving admiration and respect.7 By balancing a stone on a red-hot axe. of many of Zbigniew Herbert’s poems,
By the shape of molten wax dripped write:
into water.
Thinking Our own freedom and our very reality
Do nothing – stop and think instead. By the pattern of shadows cast onto depend upon the accuracy with which
Does this patient need a diagnostic la- plastic. we are able to perceive the suffering
bel – will it really help them? What sort By the colour of paper dipped in urine. around us, to bear witness to it, and to
of care would be right for them – at this By the growing of fresh mould in revolt against it.11
time and in this place? round dishes.
The German philosopher Hans Georg By the magnification of blood. This doing nothing while witnessing
Gadamer reminds us just how serious suffering precedes the action of revol-
this task of thinking is: By the alignment of electricity around ting against it and in general practice
the outside of the heart. that action is our responsibility for ad-
Thinking is the dialogue of the soul By the rise in a column of mercury. vocacy. We have an obligation to speak
with itself. This is how Plato described By timing exactly the formation of out for those who have no voice and
thinking, and this means at the same clots. to describe to politicians and policy-
time that thinking is listening to the By the examination of excrement. makers, as often as we can, how their
answers that we give ourselves, and policies play out in the realities of daily
that are given to us, when we raise the By the placement of sharp needles life for those struggling with relative
question of the incomprehensible.8 underneath the skin. deprivation in an unequal society.
By tapping the knee with a hammer.
The legacy of the well-intentioned em- By the bouncing of sound against a Inadequate housing, homelessness,
phasis on the evidence base of medicine full bladder. and family poverty are structural
has been the proliferation of guideli- By the interpretations of pus. issues but are no less amenable
to intervention than the health
By the attractions of the body to conditions they engender. The

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way they differ is in the type of modern medical care and perhaps the medical liability environment, and
intervention required. Advocacy is deficiency of witnessing. clinical performance scorekeepers –
structural therapeutics.12 Samuel Beckett understood more that they will be rewarded for excess
about futile doing than most. He is and penalized if they risk not doing
In June, I had the wonderful privilege described by the literary critic Chris- enough.19
and good fortune of attending a semi- topher Ricks as:
nar in Rosendal in Norway entitled: She mentioned a study she had done
‘The nature of humans and the goals The great writer of an age which with her colleagues Steve Woloshin and
of medicine’. At the seminar, I met a has created new possibilities and Lisa Schwarz in which they found that
young doctor working in interven- impossibilities even in the matter of nearly half of US primary care physi-
tional cardiology who I had first met death. Of an age which has dilated cians believed that their own patients
when she was a medical student at a longevity, until it is as much a were receiving too much medical care.20
similar seminar 8 years ago. She is also nightmare as a blessing.16 This somehow exemplifies this state-
a brilliant musician and, for this sem- ment from Vladimir Nabokov:
inar, she had written a piece of elec- In Malone dies, Beckett writes:
tronica music that she played for us. It The lovely thing about humanity is
had a repeating line in the manner of And when they cannot swallow any that at times one may be unaware of
electronic: more someone rams a tube down their doing right, but one is always aware of
gullet, or up their rectum, and fills doing wrong.21
‘I know I can see you through this.13’ them full of vitaminized pap, so as not
to be accused of murder.17 I don’t think that we in Europe are qui-
As this phrase repeated in the music, I te as bad as the Americans in this but
slowly realised how different this state- This was written more than 60 years we are not far behind and we too know
ment is from the more usual ’I know ago and it is frightening to consider that we are doing too much.
I can help you with this’ and the dif- how much truer it has become over the Brenda Sirovich also tells the stor y
ference is about witnessing and about intervening years. of Joseph Epstein, an American essay-
being there when there is little help to ‘I know I can see you through this’ is ist, short story writer, and editor. On
be had. It is an offer of companionship, the commitment doctors can make to his 60th birthday, feeling perfectly well,
of solidarity and a promise not to run the dying when doing has become fu- he promised his wife that he would
away. It is part of the art of doing no- tile and even cruel. Simply being there go for a medical check-up. He felt per-
thing. and bearing witness is never futile. fectly well, was not overweight, ate a
Arthur Kleinman, the American healthy diet, exercised regularly and
anthropologist and psychiatrist, says Preventing harm had not smoked for 20 years. He went
something similar: Finally – doing nothing and thereby for his check-up, had a normal ECG and
preventing harm. The importance had blood taken. His total cholesterol
…empathic witnessing… is the of this was emphasised in a paper was normal but his HDL level was low.
existential commitment to be with published in the Archives of Internal This was the only abnormality. In short
the sick person and to facilitate his Medicine earlier this year which came order he was referred for a stress test,
or her building of an illness narrative to a somewhat unexpected conclusion.18 an angiogram and a CABG. He went
that will make sense of and give value from feeling perfectly well to having
to the experience. This I take to be In a nationally representative a huge scar, feeling traumatised,
the moral core of doctoring and of the sample, higher patient satisfaction vulnerable and weak and wondering
experience of illness.14 was associated with less emergency whether he would ever recover his
department use but with greater previous sense of well-being. We know
And Charles Rosenberg, Professor of the inpatient use, higher overall all this because he wrote about it in
History of Medicine at Harvard, asks: health care and prescription drug the New Yorker in an article entitled
expenditures, and increased mortality. ‘Taking the Bypass – a healthy man’s
How does one manage death – which nightmare’.22 The truly remarkable
is not precisely a disease – when In a commentary on this research thing is his conclusion:
demands for technological ingenuity paper, Brenda Sirovich from the Dart-
and activism are almost synonymous mouth Institute for Health Policy and In the long view, I know I have to
with public expectations of a scientific Clinical Practice noted that: count myself lucky.
medicine?15
Practicing physicians have learned And he expresses himself grateful to
Pointing out the excess of doing in – from reimbursement systems, the his excellent doctors. As Sirovich points

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out, ’Satisfaction with seemingly ad- Conclusion 4 Schrödinger E. Nature and the Greeks. Cam-
bridge: Cambridge University Press, 1954.
verse outcomes of potentially excessive Doing nothing is preferable to leaping 5 Williams WC. The Practice. In Williams WC.
medical care appears to be the norm.’ to conclusions; applying inappropriate The doctor stories. New York: New Directions
Books, 1984.
But remember where we started this – or premature labels; medicalising ordi- 6 Jamie K. Findings. London: Sort of Books, 2005.
higher patient satisfaction is correlated nary human distress; and instigating 7 Herbert Z. King of the Ants: mythological es-
says. New York: WW Norton & Co, 1999.
with increased mortality. futile or ineffective treatments. Yet, 8 Gadamer H-G. The enigma of health. The art of
About 15 years ago, at a research while aspiring to the undoubted bene- healing in a scientific age. Stanford: Stanford
University Press, 1996.
conference, I heard a nurse reporting on fits of the art of doing nothing, we must 9 Colquhoun G. Playing God: poems about medi-
a qualitative study of nurses’ feelings also take heed of the warning from cine. London: Hammersmith Press Limited,
2007.
when they are asked to try to persuade Aimé Césaire, the great francophone 10 Berger J, Mohr J. A fortunate man. Harmonds-
worth: Allen Lane The Penguin Press, 1967.
parents to accept infant vaccination. poet from Martinique:
11 Carpenter J, Carpenter B. Introduction to Her-
Her finding was a clear conclusion bert Z. Report from the besieged city and other
poems. Oxford: Oxford University Press, 1987.
that the nurses thought that a crime of Beware, my body and my soul, beware 12 Roberts I. Deaths of children in house fires.
omission causing potential harm to an above all of crossing your arms and BMJ 1995;311:1381-2.
13 Aase Schaufel M. Sick Sinus. On CD appearing,
unvaccinated child was somehow less assuming the sterile attitude of Ischaemia Records, 2009.
than a crime of commission – precipi- the spectator, because life is not a 14 Kleinman A. The illness narratives: suffering,
healing and the human condition. New York:
tating serious side effects by giving the spectacle, because a sea of sorrows is Basic Books, 1988.
vaccination. Doing nothing was felt to not a proscenium, because a man who 15 Rosenberg CE. The tyranny of diagnosis: speci-
fic entities and individual. Milbank Q
be less bad than doing something that cries out is not a dancing bear.23 2002;80:237-60.
went wrong. Active harm is worse than 16 Ricks C. Beckett’s dying words. The Clarendon
lectures 1990. Oxford: Oxford University Press,
passive harm. So let us cultivate the art of doing no- 1995.
Joseph Epstein’s story suggests that thing but never allow ourselves to take 17 Beckett S. Malone dies. 1951. London: Penguin
Books, 1962.
this has been turned completely upside refuge in the sterile attitude of the 18 Fenton JJ, Jerant AF, Bertakis KD, Franks P. The
cost of satisfaction: a national study of patient
down – as doctors, we seem to have spectator. ▪
satisfaction, health care utilization, expendi-
persuaded ourselves that commission is tures, and mortality. Arch Intern Med
2012;172:405-11.
now much less bad than omission. Dit is een dubbelpublicatie. Het oorspron-
19 Sirovich BE. How to feed and grow your health
We seem trapped in an uncontrolled kelijke artikel zal verschijnen in januari care system. Arch Int Med 2012;172:411-3.
2013 in the European Journal of General Prac- 20 Sirovich BE, Woloshin S, Schwartz LM. Too lit-
positive feedback loop with doctors tle? Too much? Primary care physicians’ views
tice. Publicatie gebeurt met toestemming
convinced they are doing the best for van de uitgever. on US health care: a brief report. Arch Intern
Med 2011;171:1582-5.
their patients and grateful and satis- 21 Nabokov V. The assistant producer (1943). In
fied patients feeling that somehow Nabokov V. Nabokov’s Dozen. London: Penguin
Books, 1990.
their lives have been saved. It is surely References 22 Epstein J. Taking the bypass: a healthy man’s
time to step back and reconsider the 1 Bauman Z. Alone again: ethics after uncer- nightmare. New Yorker 1999:75:58-63.
tainty. London: Demos, 1994. 23 Césaire A. Return to my native land, (1939,
virtues of doing nothing before the 1956). Harmondsworth: Allen Lane The Pen-
2 Midgley M. Science and Poetry. London: Rou-
harms multiply and healthcare be- tledge, 2001. guin Press, 1969.
3 Williams WC. Old Doc Rivers, 1932. In Wil-
comes exponentially more expensive
liams WC. The doctor stories. New York: New
than it already is. Directions Books, 1984.

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