Health

Last week I stumbled home from work and struggled to find any space in the hall to deposit my baggage. Despair at the untidiness was translated into tension in my shoulders and, for a second, the urgent need to pour a drink. But then I looked again at the precarious pile of newspapers and remembered they were awaiting recycling; and I reconsidered the collection of climbing boots laid erratically by the window and realised they were not abandoned but drying.

In short, my home might look like a hybrid of mess and laziness but to conclude that would be a vast underestimation of my domestic talents. In my hall something far more serious, pointed and planned is happening than is superficially apparent.

Medically speaking, doing nothing - or at least seeming to - can be the best thing. Unfortunately, as is the case in my hallway, the absence of activity on the part of doctors can be misinterpreted as laziness or bad practice.

Medical terms have therefore evolved to disguise the truth. So we have "paced observation", "watchful waiting" or "masterly inactivity". We may even "await events, while remaining in a constant state of vigilance" - my favourite. The pity is that while doing nothing is often good; appearing to do nothing may not be.

Doctors think patients want action, dynamism, prescriptions and tests; we think we have to look like we walked off the set of ER. Meanwhile, lots of studies try to persuade us this is not always so. Patients, the studies say, sometimes see the doctor to get an opinion but not necessarily treatment. Still the medical profession gets jumpy when electing to "do nothing".

Surely, we wonder, there must be something I can do? If there are symptoms or suffering, should I not scribble down a note for something on my prescription pad?

Prescribing sometimes makes me think I am less likely to get sued because it is evidence that I have done "something" (although I remind myself there is absolutely no evidence for this).

Admittedly, some treatments are rather good - from cancer treatments to penicillin for meningitis. More commonly, though, our decisions involve things that make little or no difference to our patients.

Take sore ears. Otitis media in children can be miserable. It can cause pain and lead to a fever and may end up depriving the child and parents of sleep. Since the pain is caused by infection, should we cure it with a prescription of antibiotics?

A Cochrane systematic review, which reviews all the evidence on the subject, showed that antibiotics provided only a "small benefit". For every 15 children treated with antibiotics, only one child would benefit. But aren't such slim odds worthwhile? Perhaps not. Antibiotics have side effects (usually bowel upset) and may increase antibacterial resistance (the rise of "superbugs"). Antibiotics did not prevent recurrence, the review showed. The only benefit they had was to reduce pain after 48 hours - and then only for a minority of children.

Antibiotics for sore throats also have little effect. A Cochrane review says the absolute benefit is "modest" and, additionally, that 90 per cent of people will be free of symptoms after a week - whether they have had antibiotics or not. "The art of medicine consists in amusing the patient while nature cures the disease," said Voltaire and if you count swallowing prescribed antibiotics as amusement, then his point remains.

It would have been nice, albeit less witty, if Voltaire had added a qualification: a second sentence along the lines of "as long as the amusement isn't harmful". Lobotomy, brain trepanation and blood letting are all consigned to the history books but there are still examples of actual harm being done by treatments recently considered excellent. For example, albumin, a specific type of fluid used to treat critically ill patients with certain conditions, seemed when analysed to increase mortality.

The standard practice of performing x-rays in people with low back pain has been, in the majority of cases, found to be useless. Mostly they don't help the diagnosis or the back pain. They do, however, come with a dose of radiation.

Ordering strict bed rest for acute low back pain rather than letting normal activity continue results in more pain and reduced back function. Knee arthroscopy - a telescope operation inside the knee - may help the pain of osteoarthritis but only as much as a sham operation does, though of course with the small but attendant risks of surgery. Hormone replacement therapy does not reduce the risk of cardiovascular disease, as previously promised, but increases it. Antibiotic eye drops do not treat childhood conjunctivitis significantly better than a placebo.

In all these cases, what is underestimated is the amazing quality of - and here's another term doctors can use - "building in time" - or, as Voltaire would have it, letting nature, or placebo, or perhaps even "masterly inactivity", do the hard work.

Of course, there are distinctions between doing nothing because one is lazy and doing nothing because one has, after appropriate listening, examination and diagnosis, made a judgment that this is a reasonable or better option. And should my mother be coming to visit, no doubt I will be less brave, decide that the state of my house is a result of the former rather than the latter and prescribe myself the use of a bin bag and mop.

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