Masterly inactivity: a forgotten precept
========================================

* François Mai

When I was a medical student at the University of Cape Town, South Africa, in the mid-1950s, a wise old professor introduced me to the treatment concept of masterly inactivity. Sometimes, just waiting and seemingly doing nothing is the favoured therapeutic modality. Over a lifetime in medicine, I have seen many occasions when this approach was successful, and other times when physicians, including me, have broken this rule with unfortunate and antitherapeutic results.

For many years, I practised inpatient and outpatient liaison psychiatry. I used to joke, perhaps a little cynically and certainly with exaggeration, that I got most of my therapeutic successes by stopping, rather than prescribing, psychotropic medications. This happened especially when a patient had been prescribed two or more psychotropic drugs whose combined adverse effects were more unpleasant than the symptoms of the original illness.

For the past 10 years, I have worked in the income security programs of the federal government of Canada, appraising the applications of Canadians who apply for disability pensions and deciding on their eligibility. This task involves a detailed review of medical reports and files that often extend over many years. It provides a unique chronological perspective of each patient’s long-term medical history. I must admit that on many occasions I shake my head sadly when I see a physician ordering yet another magnetic resonance image or carrying out yet another medical procedure that will not have a meaningful or useful outcome. Often, this approach will reinforce the patient’s illness behaviour and cost overstretched health care systems additional needless dollars. I believe our patients and our society pay a huge price for this short-sighted approach.

Why do doctors do this? There are several explanations. We have all been taught to practise defensive medicine. If you don’t carry out a test or do a procedure, and the patient sues, you could be in legal trouble. Other than to follow sound clinical judgment and evidence-based guidelines, there is no easy answer to this society-imposed measure.

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/186/4/312/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/186/4/312/F1)

Image courtesy of Eduard Gurevich/iStock/Thinkstock

In addition, many patients demand that something, anything, be done to ease their complaint. They believe that action, any action, is better than waiting for the body’s built-in remedies to do their bit.

Managing the exigent patient requires tact, information and expertise. Perhaps this is where the word “masterly” registers. “Inactivity” does not necessarily mean doing nothing. Our bodies have many natural resources for coping with and counteracting disease processes, both physiologic and psychological. Waiting can promote these healing resources; by waiting, the doctor becomes a collaborator rather than a competing adversary with the body’s natural defences. This is particularly the case with the use of antibiotics. Waiting a few days gives time for immunologic defences to be provoked, which may make antibiotics unnecessary. These ideas must be conveyed to the patient in a way that he or she can understand.

The fear of missing a treatable disease is ingrained in us during our training and may be another explanation why we have forgotten the precept of masterly inactivity. To counteract this attitude, we need an equally ingrained fear of perpetuating illness behaviour, which may occur if we order unnecessary tests or carry out poorly indicated medical procedures. This is not to say that an investigation or a test should not be done when there is a clear indication, or when the likelihood of discovering useful information or achieving success is high, or the need is urgent. To delay the diagnosis of breast cancer, for example, is not going to improve the patient’s prospects.

The Choosing Wisely Canada initiative ([www.choosingwiselycanada.org](http://www.choosingwiselycanada.org)), fits with this approach to patient management. It makes specific recommendations, for example, about the use of antibiotics for respiratory illness in children, or about the use of imaging tests in back pain.

In my personal life, I have noticed how some of my medical problems, such as pain from my arthritic knees, improve if I wait a few days or weeks. I was actually able to cancel an arthroscopy that had been recommended by my physician. Perhaps, after all, there is an upside to having long wait times for certain procedures.

Physicians are counselled to: “First do no harm.” In our action-inspired society, I sometimes wonder if we have thrown out the “nature-healing” baby with the “do-something” bath water.