Masterly Inactivity

Masterly inactivity is the word mentioned in one of the surgical textbooks to emphasize the fact that, in some situations “no treatment or intervention” is the best option. Majority of the common ailments are self-limiting. All that is required is to give some comforting medication and observe. Human body has the capacity to deal with a variety of afflictions. In some people, this natural defense mechanism may not be sufficient and additional treatment is needed. A good clinician knows when and how long to wait. It is a calculated judgement.

There are a variety of areas where this “wait and watch” policy is necessary. Most of the viral illnesses are self-limiting. As we are witnessing, even the dreaded COVID is self-limiting in majority of the patients. Dengue is another viral illness that is causing grief in recent years. Only a proportion of patients whose platelet counts drops to dangerously low levels need platelet transfusion. Others only require simple supportive treatment.

Acute pancreatitis is inflammation of the pancreas gland, which is usually brought upon by alcohol intake or gallstone disease. In the initial days, all that is required is to give rest to the gut by keeping the patient fasting and giving intravenous fluids. No specific treatment is required. After the initial days, as the disease evolves, additional treatment is administered in a serial “step-up” fashion, sometimes culminating in major surgery.

Some patients with severe pancreatitis may succumb despite all the treatment. For the observer it is natural to think that the lack of aggressive treatment in the initial days is the cause of deterioration subsequently. They get baffled as no major treatment is being administered in the initial days for such a serious disease.

With increasing availability of ultrasound scan and the advent of health check-ups, there are several people being diagnosed with stones in the gallbladder. Some of them do not cause any problem and are called “silent gallstones”. Once the stones come to light, it is a matter of dilemma for the patient as well as the doctor. There are no major population studies that can guide us regarding the natural history of these silent stones.

Some of them may continue to remain silent and some may cause problems with passing of time. A small proportion of them may cause pancreatitis described above. Depending on the age of the person, any co-existing diseases and the size of the stones, surgical removal of the gallbladder is advised for some people. Others are advised to just wait and watch.

Another area is the terminal cancer. After a certain stage and trying to cure cancer, it is futile to continue aggressive treatment. It simply prolongs the life span by a few days or weeks at the most. If such a stage comes, it is better to give comfort care in the form of symptom relief and withhold treatment aimed at controlling the cancer.

In all the above situations, the treatment is tailored based on many factors and decision taken on an individual basis by the treating doctor or the team in consultation with the patient and the family. Both doctors and patients need to understand these issues and try to make decisions together based on the patient’s condition and needs.

In our society where medical care is mostly driven by fear, anxiety and unrealistic expectations, some doctors do not bother to discuss the issues with the patients for them to make an informed choice. Even if the doctors try to discuss, some patients do not or cannot decide..