The European Journal of General Practice

ISSN: 1381-4788 (Print) 1751-1402 (Online) Journal homepage: https://www.tandfonline.com/loi/igen20

The art of doing nothing

Iona Heath

To cite this article: Iona Heath (2012) The art of doing nothing, The European Journal of General
Practice, 18:4, 242-246, DOI: 10.3109/13814788.2012.733691

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Published online: 04 Dec 2012.

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European Journal of General Practice, 2012; 18: 242–246

Background Paper

The art of doing nothing

Iona Heath

Royal College of General Practitioners, London, UK

THE WISDOM OF OTHERS all day—no time to stop, to listen, to think, to notice—or
even—to go to the toilet!
In his 1994 book Alone again: Ethics after uncertainty,
The Austrian Nobel Prize winning physicist Erwin
the sociologist Zygmunt Bauman quotes the German
Schrödinger, most famous for his cat, seems to have
psychiatrist and philosopher Karl Jaspers:
understood the importance and the power of the art of
Our time thinks in terms of “knowing how to do doing nothing:
it,” even where there is nothing to be done (1).
In an honest search for knowledge you quite
In her 2001 book, Science and poetry, the British often have to abide by ignorance for an indefinite
philosopher Mary Midgley expanded on this point: period. ¼ The steadfastness in standing up to
[this requirement], nay in appreciating it as a
Out of this fascination with new power there
stimulus and a signpost to further quest, is a
arises our current huge expansion of technology,
natural and indispensable disposition in the mind
much of it useful, much not, and the sheer size
of a scientist (4).
of it dangerously wasteful of resources. It is hard
for us to break out of this circle of increasing He seems to me to be describing the importance of the
needs because our age is remarkably preoccu- pause for thought—especially in the conditions of igno-
pied with the vision of continually improving rance and uncertainty so common in general practice.
means rather than saving ourselves trouble by Taking all this wisdom into account, my conclusion is
reflecting on ends (2). that, perhaps counter intuitively, in medicine, the art of
doing nothing is active, considered, and deliberate. It is
Ours has become the age of unthinking doing—keep
an antidote to the pressure to DO and it takes many
doing, do not stop to think—there’s no time! There’s no
forms and these are just some of them:
time because we are too busy doing.
The American poet William Carlos Williams who was • Listening, noticing
also a general practitioner understood very clearly how • Thinking
easy it is for doctors to succumb to this particular vicious • Waiting
circle. In his 1932 short story about ‘Old Doc Rivers’ he • Witnessing
wrote: • Preventing harm
With this pressure upon us, we eventually do
Each is an art in its own right—requiring judgment,
what all herded things do; we begin to hurry to
wisdom and even a sense of beauty.
escape it, then we break into a trot, finally into a
mad run (watches in our hands), having no
idea where we are going and having no time to LISTENING AND NOTICING
find out (3).
Doing nothing—but instead—listening and noticing. It is
I suspect that everyone who has worked in general impossible to do and to listen intently and accurately at
practice recognises this phenomenon. Rushing around the same time. Anyone who has tried to listen to their

This paper was given as a keynote lecture ‘Art ’ at the Wonca Europe Conference in Vienna on July 5 2012. I was given this marvellous title by Professor Manfred Maier
and used it to explore the excess of doing within contemporary medical practice.
Correspondence: I. Heath, Royal College of General Practitioners, 1 Bow Churchyard, London EC4M 9DQ, UK. Fax: ⫹44 (0)20 3188 7401. E-mail: iona.heath22@
yahoo.co.uk

(Received 14 September 2012; accepted 21 September 2012)

ISSN 1381-4788 print/ISSN 1751-1402 online © 2012 Informa Healthcare
DOI: 10.3109/13814788.2012.733691
 The art of doing nothing 243
children while also trying to cook a dinner knows this to The German philosopher Hans Georg Gadamer
be true. William Carlos Williams describes the intensity reminds us just how serious this task of thinking is:
of listening in general practice:
Thinking is the dialogue of the soul with itself.
It is actually there, in the life before us, every min- This is how Plato described thinking, and this
ute that we are listening, a rarest element—not means at the same time that thinking is listening
in our imaginations but there, there in fact. It is to the answers that we give ourselves, and that
that essence which is hidden in the very words are given to us, when we raise the question of
which are going in at our ears and from which we the incomprehensible (8).
must recover underlying meaning as realistically
The legacy of the well-intentioned emphasis on the
as we recover metal out of ore (5).
evidence base of medicine has been the proliferation of
He describes this essence as the nearest most guidelines which were designed to provide guidance
patients come to the poetry of their lives as they struggle but, abetted by a multitude of subtle pressures and the
to give expression to their deepest feelings and fears in indiscriminate, and distinctly unsubtle, incentives of
the quiet privacy of the doctor ’s consulting room. performance-related pay, have been slowly transmogri-
The Scottish poet Kathleen Jamie thinks that the fied into tablets of law that make it all too easy to DO
necessary commitment and concentration of listening without pausing to think.
and noticing come close to the idea of prayer
Isn’t that a kind of prayer? The care and mainte- WAITING
nance of the web of our noticing, the paying
heed (6). Doing nothing, but having the courage sometimes to
wait—to use time as both a diagnostic and a therapeutic
And when she describes her experience of bird- tool—to see what nature does—to wait and see. These
watching—it sounds so close to the kind of receptive- are essential skills of the art of doing nothing that
ness that we need in general practice: are profoundly important if we are not to fall into the
This is what I want to learn: to notice, but not to seductive traps of over diagnosis and overtreatment.
analyse. To still the part of the brain that’s yammer- The importance of waiting is captured in one of the
ing, “My god, what’s that? A stork, a crane, an poems by the New Zealand doctor and poet Glen
ibis?—don’t be silly, it’s just a weird heron.” Some- Colquhoun:
times we have to hush the frantic inner voice that Increasingly sophisticated methods of divination
says “Don’t be stupid,” and learn again to look, to used in the practice of medicine
listen. You can do the organizing and redrafting, By observing a rooster pecking grain.
the diagnosing and identifying later, but right By the various behaviours of birds.
now, just be open to it, see how it’s tilting By balancing a stone on a red-hot axe.
nervously into the wind, try to see the colour, the By the shape of molten wax dripped into water.
unchancy shape—hold it in your head, bring it
home intact. By the pattern of shadows cast onto plastic.
By the colour of paper dipped in urine.
Right now—do nothing—just be open to the By the growing of fresh mould in round dishes.
patient—notice them and hold them in your head. Do By the magnification of blood.
not start to analyse—to diagnose—too soon.
It is Zbigniew Herbert, the great Polish poet who By the alignment of electricity around the outside
reminds us of our responsibility to those who are some- of the heart.
times the most difficult to pay attention to—to listen to—to By the rise in a column of mercury.
notice: By timing exactly the formation of clots.
By the examination of excrement.
His only weapon was abuse, the rebellion of the
helpless—without hope but precisely because of By the placement of sharp needles underneath
that, deserving admiration and respect (7). the skin.
By tapping the knee with a hammer.
By the bouncing of sound against a full bladder.
THINKING By the interpretations of pus.
Do nothing—stop and think instead. Does this patient By the attractions of the body to strong magnets.
need a diagnostic label—will it really help them? What By the characteristics of sweat.
sort of care would be right for them—at this time and in By listening carefully to the directions of blood.
this place? By waiting to see what happens next (9).
244 I. Heath
Waiting to see what happens next is indeed the Arthur Kleinman, the American anthropologist and
most sophisticated method of diagnosis and, in the psychiatrist, says something similar:
face of the ever increasing availability of expensive
… empathic witnessing … is the existential
and intimidating technology; we would do well to
commitment to be with the sick person and
remember this.
to facilitate his or her building of an illness
narrative that will make sense of and give value
BEING PRESENT to the experience. ... This I take to be the moral
core of doctoring and of the experience of
Doing nothing but simply being present—there with the illness (14).
patient—and bearing witness so that the old adage is
reversed and becomes: ‘Don’t just do something, stand Charles Rosenberg, Professor of the History of
there.’ Medicine at Harvard, asks:
In A fortunate man, which is for me the best book
How does one manage death—which is not
ever written about general practice, John Berger
precisely a disease—when demands for techno-
writes:
logical ingenuity and activism are almost synony-
He does more than treat them when they are ill; mous with public expectations of a scientific
he is the objective witness of their lives (10). medicine (15)?
John and Bogdana Carpenter, responsible for the Pointing out the excess of doing in modern medical
English translations of many of Zbigniew Herbert ’s care and perhaps the deficiency of witnessing.
poems, write: Samuel Beckett understood more about futile doing
Our own freedom and our very reality depend than most. He is described by the literary critic Christopher
upon the accuracy with which we are able to per- Ricks as:
ceive the suffering around us, to bear witness to —The great writer of an age which has created
it, and to revolt against it (11). new possibilities and impossibilities even in the
This doing nothing while witnessing suffering pre- matter of death. Of an age which has dilated
cedes the action of revolting against it and in general longevity, until it is as much a nightmare as a
practice that action is our responsibility for advocacy. We blessing (16).
have an obligation to speak out for those who have no
voice and to describe to politicians and policy-makers, In Malone dies, Beckett writes:
as often as we can, how their policies play out in the And when they cannot swallow any more some-
realities of daily life for those struggling with relative one rams a tube down their gullet, or up their
deprivation in an unequal society. rectum, and fills them full of vitaminized pap, so
Inadequate housing, homelessness, and family pov- as not to be accused of murder (17).
erty are structural issues but are no less amenable to
intervention than the health conditions they engender. This was written more than 60 years ago and it is fright-
The way they differ is in the type of intervention required. ening to consider how much truer it has become over
… Advocacy is structural therapeutics (12). the intervening years.
In June, I had the wonderful privilege and good for- ‘I know I can see you through this’ is the commitment
tune of attending a seminar in Rosendal in Norway enti- doctors can make to the dying when doing has become
tled: The nature of humans and the goals of medicine. futile and even cruel. Simply being there and bearing
At the seminar, I met a young doctor working in inter- witness is never futile.
ventional cardiology who I had first met when she was a
medical student at a similar seminar eight years ago. She
PREVENTING HARM
is also a brilliant musician and, for this seminar, she had
written a piece of electronica music that she played for Finally—doing nothing and thereby preventing harm.
us. It had a repeating line in the manner of electronic: ‘I The importance of this was emphasized in a paper
know I can see you through this’ (13). published in the Archives of Internal Medicine earlier
As this phrase repeated in the music, I slowly realized this year which came to a somewhat unexpected
how different this statement is from the more usual conclusion (18).
‘I know I can help you with this’ and the difference is In a nationally representative sample, higher patient
about witnessing and about being there when there is satisfaction was associated with less emergency depart-
little help to be had. It is an offer of companionship, of ment use but with greater inpatient use, higher overall
solidarity and a promise not to run away. It is part of the health care and prescription drug expenditures, and
art of doing nothing. increased mortality.
 The art of doing nothing 245
In a commentary on this research paper, Brenda that a crime of omission causing potential harm to an
Sirovich from the Dartmouth Institute for Health Policy unvaccinated child was somehow less than a crime of
and Clinical Practice noted that: commission—precipitating serious side effects by giv-
ing the vaccination. Doing nothing was felt to be less
Practicing physicians have learned—from reim-
bad than doing something that went wrong. Active
bursement systems, the medical liability
harm is worse than passive harm.
environment, and clinical performance score-
Joseph Epstein’s story suggests that this has been
keepers—that they will be rewarded for excess
turned completely upside down—as doctors, we seem
and penalized if they risk not doing enough
to have persuaded ourselves that commission is now
(19).
much less bad than omission.
She mentioned a study she had done with her col- We seem trapped in an uncontrolled positive feed-
leagues Steve Woloshin and Lisa Schwarz in which they back loop with doctors convinced they are doing the
found that nearly half of US primary care physicians best for their patients and grateful and satisfied patients
believed that their own patients were receiving too feeling that somehow their lives have been saved. It is
much medical care (20). This somehow exemplifies this surely time to step back and reconsider the virtues of
statement from Vladimir Nabokov: doing nothing before the harms multiply and health
care becomes exponentially more expensive than it
The lovely thing about humanity is that at times
already is.
one may be unaware of doing right, but one is
always aware of doing wrong (21).
I do not think that we in Europe are quite as bad as CONCLUSION
the Americans in this but we are not far behind and we Doing nothing is preferable to leaping to conclusions;
too know that we are doing too much. applying inappropriate or premature labels; medical-
Brenda Sirovich also tells the story of Joseph izing ordinary human distress; and instigating futile or
Epstein, an American essayist, short story writer, and ineffective treatments. Yet, while aspiring to the
editor. On his sixtieth birthday, feeling perfectly well, undoubted benefits of the art of doing nothing, we
he promised his wife that he would go for a medical must also take heed of the warning from Aimé Cés-
check-up. He felt perfectly well, was not overweight, aire, the great francophone poet from Martinique:
ate a healthy diet, exercised regularly and had not
smoked for 20 years. He went for his check-up, had a Beware, my body and my soul, beware above all
normal ECG and had blood taken. His total cholesterol of crossing your arms and assuming the sterile
was normal but his HDL level was low. This was the attitude of the spectator, because life is not a
only abnormality. In short order he was referred for a spectacle, because a sea of sorrows is not a pro-
stress test, an angiogram and a CABG. He went from scenium, because a man who cries out is not a
feeling perfectly well to having a huge scar, feeling dancing bear (23).
traumatized, vulnerable and weak and wondering
So let us cultivate the art of doing nothing but never
whether he would ever recover his previous sense of
allow ourselves to take refuge in the sterile attitude of
well-being. We know all this because he wrote about
the spectator.
it in the New Yorker in an article entitled ‘ Taking the
bypass—a healthy man’s nightmare’ (22). The truly
remarkable thing is his conclusion: ACKNOWLEDGEMENTS
In the long view, I know I have to count myself I am grateful to Glen Colquhoun for allowing me to
lucky. reproduce his poem.
He expresses himself grateful to his excellent doc-
tors. As Sirovich points out, ‘Satisfaction with seemingly Declaration of interest: The author reports no conflicts
adverse outcomes of potentially excessive medical care of interest. The author alone is responsible for the con-
appears to be the norm.’ But remember where we tent and writing of the paper.
started this—higher patient satisfaction is correlated
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