Accepting what cannot be fixed in health care

Emergency departments often reward the “front-loading” of investigations. Blood tests are ordered from triage. Cannulas inserted “just in case”. Imaging requested before a doctor has even assessed the patient. The rationale is understandable: if tests are already underway, perhaps the patient’s journey through the department will be shorter and more efficient.

Sometimes this approach is helpful. Often it is appropriate.

Yet the instinct to investigate early is not only about efficiency. Faced with uncertainty, we are frequently more comfortable initiating action than sitting with not knowing.

Contemporary medical dramas such as The Pitt have evolved beyond the invulnerable physician heroes of earlier television. Dr Robbie is exhausted, emotionally affected by the work, and frequently overwhelmed by the systems around him. Yet the narrative arc still gravitates toward rescue and resolution. The doctor remains, fundamentally, the protagonist who acts upon suffering.

Real medicine is often less dramatic and less solvable.

Families ask questions for which there are no reassuring answers. Children deteriorate despite timely treatment. Some illnesses can be managed but not cured. Some suffering cannot be fixed.

Despite this, medicine continues to reward action. Clinicians are trained to identify problems, narrow differential diagnoses, and intervene. Junior doctors, in particular, are often focused on answering the question: “What is wrong with this patient?” The implicit assumption is that more investigation brings us closer to good care. More blood tests. More imaging. More data.

Over time, however, experienced clinicians often come to recognise a different truth: the needs of the problem are not always the same as the needs of the patient. Medicine may push towards diagnostic certainty, while the patient may simply need to feel listened to, reassured, and safe.

Families may arrive asking for more tests, but what they are often really seeking is understanding. What are we worried about? Is my child safe? Are you taking this seriously? What happens next?

Communication matters more than investigation

When speaking with families, I often try to ask explicitly what they are most worried about before discussing tests or management plans. If that concern remains unaddressed, they are unlikely to feel heard, regardless of how many investigations are ordered. In many cases, the conversation is less about providing certainty than acknowledging uncertainty honestly. Sometimes the most important thing a clinician can say is not “I know”, but “I don’t know”.

This can be uncomfortable for both patients and clinicians. Medicine has traditionally positioned doctors as fixers and rescuers. Much of medical training rewards action, decisiveness, and the avoidance of inaction. Far less attention is paid to tolerating uncertainty, or recognising when further investigation may add little beyond the illusion of progress.

Campaigns such as Choosing Wisely and “Just Say No to the Just in Case Cannula” reflect growing recognition that intervention is not always benign. A cannula inserted “just in case” may feel prudent, but if it is never used it may simply add pain, distress, and potential complications without benefit.

Similar tensions arise elsewhere in emergency medicine. An older patient with advanced dementia becomes agitated after a fall. The possibility of an intracranial bleed feels difficult to ignore. Sedation follows. Then a CT scan. Yet even if the scan reveals an abnormality, the result may do little to change management or improve the patient’s quality of life.

These decisions are not driven by malice or incompetence. More often, they arise from discomfort: discomfort with uncertainty, with the fear of missing something important. In some cases, intervention may partly reflect the clinician’s discomfort with uncertainty as much as the patient’s clinical needs.

When less is more

In Subtract, Leidy Klotz argues that human beings are biased towards addition. Faced with a problem, we instinctively add something: another feature, another layer, another intervention. We are less inclined to consider whether improvement might come from taking something away instead. Medicine is not immune to this tendency. Faced with uncertainty, clinicians often respond by adding tests, treatments, or procedures, even when restraint may better serve the patient.

This does not mean that investigation or intervention are unimportant. Emergency medicine regularly involves life-saving action. Airways need securing. Septic patients need antibiotics. Status epilepticus requires rapid treatment. The problem is not that medicine fixes things. The problem arises when fixing becomes the only form of care we recognise.

Some forms of suffering cannot be solved through technical intervention. Parents may present with a struggling adolescent, hoping for a diagnosis, a medication, a fix. Yet loneliness, grief, identity struggles, family conflict, and existential angst do not reliably yield to scans, blood tests, or prescriptions. The temptation, however, is to keep searching for something actionable, because action often feels more tolerable than helplessness.

Good doctors do not simply become better at recognising disease over time. They also become better at recognising when no tests are needed. Experience teaches clinicians not only what to look for, but what can safely be left alone. It teaches proportion. Restraint. The ability to explain uncertainty clearly without abandoning the patient emotionally.

Patients and families may not remember how many blood tests were ordered or which biomarkers were normal. They are more likely to remember whether they felt listened to, whether their concerns were understood, and whether someone took the time to explain why a test was — or was not — necessary.

Medicine values action. However, difficulties arise when intervention becomes the only response clinicians are able to tolerate, and when helplessness begins to feel synonymous with failure. Much of medicine is less dramatic than the stories we tell about it. It often means staying present long after the possibility of fixing has faded.

These acts rarely appear heroic. They are harder to dramatise and more difficult to measure. Yet they may represent some of the most important work clinicians do.

Not everything can be fixed. But very little is beyond care.

A/Prof Andrew Tagg is a Paediatric Emergency Physician at Western Health in Melbourne. He is Deputy Chair of the ACEM Workforce Wellbeing Network and a strong advocate for mental health in medicine.