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  1. Ian Wacogne
  1. General Paediatrics, Birmingham Childrens Hospital, Birmingham, B4 6NH, UK
  1. Correspondence to Dr Ian Wacogne, General Paediatrics, Birmingham Childrens Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK; ianwacogne{at}

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Some of the better advice I had when I first became a consultant was from the colleague who, when the scenario had been carefully described, would say ‘If I were you, I’d fan that with my hat’. Of course, I may be slightly misquoting, but to try to explain the idiom a little, it describes a situation in which the best action is inaction. Inaction is a tremendously underrated skill, because when initially described it sounds like a negative. I don’t get the impression that many families leave a consultation and think to themselves: ‘Well, that’s excellent, we’re going to do nothing for another few months.’ Good inaction, when you think of it, has a few properties. The first is for it not to appear like—or be—neglect. The only positive modifier—and a weak one at that—for neglect is ‘benign’, which for me brings to mind a scatterbrained, distracted older relative not really noticing what you’re up to as a child.

A second property of good inaction is that it needs to have a point. Which brings me to the point of this Epistle. William Whitehouse and Shakti Agrawal have a great paper on headache (see page 58). It was commissioned by Sharon Conroy, who is a real powerhouse in the journal with an excellent eye for what papers and therapies we should be reading about. As such it really ought to be in the Pharmacy Update section, but has some how found its way into being called a review. What’s interesting is that about half of this paper which is supposed to be about the pharmacological management of headache is actually about not medicating—and quite a bit of this is about the harmful effects of giving medicines which can themselves cause headaches. The rest of the first half of this article is about the advice we can give people to avoid headache, and to manage headache without the need for second line analgesia. This paper is my editor’s choice this month. Sometimes you need to fan the headache with your hat.

A third property of good inaction is that it needs to have a boundary. If you are describing a path of inaction, you need to assure people of the triggers you’ll respond to if action becomes required—and in particular one of these is likely to be time. Simon Drysdale wrote to me a little while ago wanting to write the paper appearing here (see page 66), authored with Dominic Kelly—Enterovirus meningitis and encephalitis—when can we stop the antibiotics? I took a little persuading—because for me the answer was ‘When you get the enterovirus result.’ However, I’ve not been on the receiving end of infectious diseases consultation calls, and this is apparently a frequent theme. Sometimes when you have a diagnosis, your main treatment is to stop all the noxious therapies you’ve begun in good faith, and to then fan the patient with your hat.

A final property of good inaction is that it should not be unthinking. David King, Noreen West and Charlotte Elder give us some helpful thoughts about how to integrate teaching into everyday clinical practice—and it is striking that one of their examples is whether or not to do a test (see page 93). My willingness to avoid doing a test increases with my age, and as my memories of the people I’ve harmed with tests accumulate. Sometimes, instead of doing the test, you just need to fan it with your hat.

You might not agree that each of these examples are inaction, but this might be because you have a different view of medicine to many lay folk. There’s a good reason that the discipline of medicine and the medicine we dispense share a name—they are often seen as the same things. I’ve a vivid memory of when an up and coming NHS manager sat in my clinic and described at the end that I ‘didn’t seem to do much medicine’—which was to say that I only wrote a couple of prescriptions and requested a couple of tests all morning. I suspect my hat was put to good use though.

If you’d like to talk about hat-fanning, or you’ve got something we should be writing about, or you want to write about—or if you have an idea for our off-beat December 2017 issue, then please do get in touch.


  • Contributors All my own work.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.