Historically, in a clinical context, the term meant exercising careful wisdom and consideration in the deployment of expertise to resolve a complex clinical problem. In medicine, we often have more than one choice available, and the term “conservative” implies that the less intrusive option may prove to be the preferred choice as opposed to a riskier or more invasive strategy. Any “conservative management” plan should still seek to have a reasonable chance of resolving the issue, and therefore, by extension, should be reviewed if it isn’t working favourably. Such a clinical decision relies heavily on careful judgment and should have compassion and consideration for the individual’s wishes and preferences.
In current clinical practice, the term “conservative management” is frequently used when clinicians are presented with a pathology that might require intervention, but which is deemed either too risky, the patient isn’t fit for the intervention, or it may not bring enough benefit. The term seems to be used increasingly by specialties that offer interventions with greater complexity where the balance of risks and benefits is complicated. It is now a widely prevalent phenomenon that a specialist makes the decision to adopt a “conservative management” plan and then seeks to hand care over to generalists, on the assumption that specialist care is no longer required.
The point at which this decision is made also seems to increasingly meet the threshold for transfer of care to specialties such as general medicine and care of the elderly. Yet it is frequently unclear to the generalist what the other available choices are and the relative risks of the alternative approaches.
If the patient appears not to respond favourably to the conservative management plan, the specialist is then often nowhere in the picture. It is quite common to find that primary care physicians are at the receiving end when patients who are at home being managed “conservatively” develop further symptoms. They can then struggle to get the original specialist involved, and the patient is ultimately just bounced around. This is a recipe for poor care, causing frustrating delays for the patient and leaving them without alternative treatment options. It also risks the appearance of conflict between the specialist and the generalist, and often ownership of care seems to be less than secure.
It should be very clear that when “conservative management” is decided upon, the patient’s symptoms are still monitored. The patient should have regular assessments for any change in circumstances that might lead to a reversal or alteration of the original decision. Transferring the care of these patients entirely away from a specialist could be detrimental to their health. Furthermore, physicians choose to become specialists in their own respective area, and it is detrimental to hospital medicine to seek to protect specialist resources at the cost of undermining clinicians’ professional satisfaction, which is derived from doing their best for their patients.
The provision of joint care by different specialties can only truly work if different teams try to solve problems together, rather than passing the patient round in an uncertain shrug of who owns the problem. Many clinicians use the term “best supportive care,” which perhaps better captures how this coordination of care should work. “Best supportive care” should be provided by the teams who are able to manage the primary pathology that had resulted in hospital admission or a consultation, with the help of other teams, such as those in primary care, who would be able to alleviate their symptoms.
Conservative management should look like what it truly means: the provision of holistic care with the patient’s best interests at heart.
Vedamurthy Adhiyaman is a geriatrician at Glan Clwyd Hospital, North Wales. Twitter @adhiyamanv
Competing interests: none declared.
Sakkarai Ambalavanan practises respiratory medicine in Glan Clwyd Hospital, and is the lead for lung cancer there.
Competing interests: none declared.