My son coughed hard enough to vomit last night. Twice. He’s ten months old, and the sound of an infant struggling to clear his airway at 2 a.m. does something primal to a parent’s nervous system. Every instinct screams do something.
I didn’t. I held him upright, waited for recovery, watched his color, listened to his breathing settle, and put him back down. He slept. I didn’t—not fully—but that’s the job.
Here’s the thing: I spent years in pharmacy school and clinical training to arrive at moments like this and say one of two things. Either we should rely on someone else’s expertise, or ehh, this is nothing to worry about. The first feels like abdication. The second feels like dismissal. Neither captures what is actually happening when a clinician—or a clinically trained parent—chooses not to intervene.
What’s actually happening is stewardship. And stewardship is not passive. It is not the absence of care. It is pattern recognition, trajectory watching, and calibrated trust, held together by sentinels we call cardinal signs.
Stewardship is the act of staying close without interfering—and knowing precisely when closeness must give way to action.
The False Binary
Modern medical training excels at escalation. We learn algorithms, red flags, differential diagnoses, and referral pathways. We learn when to act. What we learn poorly—if at all—is when not to act, and how to hold that non-action with intention rather than negligence.
The result is a false binary that pervades both clinical culture and patient expectation: either something is being done, or nothing is being done. Either you’re treating, or you’re ignoring. Either the system is engaged, or you’re on your own.
But there is a third posture, and it is the one that actually governs most good care: active watching.
Stewardship lives in the space between escalation and neglect. It says: I see what’s happening. I understand the pattern. I know what recovery looks like. And I know what would break that pattern and require me to act.
This is not reassurance alone. Reassurance soothes emotion; stewardship structures trust. It names the sentinels, shares the timeline, and builds confidence through transparency—not through false comfort.
What Cardinal Signs Actually Are
A cardinal sign is not merely a red flag. It is a threshold—a signal that the trajectory has changed and the body’s recovery mechanisms are no longer adequate.
In situations like this, the questions that matter are not abstract. They are concrete:
- Recovery after each coughing fit? Present.
- Ability to sleep? Intact.
- Feeding? Unchanged.
- Color? Normal.
- Escalation over forty-eight hours? Absent.
Those aren’t just “good signs.” They are sentinels reporting back: resilience is holding.
The converse, cardinal signs I’m watching for are different:
- Cough fits becoming longer or more frequent
- Breathing pauses
- Cyanosis
- Feeding refusal
- Failure to recover between episodes
If any of those appear, trust ends and escalation begins. But until then, the job is not to intervene. The job is to witness recovery and remain close enough to catch the moment when it fails.
This is harder than it sounds. It requires tolerating discomfort—yours, not the patient’s.
Recovery Is Not an Absence of Care
One of the quiet tragedies of an over-medicalized culture is that recovery has become invisible. When a child clears a viral illness without antibiotics, we say “it resolved on its own,” as if the immune system did nothing. When a cough self-limits, we say “it wasn’t serious,” as if seriousness is only measured by intervention.
But recovery is not the absence of pathology. It is the presence of functioning repair systems. And those systems deserve recognition:
- The cough reflex is airway clearance, not malfunction.
- Fever is metabolic amplification, not chaos.
- Fatigue is enforced rest, not weakness.
- Appetite suppression is energy reallocation, not failure to thrive.
- Crying is caregiver recruitment—a system working exactly as designed.
These mechanisms are not passive. They are not accidents. They are the product of evolutionary pressure, and they work remarkably well when given time, positioning, moisture, and rest.
The problem is that none of this bills well. There is no CPT code for “watched carefully and allowed recovery.” So the system incentivizes action, and action becomes the only legible form of care.
Stewardship pushes back—not against medicine, but against the idea that care and intervention are synonymous. Presence, framing, and trajectory-watching are interventions too. They simply do not leave a procedural paper trail.
Self-Limiting Disease at Scale
This is not just a parenting philosophy. It is a health system design problem.
Yet we rarely speak about it that way. We talk about access, coverage, and reducing barriers to care—all of which matter. What we discuss far less is appropriate non-use: the visits that didn’t need to happen, the antibiotics that didn’t need to be prescribed (there’s some antimicrobial stewardship out there, I do acknowledge), the imaging that added cost without changing outcomes.
Stewardship at scale looks like:
- Teaching cardinal signs, not symptom encyclopedias
- Normalizing recovery timelines, not just warning signs
- Building caregiver confidence, not system dependency
- Reducing unnecessary utilization without reducing trust
This is not rationing. Rationing withholds care that would help. Stewardship clarifies when care is not needed—and builds the shared understanding that makes non-intervention feel like a decision, not an abandonment.
The Hardest Skill
I’ll say it plainly: the discipline of not intervening is one of the hardest skills in medicine.
It requires more knowledge than acting, not less. You must understand the natural history of disease, the physiology of recovery, the probability of deterioration, and the sentinel signs that separate noise from signal.
And then you must sit with uncertainty. You must tolerate the discomfort of not knowing while maintaining the posture of active watching.
Most of us are not trained for this. We are trained to escalate. We are trained to document. We are trained to protect ourselves. The result is a system that over-tests, over-treats, and under-trusts—both the patient and the clinician’s own judgment.
Stewardship is the corrective. It does not reject intervention. It locates intervention within a larger frame where recovery is the default expectation and escalation is the exception that proves the rule.
Rules of Stewardship
Trust resilience until trajectory breaks. Recovery is not passive; it is the body doing exactly what it evolved to do. The task is not to preempt that process out of anxiety, but to recognize the moment when it fails.
Name the sentinels. Share the timeline. Stewardship is not reassurance—it is transparency. Tell people what you are watching for, how long the pattern should hold, and what would change your posture.
That is how trust is built. Not by saying ahh, don’t worry about it, but by saying here is exactly what would make me worry.
