Managing Risk: Prognosis
Side Note: Physicians are constantly giving their patients information. From giving them test results, to information about how to take a medication to information about their diagnosis, the nature of the doctor-patient relationship is based on the transfer of information. The informed consent process illustrates the importance of this transfer of information. As most physicians know, informed consent is not a signature on a legal form –it is a back-and-forth conversation where the physician gives information, checks for understanding, and makes sure that the patient knows what to expect (or could possibly expect) for an upcoming procedure or treatment. But, what is the doctor to do when information is requested and the doctor doesn’t truly know the answer? This is often the case when a physician is asked about a patient’s prognosis.
Giving a patient a prognosis is a tricky thing for several reasons. First, a prognosis can involve a lot of different information –either information offered by the physician or requested by the patient. Most commonly, it can involve, “How long do I have to live?” or “What can I expect?” or “What are my chances of recovery?” or all of the above and then some. All of these questions can be hard to answer, depending on the situation. First, physicians are not psychic. No one can see the future. Second, the care of a patient involves a lot of variables –some of which can be unknown or very unpredictable. And, even with a lot of experience and having seen many similar cases, some cases just play out in a strange way and don’t follow the typical trajectory.
The study below of terminally ill patients and their physicians’ predictions of their length of survival illustrates this. In short, the physicians, both the patients’ generalists and specialists, were shown to not be good predictors of a patient’s survival. Only 20% of the physicians’ predictions were considered accurate. Read below for further details.
Considering that physicians are trained to always “know the answer” or “figure out the answer,” it is no surprise that they feel they should be able to give a prognosis. But, as this study and others show, predicting a patient’s prognosis is tough and must be approached with modesty. It has often been suggested that giving patients a range is a much more helpful and realistic way to approach the subject. For example, “Some patients live several months, others have lived several years, and most patients fall somewhere in the middle.” Also, it should be added that it is ok for a physician to be honest and say, “I don’t know.” That said, we here at MyMedicalMalpracticeInsurance.com know that patients can sometimes pressure physicians into giving an answer –and sometimes even pressure physicians into giving an answer that they want to hear. It can be tough. But, giving an honest answer can not only manage the patient’s expectations appropriately, it can help protect you from liability exposure. No one wants to have to worry about med mal liability or med mal coverage when practicing medicine, but it is an unfortunate reality in our litigious society.
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Extent and determinants of error in physicians’ prognoses in terminally ill patients: prospective cohort study.
Christakis NA, Lamont EB.West J Med. 2000 May;172(5):310-3.
Abstract
Objectives To describe physicians’ prognostic accuracy in terminally ill patients and to evaluate the determinants of that accuracy. Design Prospective cohort study. Setting Five outpatient hospice programs in Chicago. Participants A total of 343 physicians provided survival estimates for 468 terminally ill patients at the time of hospice referral. Main outcome measures Patients’ estimated and actual survival. Results Median survival was 24 days. Of 468 predictions, only 92 (20%) were accurate (within 33% of actual survival); 295 (63%) were overoptimistic, and 81 (17%) were overpessimistic. Overall, physicians overestimated survival by a factor of 5.3. Few patient or physician characteristics were associated with prognostic accuracy. Male patients were 58% less likely to have overpessimistic predictions. Medical specialists excluding oncologists were 326% more likely than general internists to make overpessimistic predictions. Physicians in the upper quartile of practice experience were the most accurate. As the duration of the doctor-patient relationship increased and time since last contact decreased, prognostic accuracy decreased. Conclusions Physicians are inaccurate in their prognoses for terminally ill patients, and the error is systematically optimistic. The inaccuracy is, in general, not restricted to certain kinds of physicians or patients. These phenomena may be adversely affecting the quality of care given to patients near the end of life.
