The Art of Prognosis

“It appears to me a most excellent thing for the physician to cultivate Prognosis: for by foreseeing and foretelling … the present, the past and the future, he will be more readily believed to be acquainted with the circumstances of the sick; so that men will have confidence to intrust themselves to such a physician.”

Hippocrates: “The Book of Prognostics”, 400 B.C.

This time of year, many of my patients make public announcements, at least to me, of their intentions to quit smoking, eat less of certain kinds of food, exercise more and so on. In many cases, this year’s New Year’s resolutions are the same as last year’s.

Physicians sometimes also walk around making promises that are more optimistic than realistic. Sometimes we do it as a way to invoke the placebo effect, for example when we prescribe a new antidepressant for someone who has “failed” on several others. Other times we do it because neither the patient nor the doctor is ready to admit that the disease seems to have the upper hand.

We need to be careful with our promises. Those of us who treat children know that “This won’t hurt a bit” makes for unhappy and mistrusting patients for years to come. Honest predictions like “This will hurt for just a couple of seconds, and then you won’t feel any pain at all” makes young patients more trusting and courageous the next time.

Promising recovery in a case that proves fatal is a far more serious error than to be proven wrong when predicting a patient’s death from their disease. Still, many doctors make vague promises in the name of hope and encouragement.

Little Amy Ruggles’ family doctor and consultant pediatrician more or less promised she would catch up in her development when she, in fact, had Rett syndrome (“Amy Laughs with The Angels”).

William Sykes’ pulmonologist predicted his alpha-1-antitrypsin deficiency would claim his life within 18 months (“Adverse Effects”), but Bill lived another ten years, haunted by his carelessly delivered death sentence.

One physician I know has made an art form of preparing his patients and their families for the worst possible outcome. Andy Spoerri is a brilliant infectious disease specialist, who was one of my teachers in residency. Every time he admitted or consulted on a patient with pneumonia, he called a meeting with the family. In his animated style of speaking as if time was running out, he would explain the mortality rate of pneumonia. Even in the most routine case, Andy would explain that the patient had a one-in-ten chance of dying from their condition. When the patient recovered without complications, the family would praise Andy as a genius and a lifesaver.

I have never been totally comfortable with Andy’s approach. I sometimes struggle with finding the right level of caution, of under-promise and over-delivery, without making the situation seem more serious than it is.

As physicians, we need to be aware of the power of our words in giving hope and encouragement. We need to be judicious and never promise what we cannot deliver or predict what we cannot know. We need to cultivate the skills of clinical observation and prognostication in the tradition of the old masters. And we need to be humble.

Hippocrates also wrote:

“Medicine is of all the Arts the most noble; but, owing to the ignorance of those who practice it, and of those who, inconsiderately, form a judgement of them, it is at present far behind all the other arts.”

Those words were penned over 2,000 years ago, and the body of medical knowledge has grown exponentially since then. Are we perhaps so focused on keeping up with new technical information, statistical averages and Kaplan-Meier curves that we sometimes forget the tremendous variability among individual patients? Are we sometimes neglecting the value of our own experiences as clinicians when trying to deliver a prognosis?

(An earlier version of this post was published in January 2011)

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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