From Library Journal
Copyright 1999 Reed Business Information, Inc. --This text refers to the Hardcover edition.
From The New England Journal of Medicine
These questions demand answers that will shape how patients relate to their illnesses. Prognosis affects their lifestyle choices, health care decisions, and overall outlook. Yet, many physicians dread responding to such questions. What underlies this fear, and what are its consequences?
It seems natural that we should wish to avoid sharing bad news. Offering a grim prognosis forces us as physicians to deal with a patient's grief and confront our own sense of futility. Furthermore, patients may not wish to hear what we have to tell them. Yet, even when the outlook is optimistic, discussing an uncertain future makes us cautious. There is something deeper here.
In Death Foretold: Prophecy and Prognosis in Medical Care, Nicholas Christakis proposes that prognostication evokes awe and mystery because it casts the physician in the role of prophet. Many physicians are overwhelmed by the power and responsibility of such a role and, like Jonah boarding the ship to Tarshish, attempt to flee altogether. Yet, Christakis concludes, physicians -- like prophets -- have a moral duty to predict the future and must find appropriate ways to do so.
His argument is sophisticated, extraordinarily well supported, and compelling. The book is based on his own extensive research on the attitudes of physicians toward prognosis and a thorough review of the relevant medical and sociological literature. Christakis begins by describing what he calls the "ellipsis of prognosis" in modern medical thought. Prognosis, diagnosis, and therapy are the primary functions of medicine, yet among these three, prognosis receives the least amount of attention. Although implicit in nearly all diagnostic and therapeutic decisions, prognosis per se is neglected, avoided, and even despised. Christakis points out the absence of discussion of prognosis in textbooks, medical education, and encounters with patients.
Christakis then presents data to show that physicians frequently make errors in prognosis and that such errors are not random. Physicians convey an optimistic bias when discussing prognoses with each other and when sharing them with patients and families. They are likely to overestimate survival and future quality of life. The most fascinating data from Christakis's interviews and surveys suggest that physicians believe in the self-fulfilling prophecy -- as a group, physicians believe that predicting outcomes may actually cause them to happen.
There may be logical explanations for this belief. For example, after hearing their prognosis, patients may change their behavior with respect to health and thus affect their own outcomes. However, many physicians believe that the effect of the self-fulfilling prophecy is mediated by forces beyond human control. They have internalized the sort of magical thinking we often ascribe only to patients. This has important implications. Physicians, acting in what they see to be the patient's best interests, will avoid the delivery of bad news or present prognoses in an unduly favorable light. The self-fulfilling prophecy leads to what Christakis calls the "ritualization of optimism" in medical practice.
The powerful metaphor of physician as prophet complements a view of prognosis as "meaningful, mysterious, and influential." Prophets, through divine inspiration, foretell the future and yet are frequently unpopular. They are obligated to continue their prophecies for the good of those who prefer not to hear the message. These attributes of prognosis convey strong moral overtones and motivate Christakis to conclude that, despite the problems, physicians have a duty to prognosticate. The book closes with recommendations for clinical education and practice that can help physicians fulfill this obligation.
This exceptionally well written book is spiced with quotations from interviews with physicians and audiotaped clinical encounters that highlight the painful issues raised by the discussion of prognosis. Clinicians will find these voices of medicine authentic and engaging. Trained as both a physician and a sociologist, Christakis speaks directly to doctors and presents social theory without resorting to jargon.
This book is comprehensive, although two areas could have received greater attention. First, Christakis acknowledges that he has focused solely on the attitudes of physicians. This leaves the reader wondering about what patients expect from conversations about prognosis. How do patients define hope in the face of an uncertain future, and what role do physicians have in maintaining their hope? How do we respond to patients who request an optimistic bias? We must answer these questions before articulating a comprehensive approach to the discussion of prognosis. Second, the author writes that "prognosis gives diagnosis its affective component, striking fear in patients and physicians alike." Yet, he does not fully probe the implications of this statement. Requests for information by patients, phrased in the form of questions such as "Am I going to die?" may be expressions of fear rather than true inquiries. If one does not recognize and manage skillfully the emotion underlying the question, then the honest prognostication Christakis hopes physicians will learn to convey will not be heard. Managing emotions and prognosticating are interdependent and require equal attention.
This superb book offers the most scholarly analysis ever written of prognosis, and I recommend it highly to anyone interested in the doctor-patient relationship. Prognostication is one of the most important and difficult tasks physicians perform. Informed by his own practice, Christakis has tremendous compassion for the struggle of the individual physician. He argues forcefully that the profession must take responsibility for the current widespread avoidance of prognosis and change the present culture. This prophet is one whose advice we would do well to heed.
Reviewed by James Tulsky, M.D.
Copyright © 2000 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS. --This text refers to the Hardcover edition.