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N A Christakis. University of Chicago Press, 1999, US$30.00, pp 328. ISBN 0 226 10470 2
Many doctors these days are aware of powerful disincentives to the giving of specific prognoses. The mentioning of an estimated time, even if heavily qualified, is likely to be heard by both patients and their loved ones as “the doctor gave me two months to live”. The result? Patients and relatives feeling cheated if the prognosis turns out to be an overestimate, anxious or worse if an underestimate, and colleagues critical of the doctor for having had the arrogance to predict, no matter what the actual outcome. It is not surprising therefore that doctors wishing to avoid these results are reluctant to prognosticate at all and when forced tend to make their predictions so vague as to be meaningless. For Christakis, this response simply is not good enough. In a carefully written and very well referenced book he argues cogently that prognostication is a responsibility for doctors and that “shirking the difficult questions—as most doctors tend to do—advances neither medical knowledge nor the care seriously ill patients receive”. He does so as a physician and with the backing of the results of his survey of the attitudes and self reported practice of 1500 American physicians. While accepting that patients might be harmed if erroneous predictions of imminent death result in the withholding of interventions that would otherwise save a life, his study convinces him that most of the time the problem is the reverse. The concept of the self fulfilling prophecy is helpfully explored and with a powerful combination of evidence, argument, and understanding is developed into the notion of “the ritualisation of optimism”. Christakis shows that, whatever is communicated to patients, physicians caring for terminally ill patients routinely overestimate duration of survival by a factor of three or more; he suggests that it is reasonable to expect that, knowing of this bias, systematic allowance could be made by physicians in their prognostication for the group as a whole even if errors in individual cases unavoidably persist. It is hoped that, in changing their thinking, physicians might realise there is much that patients can hope for even when death is inevitable.
Christakis claims there is a duty to prognosticate, and although the moral argument for this claim is not well developed many quotations from practising physicians seem to substantiate it. The meaning of saying nothing about the prognosis is examined carefully. In circumstances of chronic illness no news can often genuinely be said to be good news. In the intensive care setting, however, the aphorism “no step forward is a step back” may have greater validity. The saying of nothing about the future suggests that things are “on course” whether for a favourable or unfavourable outcome.
This is a thoughtful and practical book about a widely important issue. I am convinced of a duty to prognosticate and I am now much better informed about the challenge of balancing optimism and pessimism in applying knowledge and experience honestly to the concerns of patients and those close to them.