The ellipsis of prognosis in modern medical thought

doi:10.1016/S0277-9536(96)00100-1

Social Science & Medicine

Volume 44, Issue 3, February 1997, Pages 301-315

https://doi.org/10.1016/S0277-9536(96)00100-1 Get rights and content

Abstract

Contemporary textbooks of internal medicine give scant attention to the prognosis of diseases. Has this always been the case? If not, when and why did prognosis come to be de-emphasized? Using a highly regarded, standard medical textbook initially authored by William Osler, The Principles and Practice of Medicine, I performed qualitative and quantitative content analysis of entries regarding lobar pneumonia in selected editions published between 1892 and 1988, with special attention to the period between 1892 and 1947. I chose lobar pneumonia because it was a leading cause of death throughout this period and because it is recognizable across time, thus making it possible to follow the evolution in clinical thinking about prognosis while holding constant the diagnosis. I argue that two powerful forces converged to lead to the ellipsis of prognosis: (1) the emergence of effective therapy, and (2) a fundamental change in the cognitive basis of medicine. With respect to the former, I show that there is a complementary, inverse relationship between the clinical acts of prognostication and therapy; as one increases in salience in the management of a disease, the other decreases. With respect to the latter, I argue that the particular clinical facts deemed to be important about a patient's case have shifted over time, and I explore changes in the clinical and cognitive foundations of physicians' estimation of patients' prognoses—in particular, “symptoms” and “complications.” I conclude that, concurrent with a shift in clinical thought from an individual-based to a diagnosis-based conceptualization of disease, prognosis came to be seen as intrinsic to diagnosis and therapy, and explicit attention to prognosis consequently diminished.

References (27)

N.A. Christakis
Prognostication and Death in Medical Thought and Practice
(1995)
W. Osler
The Principles and Practice of Medicine
(1892)
W. Osler et al.
The Principles and Practice of Medicine
(1924)
H. Christian
The Principles and Practice of Medicine
(1947)
M. Lerner et al.
Health Progress in the United States: 1900–1960
(1963)
U.S. Bureau of the Census
Statistical Abstract of the United States
(1976)
K.M. Ludmerer
Learning to Heal: The Development of American Medical Education
(1985)
C.E. Rosenberg
The Care of Strangers
(1987)
C.E. Rosenberg
The therapeutic revolution: Medicine, meaning, and social change in 19th-century America

E.C. Atwater

Touching the patient: The teaching of internal medicine in America

F.W. Peabody

The care of the patient

J. Amer. Med. Assoc.

(1927)

A.M. Harvey et al.

Osler's Textbook Revisited

Cited by (80)

The TRIBE model: How socioemotional processes fuel end-of-life treatment in the United States
2023, Social Science and Medicine
Prior interventions have repeatedly failed to decrease the prescription and receipt of treatments and procedures that confer more harm than benefit at the End-of-Life (EoL); new approaches to intervention are needed. Ideally, future interventions would be informed by a social-ecological conceptual model that explains EoL healthcare utilization patterns, but current models ignore two facts: (1) healthcare is an inherently social activity, involving clinical teams and patients' social networks, and (2) emotions influence social activity. To address these omissions, we scaffolded Terror Management Theory and Socioemotional Selectivity Theory to create the Transtheoretical Model of Irrational Biomedical Exuberance (TRIBE). Based on Terror Management Theory, TRIBE suggests that the prospect of patient death motivates healthcare teams to conform to a biomedical norm of care, even when clinicians believe that biomedical interventions will likely be unhelpful. Based on Socioemotional Selectivity Theory, TRIBE suggests that the prospect of dwindling time motivates families to prioritize emotional goals, and leads patients to consent to disease-directed treatments they know will likely be unhelpful, as moral emotions motivate deference to the perceived emotional needs of their loved ones. TRIBE is unique among models of healthcare utilization in its acknowledgement that moral emotions and processes (e.g., shame, compassion, regret-avoidance) influence healthcare delivery, patients' interactions with family members, and patients’ outcomes. TRIBE is especially relevant to potentially harmful EoL care in the United States, and it also offers insights into the epidemics of overtreatment in healthcare settings worldwide. By outlining the role of socioemotional processes in the care of persons with serious conditions, TRIBE underscores the critical need for psychological innovation in interventions, health policy and research on healthcare utilization.
Discussing brain magnetic resonance imaging results for neonates with hypoxic-ischemic encephalopathy treated with hypothermia: A challenge for clinicians and parents
2022, eNeurologicalSci
Clinicians use brain magnetic resonance imaging (MRI) to discuss neurodevelopmental prognosis with parents of neonates with hypoxic-ischemic encephalopathy (HIE) treated with therapeutic hypothermia (TH).
To investigate how clinicians and parents discuss these MRI results in the context of HIE and TH and how these discussions could be facilitated and more meaningful for parents.
Mixed-methods surveys with open-ended and closed-ended questions were completed by two independent groups. (1) Clinicians responded to clinical vignettes of neonates with HIE treated with TH with various types of clinical features, evolution and extent of brain injury and questions about how they discuss brain MRI results in this context. (2) Parents of children with HIE treated with TH responded to questions about the discussion of MRI that they had while still in the neonatal intensive care unit and were asked to place it in perspective with the outcomes of their child when he/she reached at least 2 years of age. Open-ended responses were analyzed using a thematic analysis approach. Closed-ended responses are presented descriptively.
Clinicians reported uncertainty, lack of confidence, and limitations when discussing brain MRI results in the context of HIE and TH. Brain MRI results were “usually” (53%) used in the prognostication discussion. When dealing with day-2 brain MRIs performed during TH, most clinicians (40%) assumed that the results of these early MRIs were only “sometimes” accurate and only used them “sometimes” (33%) to discuss prognosis; a majority of them (66%) would “always” repeat imaging at a later time-point to discuss prognosis. Parents also struggled with this uncertainty, but did not discuss limitations of MRI as often. Parents raised the importance of the setting where the discussion took place and the importance to inform them as quickly as possible. Clinicians identified strategies to improve these discussions, including interdisciplinary approach, formal training, and standardized approach to report brain MRI. Parents highlighted the importance of communication skills, the stress, the hope surrounding their situation, and the need to receive answers as soon as possible. The importance of showing the pictures or making representative drawing of the injury, but also highlighting the not-injured brain, was also highlighted by parents.
Discussing brain MRI results for neonates with HIE treated with TH are challenging tasks for clinicians and daunting moments for parents.
Conversational stories & self organizing maps: Innovations for the scalable study of uncertainty in healthcare communication
2021, Patient Education and Counseling
Citation Excerpt :
If preventing or delaying death were the only outcomes to consider when choosing medical treatments, then facing uncertainties through conversation might actually not be useful for decision-making purposes. Uncertainty about the timing of death might just as well be handled by way of the prevalent social strategies of avoidance, unbalanced optimism, or doubling-down on one’s sense of unique perseverance: to declare one’s intention to “beat the odds,” whatever they appear to be [16–19]. But existential threats to a seriously ill person’s integrity, and the likely attendant forms of that person’s suffering, often precede death itself [20,21].
Understanding uncertainty in participatory decision-making requires scientific attention to interaction between what actually happens when patients, families and clinicians engage one another in conversation and the multi-level contexts in which these occur. Achieving this understanding will require conceptually grounded and scalable methods for use in large samples of people representing diversity in cultures, speaking and decision-making norms, and clinical situations.
Here, we focus on serious illness and describe Conversational Stories as a scalable and conceptually grounded framework for characterizing uncertainty expression in these clinical contexts. Using actual conversations from a large direct-observation cohort study, we demonstrate how natural language processing and unsupervised machine learning methods can reveal underlying types of uncertainty stories in serious illness conversations.
Conversational Storytelling offers a meaningful analytic framework for scalable computational methods to study uncertainty in healthcare conversations.
One last round of chemo? Insights from conversations between oncologists and lung cancer patients about prognosis and treatment decisions
2020, Social Science and Medicine
Citation Excerpt :
However, the oncologist tells him that she is very concerned that the back pain may stem from metastases growing in his back, and that she wants to admit him for acute examination. By saying that she is very concerned, the oncologist fires another ‘warning shot’ (Christakis, 1997: 108) to Harry, indicating that he may be worse off than he thinks. While the oncologists lean towards the assessment that Harry will not be able handle further treatment, the quality of the treatment option that would be available for him, immunotherapy, seems to slightly open a window of uncertainty, implying that if Harry's performance status improves, treatment could be a good option aligned with his preferences.
One more chemo or one too many? The increasing use of expensive cancer treatments close to the patient's death is often explained by oncologists' failure to communicate to patients how close to dying they are, implying that patients are often both ill-prepared and over-treated when they die. This article aims at interrogating the politically charged task of prognosticating. Drawing on an ethnographic study of conversations between oncologists and patients with metastatic lung cancer in a Danish oncology clinic, I show that oncologists utilize, rather than avoid, prognostication in their negotiations with patients about treatment withdrawal. The study informs the emerging sociology of prognosis in three ways: First, prognostication is not only about foreseeing and foretelling, but also about shaping the patient's process of dying. Second, oncologists prognosticate differently depending on the level of certainty about the patient's trajectory. To unfold these differences, the article provides a terminology that distinguishes between four ‘modes of prognostication’, namely hinting, informing, calibrating and organizing. Third, prognosticating can unfold over time through multiple consultations, emphasizing the relevance of adopting methodologies enabling the study of prognosticating over time.
Prognostication in Serious Illness
2020, Medical Clinics of North America
Diagnosis: From classification to prediction
2019, Social Science and Medicine
Over the last two decades diagnostic labels have increasingly been sub-divided based on molecular and genetic ‘signatures’. But this emphasis on disease sub-types defined in molecular terms, elides the central role of population-based predictive technologies in determining these new diagnoses. While molecular diagnostic sub-types might flow from the laboratory, the clinical validity of every putative diagnostic category must ultimately be tested against its predictive powers. In effect, the former logic of prognosis following diagnosis is reversed. This paper explores the emergence of this new method of diagnostic practice over the last half century.

View all citing articles on Scopus

View full text

The ellipsis of prognosis in modern medical thought

Abstract

Prognostication and Death in Medical Thought and Practice

The Principles and Practice of Medicine

The Principles and Practice of Medicine

The Principles and Practice of Medicine

Health Progress in the United States: 1900–1960

Statistical Abstract of the United States

Learning to Heal: The Development of American Medical Education

The Care of Strangers

The therapeutic revolution: Medicine, meaning, and social change in 19th-century America

Touching the patient: The teaching of internal medicine in America

The care of the patient

J. Amer. Med. Assoc.

Osler's Textbook Revisited