JOURNAL OF PALLIATIVE MEDICINE Volume 17, Number 6, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2014.9425
Notes from the Editor
Prognosis: How Long Do We Wait for the Doctor? Charles F. von Gunten, MD, PhD, Editor-in-Chief
S
ince the beginning of recorded medical history, patients have wanted to know three things from their physician: What’s wrong with me? (diagnosis); What will happen to me? (prognosis); and What can be done to help me? (treatment). Most of contemporary medical practice is organized around diagnosis and treatment. Though prognostic information exists, there is no systematic approach to making that information reliably and routinely available for decision making. The new whiz-bang electronic medical records and medical decision making tools nudge, cajole, bleat, and scream at the clinician to ensure that important information about diagnostic screening and testing not be missed. Patterns of practice are reviewed and reported as never before so that best treatment practices are routinely delivered. The omission of prognostic information using the same logic that puts all other medical information at the fingertips of the physician should strike everyone as odd. There is no one in the world that publicly advocates that accurate prognostic information be withheld so that physicians and their patients will make uninformed decisions. Yet, that seems to be the tacit standard. In this issue, Stavas and colleagues observed a median survival of 80 days (about 3 months) and unmet palliative care needs in patients receiving whole brain radiation for brain mets.1 Don’t you think different patterns of treatment would be initiated if they had known this ahead of time? Presumably, someone was waiting for the doctor to bring up the subject. Schenker and colleagues find that patients with advanced cancer identify many unmet palliative care needs because they are waiting for their doctor to initiate it.2 What if the referral to palliative care was part of the order sets for advanced cancer as a matter of course? Liu and colleagues note that, if the doctor does discuss prognosis, the patient remembers it.3 Zhao and colleagues confirm that in a prospective study, if the existing data corresponding with prognosis are aggregated, they can be used to make an accurate prognosis.4 Research has taught us that when unaided physicians are asked to prognosticate, they are systematically overoptimistic by a factor of three when predicting survival—that is, they are 300% more optimistic than actual measured survival.5 That includes palliative medicine physicians. This data simply cries out for providing aids to physicians in the same way we provide aids to help surgical operations be more successful and for treatment in the ICU to avoid the avoidable.
There is a wrinkle that is important to note in this otherwise smooth argument. We know that physicians are willing to tell patients their prognosis if the patients ask; patients want to know their prognosis if their doctor brings it up. I interpret this to mean there is a love relationship between physicians and their patients. It is analogous to the widely observed behaviors of married couples where each will withhold information from the other to avoid causing distress, even if it is the truth. In like manner physicians and patients avoid bringing up the subject of prognosis because they don’t want to cause distress in the other. All of this information leads me to speculate about a future state for health care. Imagine that our computer-driven decision making tools were to make the power of our prognostic data routinely available to clinicians. In other words, if we didn’t wait for the doctor. For example, imagine a patient with brain mets and an ECOG Performance Status of 3 who we know has a prognosis of about three months. Imagine that the treating clinician encounters a pop-up box on the computer screen that says, ‘‘Your patient has a prognosis of three months.’’ Don’t you think that would help the physician overcome the selfgenerated prognosis of nine months because of the overoptimistic factor? Further, to protect the lover-beloved relationship between physician and patient, imagine that the order set for ‘brain mets treatment’ has a required element for palliative care consultation for assessment and co-management. If you extrapolate that image to all the patients in your center with advanced disease, doesn’t it seem likely that an entirely different pattern of care might emerge? We can’t wait for the doctor. We need the system in place that enables the doctor to do the right thing. This is no different than every other aspect of contemporary health care. When physicians are engaged, given the right tools and the right systems, we do the right thing. From what I can see, it is a relatively straightforward path to enable this to happen. We have the data. We have the information technology. We are now in a period when systemization of care is acknowledged to improve care at lower cost. Why wait? References
1. Stavas M, Arneson K, Freidman J, Misra S: From whole brain radiation to hospice: Understanding patterns of care in radiation oncology. J Palliat Med 2014;17:662–666. 2. Schenker Y, Park SY, Maciasz R, Arnold RM: Do advanced cancer patients with unmet palliative care needs have an interest in receiving palliative care services? J Palliat Med 2014;17:667–672.
634
NOTES FROM THE EDITOR
3. Liu P-h, Landrum MB, Weeks JC, Huskamp H, Kahn KL, He Y, Mack J, Keating NL: Physicians’ propensity to discuss prognosis is associated with patients’ awareness of prognosis for metastatic cancers. J Palliat Med 2014;17:673–682. 4. Zhao J, Cui J, Zhou L, Wee B, Shen F, Ma X: Predicting survival time in non-curative patients with advanced cancer:
635
A prospective study in China. J Palliat Med 2014;17:545– 552. 5. Glare P, Virik K, Jones M, Hudson M, Eychmuller S, Simes J, Christakis N: A systematic review of physicians’ survival predictions in terminally ill cancer patients. BMJ 2003;327: 195–198.
Notes from the Editor
Prognosis: How Long Do We Wait for the Doctor? Charles F. von Gunten, MD, PhD, Editor-in-Chief
S
ince the beginning of recorded medical history, patients have wanted to know three things from their physician: What’s wrong with me? (diagnosis); What will happen to me? (prognosis); and What can be done to help me? (treatment). Most of contemporary medical practice is organized around diagnosis and treatment. Though prognostic information exists, there is no systematic approach to making that information reliably and routinely available for decision making. The new whiz-bang electronic medical records and medical decision making tools nudge, cajole, bleat, and scream at the clinician to ensure that important information about diagnostic screening and testing not be missed. Patterns of practice are reviewed and reported as never before so that best treatment practices are routinely delivered. The omission of prognostic information using the same logic that puts all other medical information at the fingertips of the physician should strike everyone as odd. There is no one in the world that publicly advocates that accurate prognostic information be withheld so that physicians and their patients will make uninformed decisions. Yet, that seems to be the tacit standard. In this issue, Stavas and colleagues observed a median survival of 80 days (about 3 months) and unmet palliative care needs in patients receiving whole brain radiation for brain mets.1 Don’t you think different patterns of treatment would be initiated if they had known this ahead of time? Presumably, someone was waiting for the doctor to bring up the subject. Schenker and colleagues find that patients with advanced cancer identify many unmet palliative care needs because they are waiting for their doctor to initiate it.2 What if the referral to palliative care was part of the order sets for advanced cancer as a matter of course? Liu and colleagues note that, if the doctor does discuss prognosis, the patient remembers it.3 Zhao and colleagues confirm that in a prospective study, if the existing data corresponding with prognosis are aggregated, they can be used to make an accurate prognosis.4 Research has taught us that when unaided physicians are asked to prognosticate, they are systematically overoptimistic by a factor of three when predicting survival—that is, they are 300% more optimistic than actual measured survival.5 That includes palliative medicine physicians. This data simply cries out for providing aids to physicians in the same way we provide aids to help surgical operations be more successful and for treatment in the ICU to avoid the avoidable.
There is a wrinkle that is important to note in this otherwise smooth argument. We know that physicians are willing to tell patients their prognosis if the patients ask; patients want to know their prognosis if their doctor brings it up. I interpret this to mean there is a love relationship between physicians and their patients. It is analogous to the widely observed behaviors of married couples where each will withhold information from the other to avoid causing distress, even if it is the truth. In like manner physicians and patients avoid bringing up the subject of prognosis because they don’t want to cause distress in the other. All of this information leads me to speculate about a future state for health care. Imagine that our computer-driven decision making tools were to make the power of our prognostic data routinely available to clinicians. In other words, if we didn’t wait for the doctor. For example, imagine a patient with brain mets and an ECOG Performance Status of 3 who we know has a prognosis of about three months. Imagine that the treating clinician encounters a pop-up box on the computer screen that says, ‘‘Your patient has a prognosis of three months.’’ Don’t you think that would help the physician overcome the selfgenerated prognosis of nine months because of the overoptimistic factor? Further, to protect the lover-beloved relationship between physician and patient, imagine that the order set for ‘brain mets treatment’ has a required element for palliative care consultation for assessment and co-management. If you extrapolate that image to all the patients in your center with advanced disease, doesn’t it seem likely that an entirely different pattern of care might emerge? We can’t wait for the doctor. We need the system in place that enables the doctor to do the right thing. This is no different than every other aspect of contemporary health care. When physicians are engaged, given the right tools and the right systems, we do the right thing. From what I can see, it is a relatively straightforward path to enable this to happen. We have the data. We have the information technology. We are now in a period when systemization of care is acknowledged to improve care at lower cost. Why wait? References
1. Stavas M, Arneson K, Freidman J, Misra S: From whole brain radiation to hospice: Understanding patterns of care in radiation oncology. J Palliat Med 2014;17:662–666. 2. Schenker Y, Park SY, Maciasz R, Arnold RM: Do advanced cancer patients with unmet palliative care needs have an interest in receiving palliative care services? J Palliat Med 2014;17:667–672.
634
NOTES FROM THE EDITOR
3. Liu P-h, Landrum MB, Weeks JC, Huskamp H, Kahn KL, He Y, Mack J, Keating NL: Physicians’ propensity to discuss prognosis is associated with patients’ awareness of prognosis for metastatic cancers. J Palliat Med 2014;17:673–682. 4. Zhao J, Cui J, Zhou L, Wee B, Shen F, Ma X: Predicting survival time in non-curative patients with advanced cancer:
635
A prospective study in China. J Palliat Med 2014;17:545– 552. 5. Glare P, Virik K, Jones M, Hudson M, Eychmuller S, Simes J, Christakis N: A systematic review of physicians’ survival predictions in terminally ill cancer patients. BMJ 2003;327: 195–198.
