Diagnosis, Treatment ... and Maybe a Prognosis?

Back in the days when modern medicine started, around the turn of the 20th century, the practice of medicine was roughly divided into  thirds: diagnosis, treatment and prognosis.

That's what Alexander Smith, palliative care expert at the San Francisco VA Hospital, told me in an interview. He attributed the approach to the illustrious William Osler, one of the founding professors of Johns Hopkins Hospital, back in the late 19th century.

But things have changed since Dr. Osler ruled in Baltimore. "Prognosis has really waned," Smith says. "Now in textbooks, there's just a few lines. The focus is on diagnosis and treatment."

Smith and a handful of colleagues are trying to refocus doctors and other clinicians on prognosis in older patients. But it looks like he has a long way to go. In today's Journal of the American Medical Association, Smith and his colleagues assess the efficacy of 16 different ways to measure prognosis. Unfortunately, the authors find that all of them are lacking in one way or another. Failure to consider prognosis is a problem, they argue, because it can lead to poor care.

"Prognosis is a critically important piece of information for decision-making in the elderly," Smith said. "For most preventive measures, the harms occur up front, but the benefits don't accrue for years."

One case in point is the colonoscopy. "There's an immediate risk of intestinal perforation. It sounds awful and it is. While uncommon, it's horrific when it happens." While colonoscopies are great at finding very early colon cancers, that's what they are, very early. This is where overall prognosis comes in. As people get older, their likelihood of dying with and not of a particular cancer goes up, so why subject patients to screening tests?

This isn't a question just of a patient's age, which is what doctors call a "blunt instrument." A better way to measure prognosis, Smith said, would be to add in other factors, "like what other medical conditions a patient has, what functional status a patient has, like walking, bathing, calculating checkbooks, what cognitive impairment they have."

Smith and his colleagues have taken the 16 current imperfect tools that measure prognosis and put them together in a new website, www.eprognosis.org, specifically for doctors and other health care workers. The goal is for doctors to use the individual tools and then rate them on usefulness. But doctors should use the information as one tool, in combination with discussions with patients and their patients' preferences.

Still, Smith stressed that doctors tend to be optimistic when estimating prognosis, and the better they know the patient, the more optimistic they become.

"If a patient has the information, then patients and doctors are more likely to make choices that are sensible. They are less likely to pursue tests and treatments that are likely to be harmful and they can shift priorities to other things like maintaining mobility and independence."