| What is the role of prognosis in medical thought and practice? Why is prognosis not as explicit a part of medicine as diagnosis and therapy? Several sources of data are used to address these questions: (1) field work in a hospital and a hospice, (2) in-depth interviews with fifteen physicians, (3) content analysis of 162 physicians' written remarks, (4) content analysis of textbooks published between 1892 to 1988, (5) a mail survey of a random national sample of internists which incorporated randomized experiments and which yielded 694 replies, and (6) a cohort of 6,451 Medicare patients referred for hospice care. Prognostication (1) informs decisions regarding whether and how to treat and diagnose patients, (2) organizes clinical knowledge, (3) provides reassurance, and (4) affects patient behavior. Yet there is an eilipsis of explicit prognostication in medical thought and practice. Physicians are socialized to avoid prognostication because of its difficulty, uncertainty, fallibility, and dependence on social factors. The avoidance of prognosis is also supported by the stress of balancing the conflicting duties to both "maintain hope" and "be honest," and by the dominance of therapy in the theoretical and clinical consideration given to disease. Several professional norms attenuate prognostication; the norms state: do not make predictions, do not discuss them with patients, do not communicate them unless asked, do not be specific, do not be extreme, and be optimistic. These norms are maintained by the judgments of colleagues, the absence of formal consideration of prognosis in textbooks and medical training, and oral folklore. However, physicians do not just avoid prognosis: they dread it. This dread arises from two sources: (1) the linkage of prognosis with death, and (2) the widely held belief in self-fulfilling prophecy. Physicians believe that predictions may be effective by (1) changing patient attitudes, behavior, or physiology; (2) changing physician attitudes or behavior; or (3) directly causing the outcome in a way that is quasi-magical. Indeed, prognosis fosters the emergence of both magical and religious rituals and sentiments in physicians. Moreover, prognosis contains strong moral overtones, a fact that makes the ellipsis of prognosis smack of the shirking an important duty. |
