Prognosis, diagnosis and uncertainty
The limits of the current model
Prognosis, diagnosis and uncertainty
I have recently attended a 2 days workshop with a clinical psychologist. Reinforcing good prognostic factors and expectations, acknowledging positive changes and embracing the idea that interaction is intervention has been the core of the event. It does look simple but comprehension could manifest on different levels.
Interestingly one participant asked “How can I get more patients?”. It is worth pointing out that this colleague was genuinely trying to understand what he could implement in his communication skills in order to gain the right amount of trust and perceived professionalism from his current patients. Ironically another participant answered “Scare them! Instilling fear is the way to have a waiting list…”
Nobody could disagree.
We live in a world dominated by fear. Media is based on fear, politics and economy too. Fear chases us from the childhood until the old age under different forms and manifestations.
This is also evident in medical practice and in our daily decision making. Uncertainty is for healthcare professionals unbearable and brings a sense of fear about what lies ahead . We are taught in our curricula and professional development that the combination of signs, symptoms and treatment responses lead to a secure diagnosis. Yet we forget to acknowledge the dynamic and variable essence of nature.
Also a depersonalised view of the human body is currently an almost unchallenged framework despite mind and body are no longer envisioned as different and separate since Descartes. Humans are hybrid creatures, integrated nature–culture .
The medicine perception of reality is unfortunately still far from the complexity and variability of nature. Personalised care is at its infancy . This is deeply rooted into the spasmodic need of a diagnosis, which often brings more negatives than positives. Furthermore over-diagnosis is an iatrogenic epidemic  that fosters fear and catastrophism thus imprisoning the changeable and positive natural history of many non-malignant disorders.
“Negative catastrophic cognitions lead to avoidance of activities and hypervigilance in monitoring bodily and pain sensations, followed by withdrawal from recreation and family activities, which then can lead to depression, physical disuse, deconditioning, and disability” .
So why should we, healthcare professionals, implicitly or explicitly promote this?
The impact of psychological factors in the experience and the maintenance of persistent pain is widely acknowledged [4, 5] together with neurophysiological changes such as impaired endogenous opioid function . The end result is a maladaptive bidirectional communication between the brain and the immune system . On the other hand, resilience is the capacity and dynamic process of adaptively overcoming stress and adversity while maintaining normal psychological and physical functioning .
Optimism, cognitive reappraisal, active coping, physical exercise, humor, prosocial behaviour and trait mindulfness are characteristics  that enhance the process of overcoming a stressful and adverse experience such as pain.
A mere disease diagnosis without evidence of its prognostic factors may at best be unnecessary and at worst do harm . This incomplete, outdated and yet very diffuse medical practice leads to unhelpful beliefs, fear and catastrophising as well as poor self-efficacy and passive coping strategies.
Medicine based on prognostic factors, instead, incorporates the variability, the positive aspects and the natural history of a disorder thus acknowledging the beautiful dynamism and evolution of a diagnosis. The role of a healthcare professional is therefore to measure and quantify the important prognostic factors and optimise them, while reassuring the patient with realistic and achievable goals.
To conclude “only uncertainty is a sure thing. Certainty is an illusion”.
“There are three powers, three powers alone, able to conquer and to hold captive for ever the conscience of these impotent rebels for their happiness those forces are miracle, mystery and authority.” Dostoevsky – The Brothers Karamazov
1. Simpkin, A.L. and R.M. Schwartzstein, Tolerating Uncertainty — The Next Medical Revolution? New England Journal of Medicine, 2016. 375(18): p. 1713-1715.
2. Kirkengen, A.L., et al., Medicine’s perception of reality – a split picture: critical reflections on apparent anomalies within the biomedical theory of science. J Eval Clin Pract, 2016. 22(4): p. 496-501.
3. Foster, N.E., et al., Stratified models of care. Best Pract Res Clin Rheumatol, 2013. 27(5): p. 649-61.
4. Gatchel, R.J., et al., Fear-Avoidance Beliefs and Chronic Pain. J Orthop Sports Phys Ther, 2016. 46(2): p. 38-43.
5. Linton, S.J. and W.S. Shaw, Impact of psychological factors in the experience of pain. 2011. p. 700-711.
6. Burns, J.W., et al., Psychosocial factors predict opioid analgesia through endogenous opioid function. Pain, 2017. 158(3): p. 391-399.
7. Alford, L., Psychoneuroimmunology for physiotherapists. Physiotherapy. 92(3): p. 187-191.
8. Wu, G., et al., Understanding resilience. Frontiers in Behavioral Neuroscience, 2013. 7: p. 10.
9. Croft, P., et al., The science of clinical practice: disease diagnosis or patient prognosis? Evidence about “what is likely to happen” should shape clinical practice. BMC Medicine, 2015. 13(1): p. 20.