Tuesday, October 23, 2007

Grand Rounds Vol 4.5 - Prognostication

Welcome to Grand Rounds Vol 4, No 5!

The theme today is...well I shouldn't have to tell you . You probably already prognosticated it. The theme for this week is 'prognostication', the over-looked, maligned medical skill. Especially when compared to the two glory hounds, 'diagnostics' and 'therapeutics,' 'prognosticating' is often derided as a 'guess', lost in a mumble of statistics about recovery, or barely even mentioned at all. Most people fail to realize being able to predict the likely medical outcome is a foundation of selecting which therapeutic options are most appropriate for a patient. It is important to realize that prognostication is not just about predicting life expectancies, and that it affects all of medicine.

Out of 30 submissions, I whittled them down to 15 posts that best reflected the variety of ways prognosis plays a role in medical care. Medscape has posted a Pre-Rounds interview of Pallimed's founder Drew Rosielle describing our approach to medical blogging.

Onward! To the posts!

The volunteer chaplain at Rickety Contrivances of Doing Good contemplates on how hope intersects with medical conditions. Prognosis and Hope hang out in the same neighborhood south of Future Blvd. and just west of Uncertainty Avenue. They both forecast what the future may bring from the corner you are presently standing on.

Predicting the likely outcome of medical politics seems to be more difficult than clinical prognostication. But girlvet gives it a try with a stream of consciousness post reviewing all the players trying to shape the future of health care. Her prognosis: universal health care is inevitable, but no certain time frame or predictions as to the quality.

Sometimes the answer to a patient's prognosis is: "There are too many unknowns to formulate a prognosis, (aka I don't know)". But that should never substitute for "I don't want to hazard an estimate." Luckily Dr. Trofatter at Fruit of the Womb is smart enough to work through a very unique case of retinal artery occlusion in a 29 year old pregnant female. Given the uncertainty of the prognosis, the answer to the appropriate therapy is closer follow-up for a potential high risk pregnancy.

The poor expected clinical outcome for patients can be predicted when medical staff find administrative policies that do not reflect the accurate flow of medical information. A key source of errors is the ever-expanding and not always correct medication list. Nurse Kim takes us on a examination of how she formulated her prediction of poor outcomes at Emergiblog.

Dainius A. Drukteinis, M.D., J.D. at NY Emergency Medicine presents a court case in which an emergency doctor could not find a consultant willing to come to the ER to perform an emergent thoracotomy. What do you tell your consultant in regards to the emergency? You have to rely on your formulated prognosis for the patient.

One of the easiest ways to prognosticate is to look at the past. Got altitude sickness before? You are highly likely to get it again. You might want to ask your physician about Diamox per Medicine for the Outdoors.

Need help trying to figure out where you are going as a medical student? Ask someone who has been there. And when they depress you and tell you the future is bleak, go talk to Tiny Shrink. She'll give you a little pep talk about your future.

To predict how patients may do with any medical condition, we need to know about the medical condition first. But what is the prognosis of public information sites like Wikipedia and Citizendium? If the masses use these sites, should the medical profession shun them or engage them? ScienceRoll gives us the scoop.

Hearing a prognosis for adults is hard enough, but when it comes to children, thinking about medical outcomes seems to bear a heavier weight. A Chronic Dose examines various programs helping children live through their illness.

Formulating a prognosis allows for uncertainty and the ability for our actions (patients and medical staff) to possibly move the huge stone called destiny. In reflecting to the past we see our future more clearly. How a patient sees their illness can be counted in numbers or described poetically, and sometimes both, like Six Until Me posts.

Are you excited about your vacation? Bet you are going to have fun, even with your knee surgery and all. The Health Business Blog predicts the future of medical tourism. 'Signs point to yes.'

Hearing a prognosis of a few months to live can be a call to action for caregivers. Mother Jones, RN at Nurse Ratched's Place posts about the need to support caregivers and the hard unpaid, under appreciated work they do. Good resources in the post and comments.

Genetics testing and Huntington's disease. You have the gene, you have your fate. Should you get the test or not? Listen to this first person account podcast of making this difficult choice from Eye on DNA. Better than your prime time medical drama show. Start listening, you won't stop. Neurologists get a hit for being somewhat reluctant in sharing information thereby forcing the public to the internet for information.

Predicting the day of death is not solely the province of the esteemed medical doctor. Sometimes patients beat us to the punch and let us know what their body is saying. Read the post from Foggy Bottom Lantern and find out if the patient was right.

Dr. Val Jones
posts about a friend whose life is unencumbered by prognosis after being diagnosed with metastatic colon cancer. The effect of hearing a possible limited life expectancy is not always a negative as some would naturally think. A short prognosis often brings the important things in life into focus, as Dr. Jones found.

Thank you for all the submissions and a great thanks to Nick Genes for organizing Grand Rounds. The baton is passed to Paul Levy at Running A Hospital for next week's Grand Rounds.

For more information on medical prognostication, please check out Pallimed's Prognosis Links, read the seminal book Death Foretold by Nicholas Christakis, or see my article on communicating a prognosis in advanced cancer in the Journal of Supportive Oncology.

Photo credits: flickr.com users jordy1, Daniel Y. Go, Blondie5000, fallsroad, mactiste.