Lost in Translation #2/4

Kyle P. Edmonds, MD Institute for Palliative MedicineSan Diego Hospice

Lost in Translation:Prognosis and the worldview of patients and providers

Patients and providers each have their own way of understanding the

world that impact their communication.

Summary

Seeing the World

Seeing the World

Seeing the World

Understanding Impacts Treatment

Weeks et al., 1998.

Understanding Prognosis

Zier et al., 2012.

• Express optimism

• Patient possesses special fortitude

• Disbelief in physician’s ability to prognosticate

• Prognosis as a “gist”

Understanding Prognosis

Adapted from: Zier et al., 2012.

“I guess I understand that

[the patient] may eventually die…I

guess I just have to hope more.”

“[…] And we are talking about my

father in this case, not just any patient.

I know that my father could do

better than what the doctor is

saying…and I think he will.”

“Ultimately, I don’t think [doctors] can

really know the percent chance of

survival unless someone comes in

dead.”

“I don’t give a lot of weight to the

individual number, I tend not to trust the individual number

as much as the overall feeling that [the physician] is

conveying.”

Meanwhile…

Weeks et al., 2012.

Outcome Spectrum

Outcome

Confidence Interval

Actions Experiences

Consistency

Empathy

Sensitivity

Understanding

Honesty

The Patient’s World

Parker et al., 2007.

Patient

DataCues

Framing

Ambival-ence

HistoryBeliefs

Coping Style

Trust in Provide

r

Chosen Role

Emotion

The Patient’s World

• Confirmation bias

• Therapeutic mis-estimation

• Therapeutic optimism

The Patient’s World: Data

• Prior illness

• Prior prognostication

• The “fighter”

The Patient’s World: History

• Subjective data from treating team

• Priming effects

The Patient’s World: Cues

•Discounting opinions•Greater prognostic disparity

The Patient’s World: Trust in Provider

• “We can do nothing or we can give you chemotherapy.”

• “Responding.”

• Number of choices

The Patient’s World: Framing

The Patient’s World: Coping Style

• Defense mechanisms

• Psychiatric risk factors

• Socioeconomic risk factors

• Personality characteristics

• Sick Role Norms

• Assertive Patient Role

• Learned Helplessness

• Social Obligations

The Patient’s World: Chosen Role

• Fear of death

• Cultural requirements

• Generates ambiguity & avoidance

The Patient’s World: Ambivalence

• Affective Narrowing

• State-dependent Learning

The Patient’s World: Emotion

• Spirituality

• Magical Thinking

• Lake Wobegone Effect

• Meaning & hope

The Patient’s World: Beliefs

Patient

Data

Cues

Framing

Ambival-ence

HistoryBeliefs

Coping Style

Trust in Provide

r

Chosen Role

The Patient’s World

The Provider’s World

Provider

Experiences

Population Data

Patient Data

Ambivale-nce

BeliefsChosen Role

Professional Norms

Education

Assump-tions

• Hidden curriculum

• Formulating prognosis

• Recognizing dying

• Different language

The Provider’s World: Education

• Formative

• Proximate

The Provider’s World: Experience

• Patients will ask

• Fact clubbing

• Decisional preferences

The Provider’s World: Assumptions

• Chronic disease optimism

• Acute disease pessimism

• Controlling the “big picture”

• Protecting “hope”

The Provider’s World: Professional Norms

• Population•Disease-specific•Patient location

• Patient•Objective•Subjective

The Provider’s World: Data

• Magical thinking

• Spirituality•Patient (“trump card”)•Provider

•Role of the patient

The Provider’s World: Beliefs

• The soothsayer

• “Sociological ambivalence”

• Generates ambiguity & avoidance

The Provider’s World: Ambivalence

• Exerting control

• Decisional style

• Accepting discomfort

The Provider’s World: Chosen Role

Chosen Role: Physicians & Morbidity

Adapted from Figure: Ubel et al., 2011.

Chosen Role: Nurses & CPR

Adapted from Figure 1: Coffey et al., 2013.

The Provider’s World

Provider

Experiences

Population Data

Patient Data

Ambivale-nce

BeliefsChosen Role

Professional Norms

Education

Assump-tions

Acknowledging the Overlap

Elements to

Negotiate

Provider Perspecti

ve

Patient Perspecti

ve

Outcome Spectrum

OutcomeFraming

Tailoring

Defining Hope

Affective Cues

AmbivalenceAssumptionsAvoidance

Confidence Interval

Lack of Trust

Actions Experiences

Patients and providers each have their own way of understanding the

world that impact their communication.

Summary

Kyle P. Edmonds, MD kyle.p.edmonds@gmail.comkylepedmonds.com

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