Vol. 130 August 1, 2015 Medical Diagnosing Websites

July 31, 2015


Have you ever gone on the internet
to seek a diagnosis for your symptoms?


Fifty million people did so on iTriage last year. Healthline.com

gets 6.5 million visits a month. WebMD’s “symptom tracker” gets 4 million visits a month.

Are they any good at making a diagnosis for you? Do they give good triage advice?

A recent study by Harvard Medical School faculty says “not too bad”, BUT “seeker beware”. (1)
There is significant accuracy variability between the websites. The authors identified 143 websites offering diagnoses in response to symptoms entered by the user. They submitted 45 standard sets of symptoms from “patients looking for a diagnosis” (entered by non-professionals) to each of the 43 websites directed at general medicine/primary care “symptom tracking”. The “patient’s” symptoms entered were in one of three categories (unlabeled and unknown to the website): 1) symptoms require urgent medical evaluation, 2) symptoms should be evaluated by a medical professional by appointment, and 3) self-care without medical evaluation is all that is recommended (the classic medical triage decision tree).

On average, half of the websites listed the correct diagnosis first. 58% listed the correct diagnosis in the top three. However, the range of correct number of #1 diagnoses varied from 5% to 50% between websites. Not unlike a medical professional’s diagnostic decision-making, the software on these websites correctly identified common diseases more frequently than uncommon ones. (The old medical student saw is true: “When you hear hoofbeats think of horses, not zebras.”)

A more comforting result of the study was that 80% of the symptoms needing urgent evaluation and care were identified correctly. The flip side was that two-thirds of the patients that could have been served well by self-care alone were instructed to seek a medical evaluation. As one web-designer physician remarked, “We try to neither unduly alarm nor inappropriately reassurance users.” The software behind the triage advice on these websites (“should I see a doctor or not”) is highly risk-adverse in suggesting so many medical evaluations for minor symptoms. This may not prove so useful to people using the websites to avoid a visit and the payment of a deductible.

The triage accuracy was comparable to that found in studies of nurse practitioner telephone triage which ran about 60-70% compliant with physician in-person recommendations. Of course, the symptom tracking websites do lack perceptions of patient anxiety, tone of voice, urgency of speech, and other subtle, but important clues (especially to pediatricians), of the nature of the situation. Perhaps as a practicing pediatrician I put too much stock in those kind of clues in assessing a patient by telephone, but I suspect that they do improve the person-to-person triage decision-making. At least, the symptom tracking websites were better than just entering symptoms into a Google.

Which symptom tracking website was the best? DocResponse.com got the highest score, but offers no pediatric content. Healthychildren.com by the American Academy of Pediatrics is the site to go to for that. MEDoctor had the worst results. e-Patient Dave, a respected non-medical patient care advocate, recommends trying 2 or 3 websites with the same symptoms.

The traffic to these kind of websites and their popularity with patients may spawn a new word in the lexicon of medical practice; “cyberchondriac”

1. BMJ 2015:351, July 8, 2015

Vol. 129 July 15, 2015 Update on FDA & Sunscreens and Bath Salts

July 15, 2015



“Herbal incense” may sound organic,
but it sure ain’t good for you.


Sunscreens (1)
Previous blogs have noted that the FDA has limited authority over and regulations for sunscreens, but it does have some. Despite “the common wisdom” that the FDA is slow to approve new prescription drugs, its approval process is generally faster than Europe’s and in 2014 the FDA approved the highest number of new drugs in 18 years – 41 products. (1)

Over-the-counter (OTC) products like sunscreens are regulated by a different process using the standard:  “ generally recognized as safe and effective”. But, in 2014 the FDA declined to permit use of 8 new ingredients in sunscreens even though they have been in use in Europe for 5 years. It cited lack of safety studies, gaps in data, and reports of adverse events. This action prompted an understandable, if   a bit of an over-the-top reaction, from the Wall Street Journal calling to “strip the sunscreen police of all powers over the stuff.”

It is obvious that the FDA has mixed, and unfunded, responsibilities for review of OTC products. A new law, the Sunscreen Innovation Act of 2014 (only in America could we come up with a name like that), tried to clarify the situation, but no new resources were allocated to implement it. In the meantime both the FDA and the CDC continue their efforts to discourage use of tanning beds and promote prevention measures against melanoma which claim 10,000 deaths a year in the U.S.

Synthetic Cannabinoids (SC) (2)

Synthetic cannabinoids (SC) arrived in the U.S. from Europe in 2008 as herbal incense, spice, and bath salts “not for human consumption”. Since 2011 the DEA has placed over 40 SCs into Schedule I of controlled substances which means they are obtainable only by prescription. The problem is that manufacturers of these SCs merely change one or more chemical bonding group or a single chemical chain and the new compound falls outside such a regulation. The compounds are easily obtained on the internet for use in e-cigarettes or are added to energy drinks. They are still labeled “not for human consumption”, and may even carry the assurance that the product “contains no regulated compounds”.

Widespread distribution and marketing have led to recent clusters of serious illness and even deaths, particularly among the young and inexperienced users. Many users reported that they used SCs in order to get high without risking a positive drug test. SCs are NOT detected by the usual urine or blood lab tests, have no available antidote, and can produce serious symptoms which are not readily identifiable as symptoms specific to SC toxicity. Some users have died before reaching an emergency department.

The number of adverse events is increasing. During a two month period in early 2015 Mississippi reported 1200 SC-related visits to the ER and 17 deaths. One reason for this uptick may be the distribution of novel SC compounds that are easily and rapidly synthesized and marketed in response to regulatory actions. They can have new, unknown effects resulting in idiosyncratic toxicity such as delirium, seizures, psychosis, kidney failure, hallucinations, coma, and death.

Ninety-one per cent of users interviewed in one study inhaled vaporized SCs from refillable e-cigarette cartridges. E-cigarettes seem to be garnering more very bad “unintended consequences” than originally predicted by its advocates.

1. NEJM July 9, 2015, pg. 101; A Spotlight on Sunscreen Regulation; J.A. Sharfstein, MD, Johns Hopkins School of Public Health
2. NEJM July 9, 2015, pg. 103, Synthetic Cannabinoids – Related Illnesses and Deaths, DEA, CDC, and University of California

Vol. 128 July 1, 2015 Obamacare is Five Years Old. Can It Walk and Talk?

July 1, 2015


“From a historical perspective,
5 years is a very short time.
Many of the key insurance provisions have been
in effect only since October 2013.” (1)

Now that the Supreme Court has decided that a key provision in the Affordable Care Act of 2010, the federal subsidy of health insurance for eligible citizens, is legal, the infancy of Obamacare is over. It looks like it is here to stay. How is the toddler doing? What has it done? Luckily, The Commonwealth Fund just published a summary of ACA effects so far. (1)

The Commonwealth Fund is a private foundation formed in 1918 with Harkness family money made from the early oil business, (Shell Oil).

“The Commonwealth Fund has sought to be a catalyst for change by identifying promising practices and contributing to solutions that could help the United States achieve a high-performance health system. The Fund’s role has been to establish a base of scientific evidence on what works, mobilize talented people to transform health care organizations, and collaborate with organizations that share its concerns. The Fund’s work has always focused particularly on the challenges vulnerable populations face in receiving high-quality, safe, compassionate, coordinated, and efficiently delivered care.”

This health-care-focussed fund and think tank reports that it is too early to see many benefits of the ACA, but lists some of its immediate, observable effects.

Access to care:

  • 7.0 to 16.4 million young adults from chronically uncovered populations ( hispanics, blacks, and those with low incomes) have gained health insurance coverage since 2010 (different survey methods and timing cause the difference in results).
  • 11.7 million Americans selected a health plan through the health insurance marketplaces established by the ACA. 87% of those people were eligible for federal subsidies of premiums.
  • 10.8 million additional Americans have enrolled in Medicaid since the ACA was passed.
  • 3 million previously uninsured young Americans have gained coverage through the ACA extension of dependent coverage to age 26.
  • 8-12 million Americans have benefitted from the ACA’s regulation that prevents insurers from discriminating against people with preexisting conditions.
  • 75% of those newly insured seeking appointments with primary care or specialist physicians have secured one within 4 weeks or less.

Delivery-System Reform:
“ The law constitutes one of the most aggressive efforts in the history of the nation to address the problems of the health care delivery system through funding many divergent experiments though lacking a coherent strategy.” (1)  The Commonwealth Fund report lumped the efforts into four categories.

1. Changes in Payments:
Reduce readmissions – There are 150,000 per year fewer Medicare hospital readmissions within 30 days of discharge partly attributed to ACA financial penalties to hospitals with higher than expected readmission rates.
Reduce hospital-acquired conditions – ACA financial penalties to hospitals in the highest quarter of avoidable hospital-acquired conditions may have helped the composite rates for those to drop by 17% from 2010 to 2013.
Pay for Performance – ACA payment incentives to hospitals and physicians to improve their performance on various cost and quality measures: “too early to tell”.
Bundled payments – This departure from fee-for-service reimbursement pays the hospital, the physician, and post-hospital services with a single payment for a procedure or condition. 7000 providers have signed up for it, but it is “too early to tell”.

2. Changes in the Organization of Health Care Delivery:
Accountable Care Organizations (ACOs) – An ACO is an organization of physicians and hospitals formed to improve the integration and coordination of ambulatory, inpatient, and post-acute services for a defined population of Medicare beneficiaries. 405 ACOs are participating in a program that allows them to keep a portion of any cost savings they can generate without degrading quality. Although the pilot program of about a dozen Pioneer ACOs “saved” $385 million in the first two years, it is “too early to tell” if the others will have a postive effect.
Primary Care Transformation – A pilot program to reduce costs and improve quality in primary care has shown a $14 per month cost reduction per Medicare enrollee and less emergency room visits and hospitalizations in the 2.5 million patients participating in its first year, but it is “too early to tell”.

3. Changes in Workforce Policy:
The effects of increased primary care reimbursement for Medicaid patient services, increased National Health Service Crops scholarships for practicing in underserved areas, and establishment of a National Health Care Workforce Commission (but remains to be funded by Congress) are all “too early to tell”.

4. Increase Innovation in Health Care Delivery:
The Center for Medicare and Medicaid Innovation (CMMI) was funded at $1 billion a year for 10 years to undertake a wide variety of experiments in improving quality for patients and reducing the 43% share of national health costs now paid by the government.

  • Commonwealth Fund says: CMMI is perhaps the most promising of the ACA efforts, but “way too early to tell”.
  • The CMMI itself reports it has launched 26 “demonstration models” of cost reduction and quality improvement. The Pioneer ACOs mentioned above is the first model “to meet the statutory criteria for expansion”.(2)
  • A separate report from Weil Cornell Medical College Department of Healthcare Policy and Research states that to date the CMMI has spent only one-third of its $10 billion, that it seems to be slow in distributing data from its experiments to participating organizations, and that it is hampered, as most quality improvement efforts are, by the lack of consensus on what constitutes “ improved quality”. So it is “too early to tell” (2)

Wow, that is definitely more than you may have ever wanted to know about the ACA so far!
It is certainly more than I can remember.
It is clear that Obamacare does have a lifetime before it.
As that lifetime unfolds one can only hope that responsible adults will guide it through its future developmental stages.

Bottom line: carry a small laminated copy of this blog in your pocket or purse to pull out when engaged … embroiled, …immersed, …or even entangled in any discussion about Obamacare, which will continue, even if Hilary renames it.

Remember, Medicare was just as controversial when first passed. One governor that opposed Medicare actually mobilized his state’s National Guard the day Medicare was passed in fear of the hordes of newly insured people that he expected to overwhelm emergency room departments.

1. NEJM June 18, 2015;  The Affordable Care Act at Five Years
2. NEJM May 21, 2015;  Assessing the CMS Innovation Center

Vol. 126 June 15, 2015 New Ways to Identify Individuals

June 15, 2015

hub“Getting to know you,
“Getting to know all about you …”

– Anna, from The King and I

Our concern about “privacy” springs from the awareness of the many ways that new technology can let other people learn about us and identify us; gleaning info from the net, monitoring phone activity, screening videos from ubiquitous security cameras, or even being photographed by a drone. It is not like we need to read about another technology people can use “to get to know us”, to identify us, whether we like it or not. Well, read on dear reader.

Individuals can now be identified by their intestinal microbes, their bacteria, like they can be identified by their fingerprints. The pattern of types and amounts of microbes in feces apparently varies by individual, and researchers at the Harvard School of Public Health were able to correctly identify which stool sample came from which person 80% of the time. We all have our own specific, consistent microbial “stool print” that remains fixed over months and even a year. No one is certain whether it is genetics, or diet, or just happenstance, but our gut flora, our intestinal microbe community, remains fairly consistent and is different for each individual. These “microbial fingerprints”, if known in the 1920’s, sure would have added another meaning to the name “Bugs Moran”.

Stool microbial fingerprints are not as reliable as DNA match-ups, and we will learn much more about that when the case of the “devious defecator” goes to trial this month in Atlanta, Georgia. The case is a result of the mysterious periodic appearances of human feces in a retail food warehouse. Laborious, traditional detective work by the employer narrowed the suspects down to two men. Each was asked for, and consented to, a mouth swab for DNA to compare with the DNA in the feces piles. Neither man was a match, so no action was taken, BUT a judge has decided that the men’s suit against the employer can go forward to a jury trial on damages ( “ridicule, embarrassment, and humiliation” ) under GINA.

GINA (Genetic Information Nondiscrimination Act)  was passed seven years ago to prevent employers and insurers from using genetic information to avoid hiring people who have genes that increase the risk of them developing a costly disease. Under this law the employer cannot ask for or buy genetic information. Even though no information on disease risk was sought or obtained in this case, the judge ruled that “a genetic test is a genetic test is a genetic test”, and the case could go to trial. In other words, “Any genetic test done to embarrass or harm an individual violates federal law”. (1).  So, “s**t happens”, and now they can tell that it’s your s**t, but your employer may not be able to do anything about it.

Meanwhile back in Boston, Harvard researchers have developed a $25, single-drop-of- blood test that can identify which of 1000 strains of 206 viruses an individual has contracted in his or her lifetime. People from different countries (U.S., South Africa, Thailand, and Peru) had different “viral fingerprints”, presumably from different exposures. If the researchers can identify your country by a viral pattern, one can only wonder how precise an identification tool this might become with 1000 x 206 data points. The test takes months to complete and is available now only as a research tool, but the patent is pending. (Virscan)

So, as we watch technology advance from fingerprint identification to bacterial, viral, and DNA “prints” as new ways for others “ to get to know us”, it is natural to ask, “Can ‘energy prints’ be far behind?”

1. NY Times June 2,2015, D6

Vol. 126 June 1, 2015 Suncreen and Bug Repellent Effectiveness

June 1, 2015

hubHere comes the sun
Here comes the sun,
and I say, It’s all right

Little Darling
It’s been a long, cold lonely winter
Little Darling
It feels like years since its been here.

– George Harrison, Beatles Abbey Road album 1969

A sure sign that summer is coming is the Consumer Report annual update on sunscreens and bug repellents (July 2015 issue, just received). Of the 1000 sunscreen products on the market, they tested and rated only the 15 lotions, 13 sprays, and 6 ultrahighs which actually delivered close to the advertised SPF (sun protection factor). Their conclusions include:

  • Advertised and labeled SPF factors are often untrue. ( actual can be 16% to 70% less) So what? If they drop below an SPF of 30 they are not as protective as the dermatologists want them to be. This is one reason they are not labeled “sunblocks” anymore.
  • Look for broad-spectrum sunscreens that reduce BOTH UVA and UVB exposure to the skin
  • “Natural” sunscreens, even those that tout a mineral base, don’t work so well. (CVS Baby Pure & Gentle SPF 60 provided an actual SPF of 18.)
  • You can get good protection for $1.65 an oz. or pay $7.20 an oz. for top rated ultra sunscreens.(SPF 70+)
  • Adult and infant sunscreens are the same except for fragrance and color and are interchangeable in terms of protection.
  • No further word from the FDA on nanoparticles.
  • Don’t forget to slather your ears and the tops of your feet.

Consumer Reports bottom line:
Best for Kids: Coppertone Water Babies SPF 50 $1.31/oz.
Best Buy: Walmart’s Equate Lotion or Spray SPF 50 $0.56/oz. for lotion and $1.33/oz. for spray.
Best “Natural” Sunscreen: California Baby SPF 30 (the only one that reached close to 30 SPF) $6.90/0z.
Not recommended: Yes To Cucumbers Natural SPF 30 provided actual SPF of 14 for $4.00/oz.
Truly Fragrance-Free: Coppertone Ultra Guard SPF 70 (actual SPF of 59) $1.38/oz.

Check out the July 2015 issue of CR for many more details and my previous blogs for pros and cons of sprays and specific recommendations of products.

Sidebar on tanning: In October 2014 a UMassMedSchool study of 125 top universities revealed that 48% had tanning booths for their students on campus despite growing evidence that exposure in tanning booths increased the rate of skin cancer. About 15% also allowed students to use their campus cash cards at off-campus tanning booths. By May of 2015 several colleges have disallowed the use of cash cards for off-campus tanning booths, in part as a result of a focused campaign led by UMMS researchers to reduce student access to tanning booths.

Battle of the Bugs
The same issue of Consumer Reports lists the results of 15 different bug repellents worn by their stalwart volunteers who subjected themselves to hordes of disease-free culex and aedes mosquitoes (the ones that do carry West Nile fever and chikungunya). Before you laugh at “chikungunya” or laugh at just trying to say it, you should know that this viral non-fatal disease has become a significant problem in South and Central America, including the Caribbean Islands. Panama has roadside billboards exhorting citizens to visit a doctor at the “first sign of fever, don’t treat your fever at home”.

Results of this torture of CR volunteers:

  • DEET is effective and NOT dangerous for you or your kids over 2 months of age as long as you use the right concentration. Concentrations of 15% or more work and above 30% work no better. Potential side-effects are much less under 30% concentration. So, use DEET 15-30%.   Off! Deep Woods – 25% or Repel Scented Family – 15% are recommended. Several Cutter products have 7% or less of DEET and are not recommended.
  • Non-DEET repellents containing 20% picaridin (a synthetic compound that mimics a chemical in black pepper plants) OR 30% oil of lemon eucalyptus (another synthetic chemical) provide up to 7 hours of protection. FDA says the oil of lemon eucalyptus should not be used on children under 3 years because it can cause temporary eye injury. Sawyer Fisherman’s Formula Picaridin (20%) and Natrapel 8 Hour (20% picaridian) are recommended.  Off! Family Care is only 5% picaridin and is not recommended.
  • Don’t spray any of the products in your face. All bug repellents cause eye irritation. Apply with your hands, especially with children.
  • “Natural” repellents don’t do the job. All of the plant-oil products failed immediately or within an hour. The “organic” label is meaningless.
  • Wristbands don’t work either. One manufacturer is being taken to court by the Federal Trade Commission for deceptive advertising.
  • For the patio, before they bite? Unfortunately the citronella candle buckets, though pleasing, offered no protection, and neither did a battery-operated diffuser of plant oils. A high-speed pedestal oscillating fan reduced mosquito landings by 45% to 65%, especially for those sitting closest to the fan, but I suspect their warbly-sounding words were an unexpected addition to the BBQ party.
  • What about Skin So Soft? Avon makes no repellent claims, and in this case the manufacturer is right. CR found it offered no protection in 1993, and this time too. Avon is now marketing combined sunscreen and repellent (picaridin) products, but the repellent concentrations are too low for protection. They are not recommended.

Summer is here, along with the sun and uninvited flying guests!


Vol. 125 May 15, 2015 E-cigarettes and Adolescents

May 15, 2015



E = M J


Seventeen per cent of high school seniors used E-cigarettes in 2014.  E-cigarette use in non–smoking adolescents increased from 79,000 in 2011 to 263,000 in 2013. The current models of E-cigarettes were developed in China in 2003 and introduced to the U.S. in 2007, though Philip Morris had been researching them since the 1990’s. (1)

The original E-cigarettes looked like a cigarette and contained a battery-powered heating element that vaporized liquid containing liquid nicotine which could be inhaled. The amount of nicotine in a single E-cigarette could vary from 36 mg. (about the amount in one Lucky Strike cigarette) to zero. Zero? Yes, zero. People vape those E-cigarettes for their various flavors which are multiple and diverse. “Vape” is the new verb to describe the process. Multiple YouTube videos compare the pros and cons of Smoking vs. “Vaping”. The major pro of vaping according to its advocates is that you can get the nicotine without the tars and other carcinogens.

The newer generation of E-cigarettes don’t look like cigarettes. They can be pen sized (called “pens”) or bigger (called “tanks”), up to 10 -12 inches long. Pens and tanks are rechargeable by the user. Multiple websites offer all kinds of flavors and nicotine strengths of E-liquids.

As E-cigarette use has increased, the use of combustible cigarettes (the traditional ones you light with a match) have decreased among children in grades 8 through 12. Some think this is good news. Others point out that even if E-cigarettes have 10x-100x LESS carcinogens than combustible cigarettes, there are still carcinogens present. Established researchers remark that “not all the ingredients in E-cigarette fluids are known or listed”. Manufactures of E-liquids rebut that by insisting that there are only four ingredients – propylene glycol, glycerin, flavoring, and nicotine – all used in other FDA-approved sprays and vaporized medicines.

E-cigarettes are not regulated by the FDA. The practical consequences of this are that 1) “face-to-face” purchase is not required (as with combustible cigarettes) and 2) there are no restrictions on youth-targeted advertisements. One of the biggest E-cigarette brands, “Blu”, may be best known for its Sports Illustrated swim suit issue ad zooming in on a blue bikinied bottom. “Seduce Juice” is the registered trademark of a variety of E-liquids, all with “snake oil” as a secondary label. Despite the fact that 40 states prohibit the sale of E-cigarettes to minors, they are readily available on the internet.

Do E-cigarettes help cigarette smokers stop smoking? One study of 5,000 attempted quitters in the U.K. suggested that it did help. (2) Studies in U.S. suggest that the use of FDA-approved nicotine vaporizers (Nicorette Quick Mist) prescribed by a physician can help people quit smoking, and many E-cigarette critics recommend that as the preferred method.  Another study showed that E-cigarettes were used by “intermediate risk” students in high schools unlike the use of combustible cigarettes by “high risk” students. Because of that use of E-cigarettes has been called a “harm reduction” strategy. Others citing the same study results suggest that E-cigarettes could act as a gateway to real cigarettes. Neither the American Heart Association nor the American Cancer Society have endorsed E-cigarettes as an aid to stop smoking.

Of course, it didn’t take long for adolescents to learn that if you could buy a rechargeable hand vaporizer and a variety of flavored liquids to put into it, why not put some marijuana juice in it.? And they do. The hashish oil used to charge pens and tanks is highly concentrated liquid THC, the active chemical of marijuana. NPR called pot-vape pens the “crack cocaine of marijuana” a year ago.  Unlike alcohol where a “shot is a shot, 30 ml., 1 oz.” the world over, a single puff from hashish oil is much stronger than a puff from a joint, and the user may not be able to reliably predict its effect. But, there is plenty of advice on how to do so on the internet. The weedblog. com has a colorful infographic explaining “How to Vape MJ rather than Smoke It.”

The contemporary pediatrician has had to add to his or her litany of history questions poised to adolescents over recent years: “Do you smoke cigarettes?”; “Are you attracted to boys or girls?”; “Do you have a gun in the house?”; and now “Are you vaping anything?” (3)

E use could = marijuana squared!

(1) JAMA Pediatrics 2015 ; 169(2): 177-82
(2) Addiction 2014; 109 (9): 1531-40
(3) Scott E. Hadland, MD MPH, Harvard Medical School, May 6, 2015  Course in Adolescent Medcine

Vol. 124 May 1, 2015 Why Can’t Physicians Prognose Better?

May 1, 2015


“It’s tough to make predictions, especially about the future.
-Yogi Berra


In 2013 seven Italian scientists were convicted of manslaughter and sentenced to six years in prison for not predicting an earthquake. The group of them, the Major Risks Committee (MRC), reassured the populace of L’Aguila which had just experienced a “swarm” (a geo-seismic term) of small tremors that the likelihood of a major earthquake was so small that “no action was needed”. Three weeks later a 6.3 earthquake in the region killed 309 people. Relatives of 29 of the fatalities pressed charges.  Such an outcome demonstrates the dangers of declaring the “unlikely” as “impossible”. In our medical world of close to “zero tolerance for risk” and a “demand for certainty” the risk of incorrect predictions can be daunting.

With all our training, scientific knowledge, and experience you would think that  physicians would be pretty good at predicting survival, aka “making a prognosis”. Several comparison studies have shown that physicians are not really any better than their patients in estimating survival time. Prognosis reliability does vary by diagnosis type and “closeness to the end” (in retrospect, of course, because we can never be sure that we are near the end until the end is here). For example, BOTH physicians and patients are overly optimistic in predicting the time left for lung cancer patients. Physicians’ prognosis of death are correct nearly 90% of the time in non-cancer nursing home patients when death occurs within 7 days later. That percentage drops to 13-16% when actual death occurs 3 – 6 weeks later.  Physicians also tend to be even more overly optimistic than patients about the expected quality of life near the end.

One Harvard explanation of this is as follows:
“Similar to other forecasting experts, physicians face different [non-monetary] costs depending on whether their best forecasts prove to be an overestimate or an underestimate of the true probabilities of an event. We provide the first empirical characterization of physicians loss functions. We find that even the physicians subjective belief distributions over outcomes are not well calibrated, with the loss characterized by asymmetry in favor of over-predicting patients’ survival. We show that the physicians’ bias is further increased by (1) reduction of the belief distributions to point forecasts, (2) communication of the forecast to the patient, and (3) physicians own past experience and reputation.”
 In other words, a physician’s gut feeling is often just “guesswork.”

All of us have heard the story of a patient who was told that he had “a year to live” and the patient went on fishing for cod or bluefish or whatever for another six years. Some of us have suffered the opposite experience. I can not forget the infant boy we diagnosed with hemophilia in the 1970’s and reassured the parents that we, along with modern medical science, could promise him a near-normal life with the use of factor VIII infusions. The patient enjoyed a healthy six years and even learned to infuse himself when only 8 years old. He became one of the first to contract HIV from factor VIII, and he died a teen ager with resistant, intractable pneumonia; a personally wrenching failure of a promise (prognosis) made by modern medicine. Technology and research have corrected that cause, but the memory lingers on.

Studies to identify specific characteristics or elements that could be used to more accurately state a survival prognosis have revealed a mixed bag. None is reliable enough for general clinical use.  If we did have a scientific consensus then the often complex, complicated negotiations of end-of-life care would be a lot easier for both physicians and patients and their families. It would perhaps be less costly for Medicare also.

Of course, despite the decades of study and technological advances we are no better at predicting the actual day a baby is born either … especially within a week of the actual delivery. At least we have “the nine-month consensus” to limit our predictive unreliability for birth dates.

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