Primary care doctors struggle with discussing long-term prognosis with patients

Despite clinical guidelines to incorporate long-term prognosis into decision making, several factors may lead primary care physicians to avoid following through on those recommendations.

Among the barriers are  the age of the patient and fears over how the patient may react, according to a new study published in JAMA Internal Medicine.

Nancy Schoenborn, MD, Johns Hopkins University School of Medicine, Baltimore and her colleagues interviewed 26 physicians and two nurse practitioners from rural, urban, and suburban practices, all affiliated with Johns Hopkins Community Physicians in Maryland.

While the participants said a patient’s life expectancy factored into clinical decisions, many admitted they avoid talking about prognosis with patients directly, especially when treating older adults.

“The participants identified multiple barriers to discussing prognosis with older adults including feeling uncertain about their prognostic estimates, having inadequate time during clinic visits, a lack of societal or cultural value for prognostic information, concerns about how patients would react to the information, and limited training on how to communicate prognosis,” wrote Mara Schonberg, MD, of Beth Israel Deaconess Medical Center in Boston; and Alexander Smith, MD, of University of California-San Francisco, in an editorial accompanying the study.

The most common consideration that outweighed a poor prognosis was if the patient specifically requested a procedure, even if life expectancy meant it was was unlikely to be beneficial.

“Do I give in sometimes and do tests that I don’t think are medically necessary? Yes… if [the patients] insist, I say, ‘ok, as long as you understand,” said one participant.

With younger patients, participants said it was even more difficult to bring up prognosis when making clinical decisions, out of fear their estimate may be wrong.

“I would feel very uncomfortable for 50-year-old patients… saying we’ll never screen again [for colorectal cancer] even though I would be shocked if they lived longer than 5 years from now,” said one participant.

Not all practitioners expressed being uncomfortable with these discussions. Several said having a strong existing relationship with the patient made a prognosis conversation easier. One participant suggested physicians should start by having the patient estimate their own life expectancy.

“You can say, ‘how long do you think that you're going to stick around?’ And then they'll tell you,” one participant said. “You say, ‘ok, if that’s what is going to happen, then probably you wouldn't need…the statin because the…benefits aren't large enough to outweigh the risk at this point in your life.’” 

Schoenborn concluded that primary care practitioners need better guidelines on how to bring long-term prognosis into discussions with patients, and recommended studying how the patients themselves would prefer the subject be addressed.