Predicting outcome of illness

As mentioned in the past; course of the disease and the outcome are dependent on the host factors, disease severity and the treatment given. For ease of explaining and understanding, disease process, especially due to infection, can be classified into four zones.

Let us say the first zone is white – this is the group of people who will not develop the disease as their immunity is high or the exposure to the infective agent is small. They do not even know that they have got the disease. Consequently, they do not need any treatment.

Next group is the green zone. This group of people have enough immunity to fight the disease. The disease is self-limiting. Whether we treat them or not, the disease will be cured. Any treatment that they receive is superfluous. It is mostly to satisfy their psyche that they are getting some treatment.

Next is orange group in which the treatment is crucial and makes the difference in achieving a cure or not. This is the group that gets benefited by correct and timely treatment. Next one is the red zone. This group of patients will not be cured, no matter what treatment they received and where. Aggressive treatment is only going to prolong the inevitable but will not stop it.

Problem is that there are no clear demarcations between these different colour zones and many a times doctors cannot predict accurately which group the patient belongs to. Doctors decide on the condition of the patient and advocate treatment depending on the clinical condition, tests as necessary and the trend or progress of the patient with passing of time.

There are number of checks and balances in place to prevent avoidable mistakes. Despite all the precautions, while assessing the condition of the patients or giving treatment, lapses may be there due to deceptive external appearances, wrong test results or lack of experience of the healthcare staff. Major confounding factor is patient developing a complication, which may happen despite optimal treatment.

The treatment process goes on taking into consideration all the above things; patients are assessed periodically, and the treatment is tailored according to the individual patient’s condition and response to treatment. The time frame may be minutes, hours or days depending on the cardinal factors - host factors & disease severity. If the patient’s condition improves, the treatment is down sized; if it deteriorates, treatment is escalated.

Most of the time the patient’s clinical course runs in a predictable fashion. Rarely patient’s condition may deteriorate rapidly, like go from white or green zone to red zone. Undiagnosed diseases like diabetes, high blood pressure, blocks in blood vessels to heart/brain/intestines or other diseases may contribute to such situation.

 It is difficult to categorically say that the patient is in the red zone and that he/she will not recover. The sudden deterioration happens rarely and is the cause for the sensational news going round in the media, aggravating the fear and anxiety in the society. The doctors are not in a position to give an accurate reason for rapid deterioration and not able to counsel the relatives properly, leading to the widening gap between the public and doctors.

Patients or the relatives want to know what the outcome is going to be; whether they will recover or not, what is the risk of complications, duration & cost of treatment etc. From their perspective it is an innocent and reasonable request. But health is a dynamic process. All that the doctors can do is try and restore the lost balance in the patient’s body systems. Doctors can give the probability of various outcomes, but no doctor can accurately predict a given patient’s course or final outcome. It is only an educated guess.

Doctors are not fortune tellers. Patients and relatives do not comprehend this truth. They think that the doctors know everything and are not divulging the information. Truth is far from it!! Most doctors also do not like to acknowledge this and say, I cannot predict accurately. When false reassurances are given or not counselled properly and the outcome is bad, it is a recipe for disaster in doctor – patient relationship.

Continuing the colour scheme from last week, it is difficult to say where exactly the patient is in the disease spectrum. Majority of the times, there is time and the disease progresses in a slow and predictable fashion, giving time for treatment as necessary. Sometimes, it does not give much time. It is again dependent on the patient/disease factors elucidated in the previous posts.

One example is the heart stroke people get. One end of the spectrum is the silent MI (myocardial infarction – heart attack), where the patient gets a very mild attack and does not get any problem. It will be identified at a later date if they get heart check up for whatever reason or get some problem due to further attacks. Other extreme is where the patient gets a massive heart attack, collapses and dies all of a sudden or in sleep, without having any warning sign or giving time to treat. In between these two extremes, there are multiple ways a heart problem can present and is dealt with.

Sometimes a patient may get heart attack while undergoing treatment for some other problem. People in their ignorance ask why the patient developed heart attack while in hospital during treatment?! When a person can get a heart attack suddenly without warning at any time at any place, why can not they get it in hospital!! Someone in hospital have higher risk of developing further problems due to the physical/mental stress of their disease process or the treatment and the hospital environment.

It is partly out of their frustration also. When the patients get a new problem while undergoing treatment, everything increases – treatment, hospital stay, risk and cost. This is very frustrating for the patients and their relatives. In their ignorance or frustration, they keep doubting the doctor and the treatment process, which does not help anyone.

Consequently, it is difficult to say categorically when one should seek medical advice. It depends on the age, general condition, and severity of the illness. For minor ailments, especially recurring problems, one can simply wait or take over the counter medicines for few days to see if it resolves with time or not. If not improving or if there is any deterioration in the general condition, one should seek medical advice.

Due to the nature of illness and the issues in our society surrounding doctors and healthcare, doctors are also worried and not taking any chance. Sometimes, small lapses are leading to negative publicity, compensation, and legal proceedings. Doctors and hospitals are also gripped in fear and anxiety. Doctors are considering everyone to be having a serious disease, investigating, and treating accordingly, leading to defensive medicine.

Majority of the times, there is a window (usually a very wide window) of opportunity to give treatment and save the patient. Rarely, there may not be time and the window of opportunity is lost. Having seen such rare incidents, everyone is frightened that they may lose the window of opportunity and running amok.