Defending "optimism bias" in the face of a grim prognosis

Doctors are learning how to communicate more clearly with families about the prognosis for critically ill patients, yet even when they communicate clearly they can be frustrated that family members don’t seem to understand. One reason is “optimism bias” –a tendency of some people to greet adversity by focusing on the potential for a positive outcome, even if that potential is slim.Today’s Hospitalist (When optimism isn’t called for) includes an insightful interview on the topic with Douglas B. White, MD, MAS who authored an article in the Annals of Internal Medicine on the topic. He makes several points:

• Physicians need to do more than communicate clearly –they also need to customize their approach based on the family’s emotional and psychological profile
• Optimism bias leads to overtreatment at the end of life, because doctors don’t push to overcome the bias
• Patients may not believe a physician’s prognosis
• Physicians should ask the family member how they will explain the situation to others. This is a good test to see if doctor and family member are on the same page
• Physicians should raise the issue of a grim prognosis early on, to give family members an opportunity to deal with it

These points are all good ones for physicians to consider and act on. But if my put myself in the place of a family member, some serious concerns remain:

• I may not believe the physician’s prognosis because the physician may be wrong or unduly certain. Of course it depends very much on the circumstances, but from what I’ve seen physicians are notoriously bad at forecasting how long an individual will live or whether they will recover and to what extent. Their point estimates are not always based on an evaluation of all the relevant information and they don’t often take into account the wide ranges of outcomes that are possible with an individual case.
• Physicians deal with death all the time. If they don’t find ways to deal with it emotionally they can’t practice medicine. But if I’m a family member I don’t want a physician to make peace with my relative’s death and move on mentally to the next patient while my relative is still alive
• In consulting we have a saying, “under promise and over deliver.” That way the client is happy when we do what we strived to do anyway, and isn’t disappointed if we slightly miss the mark. I suspect some doctors are the same way, and might provide a grimmer prognosis than warranted in order to reduce expectations. That way they won’t be blamed if things go awry, and can take credit if things go well.  So I might adjust for that possibility in a way that the doctor would call “optimism bias” even if it isn’t