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Prognosis: medical magic

I was surprised that Dr Sokol's essay on medicine and magic did not mention the soothsaying activity of doctors.1 Prophesying clinical outcome is an everyday medical activity but this relies heavily on mathematical probability. To the patient, a doctor who can foretell the future may appear to have the charisma of the magician but today most patients believe that our predictions are based on solid scientific facts. Our diagnostic skills are derived from our observations of the attributes of a disease, without necessarily identifying the cause. In fact, with the exception of diseases related to micro organisms, aetiology is a mystery around which we elaborate unproven hypotheses. Herein lies the magic of medical practice. We operate not by sleight of hand but by sleight of word. Prophesying leans heavily on historic non intervention but our ethic is to treat according to the acquired knowledge within our own speciality. Characteristically we do not recommend placebos to cancer patients as alternatives to chemotherapy. Prognosis could be seen to offer the patient either a stick or a carrot. Without treatment, ‘you will die’. With treatment, ‘you may live a bit longer’. We bolster our beliefs when, with treatment, the patient survives beyond that arbitrary deadline. What if, after a period of reflection, the patient defies the witchdoctor and goes it alone? Do we continue to review that patient in outpatients knowing that management, with their eye on the purse, see these follow-ups as loss leaders? Do these loners fall into the sympathetic laps of the nurse-specialist or practice nurse? The ‘sympathetic’ but devious medical alternative might be to continue to see the patient, except privately. If the patient changes their mind we will probably change the prognosis for the worse. How often have we seen our prognostications and those of others turned on their heads? Patients' choice may be influenced by our messianic fervour to treat and their lack of medical literacy.2 Prognosis carries a mystical/magical power of prediction and is all too easily used as leverage. The magician performs his trick and deceives us. Doctors merely deceive themselves.