In this study we evaluated how physicians working in the field of disability evaluation rated the importance of six areas of prognosis, namely disease, treatment, course of the disease, external information, patient-related aspects, and physician-related aspects. Although all six areas were considered important, there was more consensus among physicians concerning the three medical areas (disease, treatment, and course). The scores and verbatim remarks regarding the patient- and physician-related considerations (non-medical areas) reflected a more varied appreciation of importance among physicians.
Our use of a clear and severe medical case vignette may have influenced the physicians’ more limited appreciation for non-medical prognosis aspects during the prognosis assessment. Verbatim remarks were made to the effect that medical considerations sufficed, and the importance of medical prognosis aspects appeared relatively high. In contrast, physicians’ remarks regarding prognosis assessment of cases “in general,” suggested that non-medical prognosis aspects could become more important in cases with a less clear medical background. Physician-related considerations appeared not to be given an explicit role in the assessment. Some physicians actually mentioned this and scores within this area appeared lower. However, it was also mentioned that they do play a relevant, though often implicit or subconscious, role.
As a form of support, physicians mentioned some kind of overview of prognosis aspects and relevant scientific evidence. A digital form of support was preferred.
Comparison with the literature
The importance of the six areas of prognosis: diverging opinions on non-medical prognosis aspects
In disability evaluations, the framework of the International Classification of Functioning, Disability and Health (ICF) [10] has been adopted by and used in several countries [11, 12]. This classification system can also be used to describe work functioning, taking contextual and personal factors into account. However, there is some criticism that the ICF scheme is suggestive of the dominance of a medical perspective rather than a biopsychosocial one. Therefore, suggestions for a revision of the ICF have been made [13, 14]. For prognosis assessment in work disability evaluations, there is another problem with the ICF: The dynamic aspect of functioning and health over time is not addressed, nor are any consequent changes in activities or participation over time. As such, the use of the ICF during social–medical history taking and prognosis assessment is limited [11]. These two issues with the ICF (i.e., suggestive dominance of the medical perspective and absence of a time frame) leave room for diverging opinions [15, 16], especially regarding non-medical aspects, which corresponds to our findings.
The importance of the six areas of prognosis: non-medical prognosis aspects
Our study shows that the perceived relevance of patient-related considerations varies in prognosis assessment. In the case of a clear medical condition, they might not all be necessary or might make a smaller contribution to the prognosis evaluation, whereas for medically unexplained physical symptoms (MUPS) or in vocational rehabilitation settings, physicians may attribute more value to them.
In a study on arguments used in disability prognosis [17], medical clarity contributed to the type and number of arguments used. In less clear medical cases, more arguments were used, including non-medical aspects such as coping or education. In addition, Ankersmit et al. [17] found that the expected outcome reception played a role: when disability claims were substantial or the chances of appeal were considered high, physicians preferred a more comprehensive evaluation of all potentially relevant aspects, including patient-related considerations (a preference that was also mentioned by physicians in our study). Another study [18], which concerned aspects for consideration in disability evaluation, suggested that the timespan covered in the evaluation (e.g., 5 days, 3 months, or 5 years) determined the value of the aspects used: For longer timespans, less relevance was attributed to patient-related factors. Some physicians in our study made explicit comments that in vocational rehabilitation settings, they would attribute more value to those patient-related prognosis aspects and that these could be targeted by interventions. Prognostic systematic reviews have shown that, regardless of context, patient-related factors, such as coping and self-efficacy, have more prognostic value for participation in work than factors of a medical nature [19,20,21,22] and could inform prognosis assessment and re-evaluations over time.
The importance of the six areas of prognosis: implicit role of physician-related considerations
Physician-related considerations were regarded by the physicians in our study as often subconscious factors that influence the physician’s judgment. The consequences of those influences for prognosis assessment are mentioned in various medical studies within several fields [8, 23,24,25]. For example, physicians tend to express the prognosis in a way that is too optimistic. This could originate from, for example, a tendency to provide hope or to stimulate healthy rehabilitation and recovery behavior [8] and “not to harm” by taking those away [8, 24]. For example, an earlier study found that physicians performing disability assessments did not want to permanently deny young adults any hope or chance of future work participation [15], given the positive aspects of work. To overcome some of those consequences, physicians in our study said that the important thing is to be aware of these influences.
The way to support physicians: EBM as core ingredient, covering relevant prognosis aspects
The physicians in this study wanted support, including evidence-based prognostic information, preferably pre-appraised. Evidence should ideally be tailor-made, as suggested by earlier studies [7, 8]. Even if prognostic evidence is present, it requires skills to find, appraise, and apply it in a particular case and within the country-specific legislative context [26,27,28]. However, studies have demonstrated that training in evidence-based medicine may improve the quality of disability evaluations, prognosis assessment, and job satisfaction [4, 29]. Some physicians in our study mentioned that useful prognostic search strings might be provided, thus meeting the demand for help in finding prognostic evidence. This demand was also reported in other studies [26, 30], which led to research providing potential search strategies, filters, or strings regarding themes such as prognosis and work participation [30,31,32]. The desire for user-friendliness, simplicity, and help in overseeing the various prognostic aspects was also identified by Kox et al. [8] and Louwerse et al. [33], both of whom were exploring possible prognostic tools. In contrast, when presented with possible prognostic tools, physicians also stressed the importance of preserving their professional autonomy to make unique, tailored evaluations. [34, 35] Moreover, they needed to become acquainted with them and they wanted to estimate their validity. [35]
Strengths and limitations
A strength of our study is that it combined insights from the quantitative data with qualitative data from corresponding remarks from physicians. However, our questionnaire was not suited for an in-depth exploration of the reasons why the importance was scored higher or lower. Also, we cannot exclude a selection effect, as the physicians attending the workshop may be more interested in this topic, but it is not clear how or in which direction this could have influenced the results.
The fact that the case vignette concerned a clear, severe medical condition might explain why the physicians did not elaborate much on the functional abilities of the patient. Some commented that this patient had no abilities for work at all and referred to the medical condition. It would be useful to evaluate the importance of prognostic aspects in a similar study that includes a case vignette with a less severe, chronic health condition (e.g., rheumatoid arthritis) or a condition with less medical clarity (e.g., MUPS). However, we tried to partially counter this disadvantage by asking for opinions on the prognosis for “general” cases, although we acknowledge that what is “general” could mean different things for the participants in this study.
Conclusions
This study demonstrated that all six areas of prognosis are important and that their individual contribution during prognosis assessment may vary from case to case. There is a need for evidence-based prognostic decision-making as well as tools to assist physicians in searching for, appraising, and applying prognostic evidence to substantiate their prognosis assessments.