As GPs we communicate risk many times every day, so why is it hard to do it well?
Risk is like beauty; it is in the eye of the beholder. The point is you are not the beholder, your patient is and, like beauty, they will see risk differently to you.
Information might narrow the gap, but this is not always the case. This is the spanner in the works of the whole informed consent debate.
We know that different people have different concepts of health risk. There are those who believe they can control their level of exposure to illness by following advice on diet, exercise, medical check-ups and screening procedures, while members of another group make minimal effort to look after themselves.
There is also a disproportionate number who believe it is not up to either them or fate but rather you, as a representative of the medical profession, to look after their health.
Most people are a mixture of all three of these traits, being rational and logical in some areas and careless in others. For example, you may have an insulin-dependent patient who looks after herself and her diet scrupulously but who continues to smoke.
Or maybe you have an obese patient who never misses an appointment for a check-up and meticulously watches his cholesterol and BP readings, but who still eats an unhealthy diet and drinks more than the recommended units of alcohol.
Risk and screening
Risk and the screening industry is a hot potato. Take screening for bowel cancer using faecal occult blood, for example. In a study on uptake of bowel cancer screening, Australian researchers randomised participants with a low level of education into groups and in two of the groups they used decision support aids which clearly explained the procedure.1
The study revealed that those with more information reported that they knew more, made more informed choices and found the decision easier to make than those who did not receive further information.
The surprising finding was that fewer of the 'informed' group decided to take the test. The paper suggested that 'adherence' may be better achieved by 'a policy of informed uptake rather than informed decision making'.
This is not a new debate; the initial introduction of cervical screening was characterised by paternalistic withholding of information and the mammogram screening debate is still mired in controversy, with the much-promised new leaflet outlining a balanced approach to harms and benefits still to appear.
The doctor's role
The problem appears to be that doctors fear that information may get in the way of letting them do what is good for their patients. This may be true, but the use of the internet means that doctors can no longer control information, and the emphasis is now on personal choice and shared decision making.
Experts in the area of risk have suggested that the whole population needs more education in the understanding of risk to allow effective shared decision making to become a reality. If you believe in choice related to risk, then you have to allow for those patients who will continue to do things you disagree with, but you have to be clear that they are as informed as can be reasonably expected. This requires practised consultation skills.
We doctors are taught scientifically; we learn thousands of new words and have models of disease imprinted in our brains. Patients are not like this. We both have reasons for believing in and doing what we do. The trouble is these reasons are quite different. Take hypertension; until the advent of cheap electronic machines, only professionals could diagnose this condition. We insist to our patients that high BP produces no symptoms and can only be effectively treated by regular medication and frequent monitoring. This is the concept of the asymptomatic risk factor.
Many patients do not understand this and so use more obvious explanations to help them cope with what they perceive as an illness.
Most patients think hypertension is a description, and take their medication depending on how they feel. If they have a headache and feel tense it is obvious that they are 'hyper-tensive' and need to take their tablets, but on days when they are feeling serene and relaxed they may feel that tablets are not necessary.
To communicate risk effectively you must be able to negotiate and establish a shared dialogue. It is helpful to think of this dialogue as a meeting of experts - you with knowledge of statistics and the medicine and your patient with their health beliefs and concerns.
If you can tease out the patient's hopes and fears related to a particular medical risk then you stand a chance of emphasising the positive and countering the negative. This does take time and it needs practice, but we must do it.
- Dr Tate is a retired GP in Corfe Castle, Dorset, author of The Doctor's Communication Handbook and the Effective Consulting DVD. To order your copy of the DVD for £24.99 visit www.gponline.com/consulting
1. Smith SK, Trevena L, Simpson JM, et al. A decision aid to support informed choices about bowel cancer screening among adults with low education: randomised controlled trial. BMJ 2010; 341: c5370.
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