Published in the December 2006 issue of Today’s Hospitalist
When physicians and patients start discussing risk, they often don’t seem to be speaking the same language. Too frequently, these conversations are marred by scientific jargon, confusing statistics and a basic misunderstanding of what even common terms mean.
Take, for instance, the concept of “low risk.” To some patients, low risk means a one-in-100 chance of something going wrong “odds not worth taking. But to others, low risk may mean one in 1 million, a risk they’re more than willing to go for.
Put that conversation in a medical context, and things only get more complicated because patients tend to cling to one definition, while physicians may mean another. As a result, says communications expert John Paling, PhD, founder and research director of The Risk Communication Institute in Gainesville, Fla., what patients hear may be quite different from what health professionals are actually saying. That can lead patients to make treatment decisions based on an emotional assessment of risk, not a sound understanding of the facts.
One solution, Dr. Paling says, is for physicians to improve the way they communicate information about treatment risks.
Common communication mistakes include presenting numbers out of context, using vague labels like “low” and “high” risk, and discounting the importance of emotion in both comprehension and decision-making. They all add up to making a bad situation even worse.
In his new book, “Helping Patients Understand Risks: Seven Simple Strategies for Successful Communication,” Dr. Paling offers physicians a way out of this dilemma. He outlines a toolbox of easy-to-implement strategies to help physicians explain risk in ways that patients will understand.
Here’s a look at some of Dr. Paling’s strategies:
“¢ Show patients that you care. When they talk to patients about risk, physicians often try to prove their expertise and competence by cramming the discussion full of facts and evidence. But to establish your authority with patients, Dr. Paling says, you should consider taking the opposite tack.
Because patients start off assuming that their physician is competent, they need to be shown that physicians care. That’s a crucial perception to establish, he explains, because people fear risks more when those risks are communicated by someone the listener doesn’t trust or consider to be “on my side.”
How can you establish caring and concern? Dr. Paling suggests simple strategies like sitting beside patients when you talk to them, instead of standing next to their bed and looming over them. He also suggests that you begin your discussion by empathizing with them over any pain or difficult feelings they may be having.
“¢ Use language that everyone will understand. Make sure that patients understand what you mean, even when you’re using seemingly common terms. If you describe a treatment as “low risk,” for example, clarify that that means between a one-in- 1,000 and one-in-10,000 chance.
The same applies to explaining statistics. Make sure you use common denominators so you’re comparing apples to apples.
“If you are going to give probabilities and make comparisons,” Dr. Paling says, “don’t say ‘one in 333 compared to one in 16.’ Research has shown that 40 percent of patients in the U.S. will assume that a bigger number is a bigger risk than a smaller number.”
Instead, convey any comparison with one in 1,000 vs. X-many in 1,000. “That’s not diminishing the science or patronizing your patients,” he explains, “but making your meaning clear.”
“¢ Avoid discussing relative risk. While you may factor relative risk into your decision-making, patients find it very confusing.
“The idea of a 29 percent increase or decrease gives the impression of a huge impact, whereas in absolute numbers, the numbers can be small,” Dr. Paling points out. As a result, patients frequently make health care decisions that physicians find bewildering.
A good example is the discussion many clinicians have had with patients about the risks and benefits of hormone therapy (HT) to relieve postmenopausal symptoms. While HT can increase a woman’s relative risk of breast cancer by 29 percent, that statement typically terrifies women patients.
But if you translate that relative risk into frequencies, the risk becomes much less worrisome: In any one year, you can predict that 3.8 women out of 1,000 on HT would get breast cancer, compared to three out of 1,000 not taking it.
“¢ Accentuate the positive. Keep in mind, Dr. Paling says, that humans are hardwired to focus on the negative “those 3.8 women “rather than on the positive. If four people out of 1,000 could be harmed by a therapy, try turning that statement around and explaining that 996 people likely won’t be.
“¢ Use visual aids. There’s a good reason why so many books and lectures feature pie charts and bar graphs: Visual aids go a long way to communicate complicated information, including the concept of medical risks vs. benefits.
Dr. Paling offers a tool he calls the 1,000-person palette, which gives patients a graphic illustration of what four out of 1,000 vs. 996 out of 1,000 looks like. (Physicians can download two different palette templates from his Web site.)
“Visual aids actually reinforce the communication of information, which puts data in context,” Dr. Paling says. Using simple palettes and other illustrations also serves another key purpose: communicating complicated information about risk to the large number of people who are illiterate or marginally literate.
Dr. Paling’s palettes also give patients a chance to show you what they think their risks may be so you can tailor your discussion accordingly. By having a patient indicate risk on such a palette, for instance, you may be able to reassure her that she is greatly overestimating her risks “and underestimating the benefit “of a particular treatment.
And Dr. Paling recommends a second visual aid: a perspective scale that helps patients put risks into perspective, showing them the risks people are comfortable with in their daily life.
Such a scale could show, for instance, that the annual risk of getting cancer from drinking one light beer a day falls in the “very low-risk” category of between one in 10,000 and one in 100,000.
Using such everyday examples of risk helps people make comparisons about what level of risk they are willing to take.
“¢ Anticipate the role that emotions play in decision-making. Physicians need to understand that patients hear what you’re saying through an “emotional filter.” On the one hand, a patient’s excessive fears might totally override any rational consideration of facts about the benefits of a treatment. On the other hand, unbounded optimism can swamp any caution about risks.
Not only do people tend to let emotions dominate their assessment of risk, but they also differ widely in how much information they want to know and how involved they want to be in decision-making. Physicians should ask patients directly how much they want to know about risks and benefits and then tailor the discussion.
Deborah Gesensway is a freelance writer who reports on U.S. health care from Toronto, Canada.