COMMUNICATING RISK

1
COMMUNICATING RISK
2
(No Transcript)
3
NEWSFLASH!!

• Breaking News..Mrs Dumpty sues GP for failing to
  explain adequately risks of sitting on walls

4
!

• Mr Smith, your serum potassium is at the upper
  limit of normal.
• What does that mean?
• Nothing really, you shouldnt worry.
• Well, why did you tell me?
• I thought you wanted to be kept informed.

5
Defining Risk Richard Smith, BMJ

• A risk is a combination of a probability of
  something happening (where statisticians might be
  able to help you but often cant), a feeling of
  the dreadfulness of that event (which is very
  personal), and a context for the event.

6
Estimate in terms of probability the following
risks

• Unlikely
• A chance
• Occasionally
• Rarely
• Probably
• Usually

7
Successful risk communication depends on
establishing a relationship of mutual respect and
trust between those concerned

• The professional values of competence, expertise,
  empathy, honesty and commitment are all relevant
  to communicating risk getting the facts right
  and conveying them in an understandable way are
  not enough.
• Adrian Edwards BMJ 2003327693

8
Risk Assessment

• Clarity
• Context
• Uncertainty
• Woloshin et al BMJ 2003327696-7

9
Elements of risk and selected sources Clarity
about the risk What risk is being discussed?
What are the numbers? What is the time period?
How dangerous is the disease? Sources Getting
and dying from most cancers at specified times
(National Cancer Institute's surveillance,
epidemiology and end results website,
http//seer.cancer.gov/query/) Getting breast
cancer in the next 5 years (National Cancer
Institute's breast cancer risk assessment tool,
http//bcra.nci.nih.gov/brc/) Myocardial
infarction or cardiac death in next 10 years
(National Cholesterol Education Program heart
risk calculator, http//hin.nhlbi.nih.gov/atpiii/c
alculator.asp?usertype prof) Getting lung
cancer in the next 10 years (long term smokers)
(Memorial Sloan Kettering Cancer Center lung
cancer risk assessment tool, www.mskcc.org/mskcc/h
tml/12463.cfm) Get context How does my risk
compare to risk of an average person? similar
disease? leading causes of death? all-cause
mortality? Sources Dying from various and all
causes in the next 10 years (risk charts
http//jncicancerspectrum.oupjournals.org/cgi/cont
ent/full/jnci94/11/799) Acknowledge uncertainty
Has the risk factor been shown to change risk
(is it really a risk factor)? Does the risk
factor really cause disease? How precise is the
risk estimate? No single data source See BMJ 's
BestTreatments website How to use research to
support your treatment decisions6
https//www.besttreatments.org/risk Source   Ste
ven Woloshin et al BMJ 2003327696
10
Bowel symptoms

• 71 year old woman, rectal bleeding, loose stool
  gt6 weeks.
• 58 year old man change in bowel habit, no rectal
  bleeding, gt6weeks.
• 39 year old man, single episode rectal bleeding,
  worried re bowel Ca.
• What do you do? How do you explain? What words do
  you use?

11
What factors influence how we present risk to
patients?

• What we know (is our knowledge sufficient and
  accurate?)
• Communication skills
• Engaging patient (discovering their beliefs etc)
• What outcome we want??

12

• Parents seem to neglect the most obvious risks
  to their children (such as road crashes), reject
  expert assessment (as over BSE), and amplify a
  virtually non-existent risk (autism from
  vaccination).
• BMJ 2003327727

13
DISTORTING RISK
14
Editor's choice Think harm always How do you
deal with something unpleasant? The commonest way
is not to think about it. That, I suspect, is why
medicine has paid so little attention to the harm
it may causedespite the ancient instruction
"first, do no harm." Many people try to deal with
death by not thinking about it, but Montaigne
advises us to do the opposite and think about it
all the time. The same advice might apply to
thinking about harm every intervention by a
doctor, even a throwaway comment or a test "just
to be sure," carries the potential for harm,
whereas many of those interventions have no
possibility of bringing benefit. This long
overdue theme issue explores some of the many
ways in which health care might result in harm.
Very few people attend a doctor thinking that
they may come out worse than when they went in.
But many do. When referring a patient to hospital
should a doctor say "I must warn you that the
simple fact of being admitted to hospital means
that you have something above a one in 10 chance
of suffering an adverse event and a one in a 100
chance of dying"? I put this point to the
Helsinki meeting of the World Medical
Association, a body that has made its name (and
possibly created harm) by promoting informed
consent. The audience looked quizzical, and I've
never heard of a doctor issuing such a warning.
But doctors will regularly warn patients of much
less common risks attached to particular
interventions. Imagine an applicant to medical
school answering the universal question of "Why
do you want to study medicine?" with "My main
ambition is to try to do less harm than good" or
"I'd like to devote myself to exploring the harms
caused by doctors." The applicant would be
thought very odd even though he or she would be
enlarging on "first, do no harm." Yet the balance
between doing good and creating harm in a
lifelong medical career undertaken with
commitment and compassion may be fine. The harm
is omnipresent, the benefit sometimes fleeting.
As a junior doctor I dutifully prescribed
lignocaine to many patients who had had heart
attacks. The logic was, I believe, that the drug
would prevent the arrhythmias that might kill
patients. It never occurred to me that this might
kill patients rather than save them, but I learnt
years later that the result of my hard work was
more not fewer deaths. As my parents took me to
hospital as a 7 year old and left me alone (on
the hospital's instructions) to have my tonsils
removed they never for an instant thought that
the harm of the procedure might outweigh the
benefitbut it probably did. The hospital
admission certainly made me miserable and caused
me to miss my big break playing the Archangel
Gabriel. Hard and uncomfortable as it may be, we
need to think about harm all the time. Richard
Smith, editor
15
Letter Balancing benefits and harms in health
care Editor's choice was sensationalist but not
true EDITORI have for a long time thought that
one of the chief obstacles to the public's
understanding of medicine is the inability of the
average punter to understand the concepts of
probability and risk-benefit analysis that
underpin most of the treatment decisions we make,
and our failure as a profession to dispel that
ignorance. It was disappointing to read Smith's
Editor's choice, in which he bemoans the fact
that doctors seldom say to their patients "I
must warn you that the simple fact of being
admitted to hospital means that you have... a one
in a 100 chance of dying."1 We don't say it
because it's not true. It may well be the case
that 1 of patients admitted to hospital die, but
very few patients enter hospital with a one in
100 chance of dyingfor most, it's much less than
that. Would Smith have us tell a young, fit
patient admitted for a hernia repair that there
is one chance in 100 that he or she won't come
out alive? If not, which patient would he choose
as the recipient of this alarming message? The
patient in a road crash with multiple fractures
and an aortic laceration perhaps? But in that
case, of course, 1100 would be a significant
underestimate of his or her chance of dying. This
is not just statistical semantics for individual
patients the 1 death rate is a complete
irrelevance, and suggesting that this figure is
something that they need to worry about is
grossly misleading. Such a figure may make for a
headline grabbing editorial (and making a splash
in the tabloids seems to have overtaken the
impact factor as a measure of success for the
BMJ), but it is not science. Bob Bury,
consultant radiologist
16
Hormones and Cancer up to date
information   Dear Patient   The media
continually report a threatening increase in
cancer in connection with the use of HRT during
menopause. In what follows we give you an up to
date review of the proven facts so that you have
an objective basis for making a
decision.   Breast cancer HRT may be associated
with a minimal increase in the incidence of
breast cancer. Usually about 60 out of 1000 women
develop breast cancer in a lifetime after 10
years of treatment with HRT, 6 more women develop
breast cancer. That is, the risk may possibly
increase by 0.6 (6 in 1000)   Other cancers Not
only does HRT not increase colorectal cancer,
which is relatively frequent, but it has been
proven to protect women against colorectal cancer
by up to more than 50 per cent. That is, women
who receive HRT develop colorectal cancer only
half as often.
17
Risks Unnecessary worry and fear of cancer
Physical harm from investigations Colonoscopy
117 000 deaths and 11000 perforations Barium
enema 157 000 deaths
18
HOW CAN WE DO IT?

• Effective Options
• Where evidence is clear-cut, e.g. with smoking
  cessation
• Issues relate to implementation.

• Preference Sensitive Options
• Where balance between risk and benefit less clear
• Need to help patient balance risks and come to a
  personal decision

19
Numerical representations

• Single Event Probabilities
• Conditional Probabilities
• Relative Risk

20
Conditional probabilities The probability that a
woman has breast cancer is 0.8. If she has
breast cancer, the probability that a mammogram
will show a positive result is 90. If a woman
does not have breast cancer the probability of a
positive result is 7. Take, for example, a woman
who has a positive result. What is the
probability that she actually has breast cancer?
21
Natural frequencies Eight out of every 1000
women have breast cancer. Of these eight women
with breast cancer seven will have a positive
result on mammography. Of the 992 women who do
not have breast cancer some 70 will still have a
positive mammogram. Take, for example, a sample
of women who have positive mammograms. How many
of these women actually have breast cancer?
22
(No Transcript)
23
Strategies / Aids

• Most patients assessment of risk is primarily
  determined not by facts but by emotions.
• Start by reminding patients that all treatments
  have some risk of possible harm.

24
Visual Aids

• Paling Perspective Scale
• Paling Palette
• Revised Paling Perspective Scale
• www.besttreatments.org/risk

25
Analogies

• Driving to hospital
• GM vs Mobiles
• Diabetic leaving the house
• Car crashes

26
Conclusions
27
Finally.

• Remember you cannot predict the future, so dont
  pretend you can!

28
(No Transcript)