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COMMUNICATING RISK

COMMUNICATING RISK. NEWSFLASH!!. Breaking News…..Mrs Dumpty sues GP for failing to explain adequately risks of sitting on walls…. !. “Mr Smith, your serum potassium is at the upper limit of normal.” “What does that mean?” “Nothing really, you shouldn’t worry.” “Well, why did you tell me?”

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COMMUNICATING RISK

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  1. COMMUNICATING RISK

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

  3. ! • “Mr Smith, your serum potassium is at the upper limit of normal.” • “What does that mean?” • “Nothing really, you shouldn’t worry.” • “Well, why did you tell me?” • “I thought you wanted to be kept informed.”

  4. 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 can’t), a feeling of the dreadfulness of that event (which is very personal), and a context for the event.

  5. Estimate in terms of probability the following “risks”: • Unlikely • A chance • Occasionally • Rarely • Probably • Usually

  6. 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 2003;327:693

  7. Risk Assessment • Clarity • Context • Uncertainty • Woloshin et al BMJ 2003;327:696-7

  8. Elements of risk and selected sources Clarity about the risk Whatrisk is being discussed? What are the numbers? What is thetime period? How dangerous is the disease? Sources: Gettingand dying from most cancers at specified times (National CancerInstitute's surveillance, epidemiology and end results website,http://seer.cancer.gov/query/) Getting breast cancer in thenext 5 years (National Cancer Institute's breast cancer riskassessment tool, http://bcra.nci.nih.gov/brc/) Myocardial infarctionor cardiac death in next 10 years (National Cholesterol EducationProgram heart risk calculator, http://hin.nhlbi.nih.gov/atpiii/calculator.asp?usertype = prof) Getting lung cancer in the next 10 years (long termsmokers) (Memorial Sloan Kettering Cancer Center lung cancerrisk assessment tool, www.mskcc.org/mskcc/html/12463.cfm) Getcontext How does my risk compare to risk of an average person?similar disease? leading causes of death? all-cause mortality? Sources: Dyingfrom various and all causes in the next 10 years (risk chartshttp://jncicancerspectrum.oupjournals.org/cgi/content/full/jnci;94/11/799) Acknowledgeuncertainty Has the risk factor been shown to change risk (isit really a risk factor)? Does the risk factor really causedisease? How precise is the risk estimate? No single data source SeeBMJ 's BestTreatments website: How to use research to supportyour treatment decisions6 https://www.besttreatments.org/risk Source: Steven Woloshin et al BMJ 2003;327:696

  9. Bowel symptoms • 71 year old woman, rectal bleeding, loose stool >6 weeks. • 58 year old man change in bowel habit, no rectal bleeding, >6weeks. • 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?

  10. 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??

  11. “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 2003;327:727

  12. DISTORTING RISK

  13. Editor's choice Think harm always How do you deal with something unpleasant? The commonest wayis not to think about it. That, I suspect, is why medicine haspaid so little attention to the harm it may cause—despitethe ancient instruction "first, do no harm." Many people tryto deal with death by not thinking about it, but Montaigne advisesus to do the opposite and think about it all the time. The sameadvice might apply to thinking about harm: every interventionby a doctor, even a throwaway comment or a test "just to besure," carries the potential for harm, whereas many of thoseinterventions have no possibility of bringing benefit. Thislong overdue theme issue explores some of the many ways in whichhealth care might result in harm. Very few people attend a doctor thinking that they may comeout worse than when they went in. But many do. When referringa patient to hospital should a doctor say: "I must warn youthat the simple fact of being admitted to hospital means thatyou have something above a one in 10 chance of suffering anadverse event and a one in a 100 chance of dying"? I put thispoint to the Helsinki meeting of the World Medical Association,a body that has made its name (and possibly created harm) bypromoting informed consent. The audience looked quizzical, andI've never heard of a doctor issuing such a warning. But doctorswill regularly warn patients of much less common risks attachedto particular interventions. Imagine an applicant to medical school answering the universalquestion of "Why do you want to study medicine?" with "My mainambition is to try to do less harm than good" or "I'd like todevote myself to exploring the harms caused by doctors." Theapplicant would be thought very odd even though he or she wouldbe enlarging on "first, do no harm." Yet the balance betweendoing good and creating harm in a lifelong medical career undertakenwith commitment and compassion may be fine. The harm is omnipresent,the benefit sometimes fleeting. As a junior doctor I dutifully prescribed lignocaine to manypatients who had had heart attacks. The logic was, I believe,that the drug would prevent the arrhythmias that might killpatients. It never occurred to me that this might kill patientsrather than save them, but I learnt years later that the resultof my hard work was more not fewer deaths. As my parents tookme to hospital as a 7 year old and left me alone (on the hospital'sinstructions) to have my tonsils removed they never for an instantthought that the harm of the procedure might outweigh the benefit—butit probably did. The hospital admission certainly made me miserableand caused me to miss my big break playing the Archangel Gabriel. Hard and uncomfortable as it may be, we need to think aboutharm all the time. Richard Smith, editor

  14. Letter Balancing benefits and harms in health care Editor's choice was sensationalist but not true EDITOR—I have for a long time thought that one of thechief obstacles to the public's understanding of medicine isthe inability of the average punter to understand the conceptsof probability and risk-benefit analysis that underpin mostof the treatment decisions we make, and our failure as a professionto dispel that ignorance. It was disappointing to read Smith's Editor's choice, in whichhe bemoans the fact that doctors seldom say to their patients:"I must warn you that the simple fact of being admitted to hospitalmeans 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 casethat 1% of patients admitted to hospital die, but very few patientsenter hospital with a one in 100 chance of dying—for 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 chancein 100 that he or she won't come out alive? If not, which patientwould he choose as the recipient of this alarming message? Thepatient in a road crash with multiple fractures and an aorticlaceration perhaps? But in that case, of course, 1:100 wouldbe a significant underestimate of his or her chance of dying.This is not just statistical semantics; for individual patientsthe 1% death rate is a complete irrelevance, and suggestingthat this figure is something that they need to worry aboutis grossly misleading. Such a figure may make for a headline grabbing editorial (andmaking a splash in the tabloids seems to have overtaken theimpact factor as a measure of success for the BMJ), but it isnot science. Bob Bury, consultant radiologist

  15. 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 tomore than 50 per cent. That is, women who receive HRT develop colorectal cancer only half as often.

  16. Risks Unnecessary worry and fear of cancer Physicalharm from investigations: Colonoscopy 1:17 000 deaths and 1:1000perforations Barium enema 1:57 000 deaths

  17. “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 HOW CAN WE DO IT?

  18. Numerical representations • Single Event Probabilities • Conditional Probabilities • Relative Risk

  19. Conditionalprobabilities The probability that a woman has breast canceris 0.8%. If she has breast cancer, the probability that a mammogramwill show a positive result is 90%. If a woman does not havebreast cancer the probability of a positive result is 7%. Take,for example, a woman who has a positive result. What is theprobability that she actually has breast cancer?

  20. Natural frequencies Eightout of every 1000 women have breast cancer. Of these eight womenwith breast cancer seven will have a positive result on mammography.Of the 992 women who do not have breast cancer some 70 willstill have a positive mammogram. Take, for example, a sampleof women who have positive mammograms. How many of these womenactually have breast cancer?

  21. 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.

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

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

  24. Conclusions

  25. Finally……. • Remember you cannot predict the future, so don’t pretend you can!

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