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BMJ. Sep 27, 2003; 327(7417): 691–692.
PMCID: PMC200790

Communicating risks

Means that patients too have to learn to live with uncertainty

The epidemic this year of severe acute respiratory syndrome (SARS) etched another chapter into the annals of risk science. So do all the major “scares”: bovine spongiform encephalopathy (BSE) and its potential effect on humans through variant Creutzfeldt-Jakob disease; the scare about third generation oral contraceptives in 1995; and the feared link between autism and measles, mumps, and rubella (MMR) vaccination. On p 725 Bellaby discusses these particular risks and describes how public reactions that on the face of it may seem irrational in fact have understandable origins.1 Most of this theme issue, however, is concerned not with mass communication about risks but with one to one interactions between healthcare professionals and patients about their individual risks. Clinicians want to know how best to communicate risk to their patients, and this issue aims to help.

Thus O'Connor et al (p 736) describe how decision aids may help by structuring the way risk information is presented, displaying options, and helping patients to clarify their values in healthcare decisions.2 Gigerenzer and Edwards (p 741) show how numerical information can be simplified to turn innumeracy into greater insight.3 Paling (p 745) develops this further, offering some simple rules of thumb for clear risk communication.4 Experts may think of risk as derived from scientific research, but patients want to know whether or how they will be affected. Alaszewski and Horlick-Jones (p 728) examine how we need to understand more about individual perspectives, people's understanding of risk, the context in which they would have to “live” this risk, their beliefs, and opportunities to influence the risk in question.5

Yet risk communication also needs to be set in a much wider context. All these authors emphasise that successful risk communication depends on establishing a relationship of mutual respect and trust between those concerned (usually the patient and the professional). Trust is a function of both care and competence.4 It is also integral to credibility—a key consideration for whether a message is received and taken up (by individuals or populations). So 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.6

Trust and support are built up most through conversations between clinicians and their patients.7 The nature of the interaction does not, however, remain static. Mazur, and his commentators from France and Britain, discuss the legal requirements for informed consent that set the framework for both research and everyday practice (p 731).8 This provides an important context for much of risk communication today, although there is much more to consent than just signing a form.9 Indeed, the “new medical conversation” outlined by Mazur10 builds on existing skills and traditional values in interactions between doctors and patients. It addresses patients' needs for information while maintaining other aspects, such as support.

Support is necessary because communicating risks entails confronting important uncertainties, and this is often uncomfortable for both patients and professionals. The information available is full of uncertainties, and uncertainty is also irreducible about who will or will not be affected by specific outcomes. Offering too much apparent certainty may be to misinform.

It is also important to ask what we are trying to achieve in communicating information on risks to our patients. Traditionally perhaps the goal was seen as simply trying to reduce risk and improve the population's health. But with shifts towards greater autonomy for patients, the goal is changing to become one of informing people, enabling them to make their own choices, regardless of whether this reduces risk. Godolphin sets risk communication firmly in a context of shared decision making,11 and studies show that patients want not only information but also often participation in the decision making.12 This may lead to “informed dissent” (a somewhat pejorative term), which may in turn produce tensions between what is perceived to be good for populations and what individuals perceive to be good for themselves.13 We may need to accept that increased involvement of patients (and risk communication as a means towards this) may therefore be based more on values than on evidence.

The new medical conversation thus integrates risk communication into the doctor-patient interaction while remaining loyal to core consulting values. The information offered should be simple, relevant, and responsive to the needs and values of individual patients, not assuming what is most important. There should be a two way exchange of opinions and values, as well as information, seeking to maximise trust and support. This may need to be done over a series of consultations rather than being one event. Truthfulness is fundamental—but will leave uncertainties. Yet acknowledging these uncertainties, and accepting patients' decisions, may enhance the role of and respect for professionals, not diminish it.14 In this way a balance may be struck between the “high touch” and the “high tech” approaches.14

Notes

Competing interests: None declared.

References

1. Bellaby P. Communication and miscommunication of risk: understanding UK parents' attitudes to combined MMR vaccination. BMJ 2003;327: 725-8. [PMC free article] [PubMed]
2. O'Connor AM, Stacey D, Légaré F. Risk communication in practice: the contribution of decision aids. BMJ 2003;327: 736-40. [PMC free article] [PubMed]
3. Gigerenzer G, Edwards A. Simple tools for understanding risks: from innumeracy to insight. BMJ 2003;327: 741-4. [PMC free article] [PubMed]
4. Paling J. Strategies to help patients understand risks. BMJ 2003;327: 745-8. [PMC free article] [PubMed]
5. Alaszewski A, Horlick-Jones T. How can doctors communicate information about risk more effectively? BMJ 2003;327: 728-31. [PMC free article] [PubMed]
6. Nicholson P. Communicating health risk. Occup Med 1999;49: 253-6. [PubMed]
7. Katz J. Informed consent—must it remain a fairy tale? J Contemp Health Law Policy 1994;20: 69-91. [PubMed]
8. Mazur D. Influence of the law on risk and informed consent. BMJ 2003;327: 731-6. [PMC free article] [PubMed]
9. Gigerenzer G. (Un)informed consent. In: Reckoning with risk—learning to live with uncertainty. 1st ed. London: Penguin, 2002: 87-114. (Chapter 6.)
10. Mazur D. The new medical conversation. Boulder, CT: Rowman and Littlefield, 2002.
11. Godolphin W. The role of risk communication in shared decision making. BMJ 2003;327: 692-3. [PMC free article] [PubMed]
12. Guadagnoli E, Ward P. Patient participation in decision-making. Soc Sci Med 1998;47: 329-39. [PubMed]
13. Edwards A, Unigwe S, Elwyn G, Hood K. Effects of communicating individual risks in screening programmes: Cochrane systematic review. BMJ 2003;327: 703-7. [PMC free article] [PubMed]
14. Edwards A, Elwyn G, Mulley AG. Explaining risks: turning numerical data into meaningful pictures. BMJ 2002;324: 827-30. [PMC free article] [PubMed]

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