Five Ways to Communicate Risks So That Patients Understand

 

When discussing a patient's risk of developing a disease or the risks associated with a screening test, these simple techniques can ensure clarity.

Fam Pract Manag. 2018 Nov-Dec;25(6):28-31.

Author disclosure: no relevant financial affiliations disclosed.

Effective communication is a hallmark of patient-centered primary care, but communicating with patients about risk can be complicated. Patients' risk of developing a certain disease, their risk reduction from taking a certain medication, or the risks and benefits of a certain screening or procedure are not easy to understand. Nevertheless, risk conversations are crucial to helping patients make informed decisions that align with their personal values and perspectives. We call this shared decision making.1

People's perception of risk can be affected greatly by the way their physician communicates about risk as well as a number of other factors. Data have shown that clinicians tend to overestimate the risk of a condition and underestimate the risk of complications and side effects.2 Additionally, emotion can affect patients' understanding of potential risks.3 For example, hearing a risk estimate of a 1 in 27 chance of developing bladder cancer will naturally feel scarier than the same risk estimate for a rash. People also have strong emotions if they have had a personal experience with a condition and may interpret the data differently based on that experience. For example, if a patient's neighbor had an infection after a hip replacement and needed to be re-admitted for IV antibiotics, that patient may not believe a surgeon who later says the patient's risk of infection is low. Patients' understanding of risk can also be affected by numeracy, that is, their ability to understand numbers or percentages. There is evidence that numeracy may be a strong predictor of a patient's decision-making skills.4 Patients with low numeracy may have difficulty understanding the risk of side effects or the benefits versus risks of screening tests, and they may be less likely to ask questions about treatment or screening decisions. Low numeracy is indirectly related to health outcomes.5

Numeracy screening questions may be helpful in certain situations (see “Two questions to assess patient numeracy”); however, routine numeracy screening of all patients is not practical or recommended. Instead, physicians should take universal precautions to provide understandable and accessible information to all patients, regardless of their numeracy or health literacy levels.

KEY POINTS

  • Remind patients that all options confer some risk.

  • Using absolute risk can help you avoid bias because relative risk tends to make changes in risk appear larger.

  • How you present numbers, whether you use visual aids, and the language you use can all affect a patient's ability to understand risk.

TWO QUESTIONS TO ASSESS PATIENT NUMERACY

Routine screening of patient numeracy is not feasible; however, the following questions may be helpful in certain situations, for example, if a risk conversation is not moving forward due to a lack of understanding.

1. Which of the following indicates the greatest risk of getting a disease?

A. 1 in 10.

B. 1 in 100.

C. 1 in 1000.

2. Which of the following is bigger?

A. A

ABOUT THE AUTHOR

Dr. Schrager is a professor in the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health, Madison, Wis.

Author disclosure: no relevant financial affiliations disclosed.

References

show all references

1. Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361–1367....

2. Hoffmann TC, Del Mar C. Clinicians' expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Intern Med. 2017;177(3):407–419.

3. Fischoff B, Brewer NT, Downs JS (eds). Communicating Risks and Benefits: An Evidence-Based User's Guide. Silver Springs, MD: FDA. http://www.fda.gov/ScienceResearch/SpecialTopics/RiskCommunication/default.htm. Accessed Sept. 24, 2018.

4. Cokely ET, Feltz A, Ghazal S, Allan JN, Petrova D, Garcia-Retamero R. Decision making skill: from intelligence to numeracy and expertise In: Ericsson KA, Hoffman RR, Kozbelt A, Williams AM (eds). Cambridge Handbook of Expertise and Expert Performance New York: Cambridge University Press; 2018.

5. Garcia-Retamero R, Andrade A, Sharit J, Ruiz JG. Is patients' numeracy related to physical and mental health? Medical Decis Making. 2015;35:501–511.

6. Bean RB, Bean WB. Sir William Osler: Aphorisms From His Bedside Teachings and Writings. New York: Henry Schuman; 1950.

7. Akl EA, Oxman AD, Herrin J, et al. Using alternative statistical formats for presenting risks and risk reductions. Cochrane Database Syst Rev. 2011(3):CD006776.

8. Fagerlin A, Zikmund-Fisher BJ, Ubel PA. Helping patients decide: ten steps to better risk communication. J Natl Cancer Inst. 2011;103(19):1436–1443.

9. Zipkin DA, Umscheid CA, Keating NL, et al. Evidence-based risk reduction: a systematic review. Ann Int Med. 2014;161(4):270–280.

10. Trevena LJ, Zikmund-Fisher BJ, Edwards A, et al. Presenting quantitative information about decision outcomes: a risk communication primer for patient decision aid developers. BMC Med Inform Decis Mak. 2013;13(Suppl 2):S7.

11. Zikmund-Fisher BJ. Continued use of 1-in-X risk communications is a systemic problem. Med Decis Making. 2014;34(4):412–413.

12. Stacey D, Légaré F, Lewis K, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 20174CD001431.

13. Zikmund-Fisher BJ, Ubel PA, Smith DM, et al. Communicating side effect risks in a tamoxifen prophylaxis decision aid: the debiasing influence of pictographs. Patient Educ Couns. 2008;73(2):209–214.

14. Hawley ST, Zikmund-Fisher BJ, Ubel PA, Jankovic A, Lucas T, Fagerlin A. The impact of the format of graphical presentation on health-related knowledge and treatment choices. Patient Educ Couns. 2008;73(3):448–455.

15. Paling J. Strategies to help patients understand risks. BMJ. 2003;327745–748.

 
 

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