Discussion of risk pervades doctor-patient communication

Editor—Edwards et al neatly summarised the state of current knowledge on communicating risk.¹ I have three further points to add.

Firstly, readers may be interested in the risk ladder we developed to display the risks associated with anaesthesia in comparison with some everyday risks (figure).²,³

Secondly, I think that the authors either have chosen not to address or been unaware that communication about risk and safety takes place throughout a consultation and not simply when the conversation turns specifically to that issue. Likewise, in written materials, it is located not only in the section describing risks but throughout the whole document. My experience with the Royal College of Anaesthetists' patient information project has shown me that patient information is not simply about putting facts down on paper. Rather, it throws the entire implied relationship between clinician and patient into focus and nowhere is this better seen than in the related issues of safety and risk. The choice of words and the professional self image doctors project may be more powerful influences on patients' decisions than precise numerical estimates of risk or their visual analogues. Take, for example, the following text, typical of a preoperative leaflet about anaesthesia:

“Q: What happens once I am asleep?

“A: You are never left alone during an operation. Your anaesthetist stays with you and keeps you safe, pain free, and unaware of what is going on. Drugs are constantly being given to you throughout the operation to make sure you are kept safe.”

In this example, a question, which could simply be one of curiosity, is used as an opportunity both for reassurance and also possibly for education about the role of anaesthetists in general. The answer mentions safety, although the question does not. Is the writer of the booklet justified in assuming that patients regard anaesthesia as being so risky that an answer to a simple question about procedure can be expected to allude to safety as a matter of course?

For the patient who had not considered that anaesthesia might be risky would this be a disconcerting change of tone? Furthermore, if safety is an issue, what do patients need to be kept safe from? The excesses of the surgeon? The undesired effects of the anaesthetic? Electrical, infectious, or other hazards? Without qualification, “safe” is not only meaningless but may actually provoke anxiety. The analysis could continue further, but I have made my point.

Finally, risks must be considered, and the fact that doctors lack reliable data for many risks is a cause for concern. More sobering still is the thought that doctors are still waiting for reliable evidence of benefit for many healthcare interventions.⁴

Figure.

Risk ladders for everyday and clinical risks. Reproduced with permission of Blackwell Scientific²