Table 3.

Quotations on barriers to communicating risk.

Barriers	Sample quotations
Time constraints	Patient
	Usually when you go to see the doctor, they don’t have so much time to explain.
	Since the office visit is very hurried, five or seven minutes, he doesn’t have time to go over my personal circumstances.
	Even if you have so many questions, the doctor will come out and tell you that they have other patients to see and they don’t have time.
	Provider
	The time in the doctor’s room is pressured.
	A lot of time they don’t realize what it’s about and they bring it up at the end. In that case, when I’ve already spent 45 min with them and we only have 15 min., then it does open this Pandora’s box.
	15 min? That’s a very sick patient. It’s between 6–8 minutes, always with a follow up. You spend 30–45 minutes waiting outside if you are lucky before seeing the doctor, another 3–5 minutes getting weighed, another 3–5 minutes to get undressed especially if its the first time they are seeing you. I see 25–35 new patients every day and I am going in there looking to see if they have 35 gowns. 10 minutes to take your blood pressure, listen to your heart to make sure you have no heart problem, listen to your lungs to make sure you have no lung problem. 3–5 min doing the medications, and 2 minutes to write the note. The mere time with the doctor is 6–8 min.
	This encounter with the patient and the physician are getting so long. All the interest groups are coming in and wanting a piece. It’s true we don’t recommend to anybody to do it all in one sitting but then you have to remember what you did last time. You have to go back and review the history. This leads to less efficiency and this is why primary care is such a difficult field. It can open a potentially disastrous box. They already have a ton of complaints that can’t be addressed in a short period of time, then will this [breast cancer risk assessment] add another thing to the list?
Lack of knowledge	Patient
	Because we don’t have the knowledge and don’t ask, the doctor won’t give it to you.
	Provider
	I think in addition to communicating risk, I think communicating what a screening test is. I think a lot of patients go for their mammogram or pelvic exam that it is an intervention preventing them from disease. I don’t think they even understand what screening is.
	It’s a difficult discussion. We get a test result and it’s a number and its chance. Our job is to, well you have a 1 in 10,000 chance of having a child with Down’s Syndrome and they are like what does that mean? And then I’m like oh God I said that wrong. We aren’t allowed to say it’s negative. We follow that statement by saying that the only way to know for sure is with an amniocentesis. And try saying that in Spanish. I hate it because I don’t think any of them make an informed decision.
Low health literacy	Provider
	My struggle is how to get this information across without creating more anxiety with the health literacy issues and with that lack of knowledge about science and statistics and how to put it all in perspective creates a lot of anxiety even though they want to be involved. Sometimes the information they get creates more anxiety.
	I don’t know what percentage of my patients are illiterate and part of it may be in terms of having very low education level but also not having good health literacy.
Language barriers	Provider
	Facilitator: How do you try to go about explaining risk to your patients? I still don’t have a good way. A lot of it is a language barrier.
	Yes the form is in English and Spanish. There are people that can speak both languages but can’t read it.