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Putting risk into context

^1. University of Leeds, Department of Obstetrics and Gynaecology, Clarendon Wing, Belmont Grove, Leeds, LS2 9NS, UK. Email: j.o.drife{at}leeds.ac.uk(corresponding author)

	Abstract

TOP Abstract Introduction Understanding risk The doctor's attitude Communicating risk Understanding the woman's view Learning how to communicate... Summary References

 
Key content:

• Risks are measured in various ways by epidemiologists and portrayed with varying degrees of accuracy by the media.
  
• Doctors should examine their motives for explaining risks. These may include the wish to avoid litigation or to persuade women to take a specific course of action.
  
• Communicating risk requires a background knowledge of how risk is measured and a relationship of trust between doctors and women.
  
• Words and numbers are useful in communicating risk and decision aids are now available to help this process.
  
• Understanding the woman's view is essential – remembering that it may change during pregnancy – and there are techniques for learning this skill.
  

Learning objectives:

• To understand how risks are measured and how they are perceived by women.
  
• To be aware of the importance of the doctor's attitude to risks.
  
• To know the prerequisites for communicating risk and the range of techniques for doing so effectively.
  

Ethical issues:

• Does the doctor's opinion bias the information he or she gives?
  
• When a woman finds it difficult to take a decision herself, should the doctor do this for her?
  

Please cite this article as: Drife J. Putting risk into context. The Obstetrician & Gynaecologist 2007;9:42–47.

Keywords contraception / decision aids / empathy / media / risk

	Introduction

TOP Abstract Introduction Understanding risk The doctor's attitude Communicating risk Understanding the woman's view Learning how to communicate... Summary References

 
‘Living with risk has always been a part of life and it is always likely to be so.’¹

Nevertheless, obstetricians and gynaecologists are expected to reduce risks to a minimum and part of our job involves discussing with women how best to do so. Box 1 indicates the range of issues involved. Most of these items affect healthy women, who need to know about risk in more detail than patients with life-threatening disease, whose treatment options may be limited.

View larger version (24K): [in this window] [in a new window]   Box 1 Examples of risks that may need to be put into context

• The doctor must understand the data and have some idea of how statistics relating to risk are formulated.
  
• The doctor should have insight into his or her own attitude to the risk under discussion. This attitude will almost certainly convey itself to women.
  

Communicating risk to a woman involves several processes:

• establishing trust
  
• using appropriate language
  
• using decision aids
  
• understanding the woman's view.
  

These processes occur simultaneously, not one after another. Some have been the subject of research, summarised below, but communicating risk is an art as well as a science. Like other arts, it can be learned.

	Understanding risk

TOP Abstract Introduction Understanding risk The doctor's attitude Communicating risk Understanding the woman's view Learning how to communicate... Summary References

 
Epidemiology is in the syllabus of the Part 1 MRCOG examination, so the trainee or specialist should have a basic understanding of how epidemiologists measure risks. A few salient points will be mentioned here.

Definitions

• A hazard is a set of circumstances that can have harmful consequences.
  
• A risk is the probability of a hazard causing a harmful effect.
  

To give an example, a bottle of tablets is a hazard. If it is left open near a small child the risk is high but if it is locked in an inaccessible cupboard the risk is reduced, though never to zero.¹ Implicit in the definition is the idea that risk can be quantified.

Epidemiological methods

• Case reports may be the first sign of a hazard such as an adverse effect of a drug, but in themselves they give little idea of the size of the risk.
  
• Cohort studies involve following up a large number of exposed people over a long period of time, for example, the Oxford Family Planning Association study of women using oral contraception.² They can reveal unsuspected risks.
  
• Case control studies involve matching exposed people, for example, oral contraceptive users, with controls who are otherwise similar. Perfect matching is impossible, however, and small differences may cause ‘confounding’. For example, smoking is more common among oral contraceptive users and its effects may be mistakenly attributed to the oral contraceptive pill.
  

Although case control studies give the most accurate estimates of risk, they are not always available to answer important questions. For example, if asked whether home or hospital delivery is safer for a low risk woman, we have to rely on observational studies.³ Obstetric complication rates in the UK are so low that it is debatable whether a large enough case control study could be organised.⁴

Relative risk and absolute risk
Results of epidemiological studies are usually reported as relative risks or odds ratios. This can cause unnecessary alarm. For example, in 1995 epidemiologists reported that third generation oral contraceptives doubled the risk of thromboembolism compared with second generation oral contraceptives. The initial reports⁵ did not mention that the absolute risks were low: 1 in 3 000 compared with 1 in 6 000, that the background risk in non-users was 1 in 20 000 or that the increased risk of death was around 1 in 1 000 000. Because the risk was not put into context, public panic ensued. Medical editors learned from this experience and major journals now require reports to include absolute as well as relative risks, making the clinician's job that bit easier.

The influence of the media
The media have a major influence on perceptions of risk.⁶ Often, the doctor's task is not to give information but to try to correct misinformation that the woman has obtained elsewhere. For example, in the early 1990s the UK abortion rate was steadily falling until the ‘pill scare’ of October 1995 (Figure 1), after which the rate immediately rose and stayed up. The distress caused to women is hard to imagine. Later studies did not confirm the risk but during a health scare the task of putting risk into context is almost impossible for an individual doctor.^7,8

View larger version (90K): [in this window] [in a new window]   Figure 1 Cover of The Sunday Times Magazine, 19 November 1995, after the October 1995 ‘pill scare’. The Sunday Times Magazine

Internet access is increasing and in day-to-day counselling you should bear in mind that women may have checked out the web before they see you. Often, they will not mention this unless you ask. This should not cause embarrassment: after all, it is what you would do yourself. If your advice agrees with their chosen website they will feel reassured. If not, they will decide which to believe and this depends on how much they trust you, which is discussed further below.

Keep in mind that other women will have little, if any, background information. Do not assume that everyone reads the newspapers.

A changing picture
Sometimes a woman has out-of-date information. For example, in 2002 and 2003 the risk/benefit balance of hormone replacement therapy (HRT) was radically reassessed as a result of the Women's Health Initiative (WHI) study in the USA. It is perfectly reasonable for a woman to ask why the medical profession has suddenly changed its mind and the doctor should be able to explain why. (Incidentally, the WHI recently published findings that seem to change the balance again.⁹)

Unknown risks
It is a mistake to state risks too dogmatically. Not only may today's findings be out of date tomorrow, but uncertainty is always present; for example, the risks of drugs in pregnancy. The few drugs that carry clear risks are well known but for all the rest the only accurate statement is that their safety is unproved. For some drugs we can say that they have been used for decades with no adverse effects. This honest answer is more reassuring to most women than a dismissive ‘don’t worry' or a bland reassurance that the drug is ‘quite safe’.

	The doctor's attitude

TOP Abstract Introduction Understanding risk The doctor's attitude Communicating risk Understanding the woman's view Learning how to communicate... Summary References

 
Perhaps the most difficult aspect of communicating risk is to be aware of our own attitudes. Our motivation may not be a disinterested desire to share information. We may want to obtain the woman's consent for a treatment which we think is necessary and this can tempt us to minimise its risks or exaggerate its benefits. Conversely, we may be anxious to cover ourselves against the possibility of litigation and this tempts us to discuss rare risks in unnecessary detail. We may disapprove of a woman's lifestyle and give unjustifiably stern warnings about its risks.

We may even find ourselves drawn into a battle of wills with a woman. This is very dangerous ground. For example, if a woman withholds consent for a caesarean section in labour, the staff's perceptions of the risk to her baby can cause them distress and in the past they have led doctors to seek court-ordered intervention. It is hard to keep a balanced view in such an emotionally charged situation, but you must remember that a woman has the right to refuse any procedure.¹⁰ Document your advice and her response as dispassionately as possible.

Counselling about termination of pregnancy is another example where a doctor's opinion could influence his or her assessment of risk. Indeed, when opinion is polarised on a contentious issue the research literature itself can be unhelpful, dividing itself into two schools of thought, with the conclusions of each paper predictable from its authorship. RCOG guidance is invaluable, as the College strives to take a balanced view.¹¹

Ignoring risks
Doctors' perspective on risks is strangely selective. In the antenatal clinic we spend time discussing risks of chromosomal abnormality around the 1 in 250 level (regarded as ‘screen positive’ for trisomy 21 screening) but we do not tell a 30-year-old primigravid woman that she has a one in three chance of instrumental delivery. The only way she can be sure of avoiding this risk is by choosing caesarean section and we prefer not to offer this option.¹²

	Communicating risk

TOP Abstract Introduction Understanding risk The doctor's attitude Communicating risk Understanding the woman's view Learning how to communicate... Summary References

 
Communication is a two-way process. Giving a woman information involves listening as much as talking. It involves watching her reaction as you speak and prompting her to tell you what she is thinking.

Establishing trust
A relationship of trust between doctors and women is essential for successful risk communication.¹³ As you talk, the woman is watching you and forming an impression of you as a doctor and an individual. She will also notice whether the nurses and midwives seem to respect you. Traditional professional values: competence, expertise, empathy, honesty and commitment, count for a great deal and are much more than high-sounding words. Honesty, for example, means admitting uncertainty as well as demonstrating your knowledge. Above all, remember that you are not trying to get a woman to agree with you but are trying to help her make a decision that is right for her.

Effective communication
Much research has been carried out on effective communication, although it must be admitted that, ironically, the resulting papers are often difficult to understand. A recent systematic review¹⁴ addressed three questions:

1) What are the most effective communication tools to improve women's understanding of ‘evidence’?

Communication tools (for example, decision aids, printed material, videos, websites) are helpful and the more tailored and interactive they are, the better. It is not clear from the evidence whether they are best used before, during or after the consultation.

2) What are the most effective formats to represent probabilistic information?

In both written and verbal communication, women have a more accurate perception of risk after being presented with numbers rather than words. Absolute risks should be given but relative reductions can be understood if they are accompanied by baseline risk. In written material, illustrations and cartoons are helpful.

3) What are the most effective strategies to elicit women's preferences/beliefs/values?

In general this area is poorly researched but decision aids and decision analysis are effective for eliciting preferences, as are exercises for clarifying relative values.

Words and numbers
Despite the conclusion under question 2, above, a study of women's understanding of the effectiveness of contraceptive methods found that tables with categories communicated relative effectiveness better than numeric tables. However, women grossly overestimated the risk of pregnancy unless they were shown tables with numbers, so a combination of both methods is best (Figure 2). The study also concluded that effectiveness is the most important factor in choosing a contraceptive method.¹⁵ A study of women's understanding of HRT risks¹⁶ also indicated that a combination of words and numbers is most helpful.

View larger version (69K): [in this window] [in a new window]   Figure 2 Risk language proposal27

The numerical probability of a risk, however, is less important than the perceived severity of the hazard.¹⁶ There has been little research on such perceptions but intuitively we understand that cancer seems a more serious hazard than a fracture, so in the context of HRT, the risk of breast cancer outweighs the benefit of osteoporosis reduction, almost regardless of incidence or mortality figures.

Decision aids
Calculators are available on the web to help people understand the risks they face (Figure 3) but it is not easy for women to interpret them without help.¹⁸ Making sound decisions about whether to accept screening is difficult as the risks can easily be underestimated and benefits are infrequent but decision aids for screening are, as yet, poorly developed.¹⁹

View larger version (109K): [in this window] [in a new window]   Figure 3 Portrayal of risks and benefits of treatment with antibiotics for otitis media designed with Visual Rx, a program that calculates numbers needed to treat from the pooled results of a meta-analysis and produces a graphical display of the result (www.nntonline.net)28

• improve knowledge
  
• improve the realistic perception of benefit and harm
  
• reduce uncertainty
  
• reduce the proportion of women who are passive in decision making
  
• reduce the proportion who remain undecided after counselling
  
• improve agreement between women's values and their choices.
  

Decision aids related to surgery consistently reduce the number of people opting for major procedures such as hysterectomy. Instead, women choose more conservative surgical or medical options. Outcomes and satisfaction are unaltered.²⁰ Quality criteria have recently been developed for appraising decision aids.²¹

	Understanding the woman's view

TOP Abstract Introduction Understanding risk The doctor's attitude Communicating risk Understanding the woman's view Learning how to communicate... Summary References

 
When a woman is given information she will interpret it in the context of her personal experience and core beliefs. As far as possible we should try to tailor the information to the individual. Her family history is important, not only because it affects numerical risk,²² but also because many people believe that certain diseases ‘run in the family’. Her past history is relevant: for example previous decisions about oral contraceptives provide a context for discussion about benefits and risks of HRT.¹⁶

Personal beliefs about fatalism, choice, control and ‘womanhood’ all affect individual decision-making.¹⁶ Inevitably, decisions are influenced by emotion as well as logic. People often worry with intensity disproportionate to the actual danger,²³ but if the doctor can achieve empathy and encourage the woman to say what really worries her, it may be possible to help put her worries into proportion.

Pregnant women may be more risk-averse than obstetricians. In a decision analysis experiment, women were asked what level of risk they would accept to their baby before requesting a caesarean section (assuming the caesarean section could be done without risk to the mother).²⁴ The mean level of stillbirth accepted by nonpregnant women was 1 in 4 000 and by pregnant women 1 in 20 000. These risks may seem unattainably low but, in fact, the intrapartum stillbirth rate in Dublin's three main maternity hospitals in 2003 was 1 in 7 642—well below that reported in observational studies of home delivery.³

	Learning how to communicate risk

TOP Abstract Introduction Understanding risk The doctor's attitude Communicating risk Understanding the woman's view Learning how to communicate... Summary References

 
Techniques for helping undergraduates to learn about communicating risk include exercises linking words like ‘occasionally’ and ‘probably’ to numerical values, role playing with colleagues, and videoing consultations.²⁵ For postgraduates, a useful role play is to try explaining risks to a journalist, whom you can imagine asking searching questions to test your knowledge and communication skills.

	Summary

TOP Abstract Introduction Understanding risk The doctor's attitude Communicating risk Understanding the woman's view Learning how to communicate... Summary References

 
Putting risk into context is a high-level clinical skill that requires knowledge, insight and empathy. The doctor must know how statistics are produced and how bias may creep in. Their knowledge must be up to date. When our personal views differ from the mainstream we should be ready to explain both. We must check how much a woman wants to know but be wary of assuming that she wants to leave decisions to us. To quote an editorial from a special BMJ issue on this subject, ‘taking responsibility for decisions is not easy but can be helped by sharing the process with a skilled and sensitive health professional’.²⁶

	References

TOP Abstract Introduction Understanding risk The doctor's attitude Communicating risk Understanding the woman's view Learning how to communicate... Summary References

 

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