Leaving work the other day in New York City, I spotted a motorcyclist zooming down the street wearing a mask but no helmet. During the COVID-19 pandemic, masking is required for all state residents when unable to socially distance (motorcycle helmets are always required). I found this scene intriguing because it seemed to be an overt display of how members of the public can interpret risk. I do not know what went through his head as he got on his motorcycle that afternoon, but he appeared to have decided that the risk of COVID-19 transmission was greater than the risk of a head injury from a motorcycle crash. Was dying from COVID-19 worse than dying from a motorcycle-induced head injury? However he chose, there are some lessons for how physicians communicate risk to patients so that we can help promote their health.
Promote Clarity and Accuracy
Professionally, our most frequent interaction with risk involves the conversations we have with patients about treatments and procedures for their medical care. Those conversations about risk are mediated by the informed consent discussion and physicians’ disclosure and the patients’ understanding of the harms and benefits of various treatment options. The words physicians choose when discussing risk should promote clarity and accuracy of information exchange. Specifically, physicians should frame treatment options by their “harms and benefits,” not by their “risks and benefits.” As Daniel J. Morgan, MD, and colleagues describe in a recent article, “Referring to harms as ‘risks’ emphasizes that the unfavorable outcome may or may not happen, whereas there is no parallel language that highlights the equally probabilistic nature of ‘benefits.’ Presenting treatment decisions as a comparison of risks vs benefits creates an inherent imbalance in which benefits simply exist, whereas harms are uncertain.”1
Probability and Magnitude
Physicians may understand the risks of a treatment, but how should the risks be communicated so that patients understand? First, risk can be broken down into probability and magnitude: the likelihood of an event occurring and how large or small that outcome is. Some risks are unlikely but serious, whereas others may be common but benign. For example, the probability of death from a treatment might be extremely low, but most would consider death a risk of large magnitude. Conversely, a medication’s side effect might be extremely common but hardly noticeable.
There are also barriers that interfere with risk perception, such as when risks are withheld or misrepresented through overly emotive language or cognitive biases. Physicians may downplay risks by not mentioning them, as when they avoid disclosing cancer diagnoses and poor prognoses to patients. This is a problematic strategy from an ethics perspective as competent patients are entitled to relevant information to make decisions about their care.
Using technical language or emotive descriptions may overly influence or confuse patients and impair communication. A “negative test result” or a treatment that is “very high risk” without reference to specific numbers or context may mean different things to patients. Framing, a type of cognitive bias in which physicians describe risk in one form exclusively, can lead to inaccurate risk assessment by patients. A risk of 5% mortality rather than 95% survival is clinically equivalent even if patients interpret the latter more favorably.2 Another potential issue is availability bias, which is an overemphasis of a risk because of a recent association with it.
Factor in Literacy and Numeracy
Patients may also have limited literacy or numeracy, making written materials sometimes unhelpful. However, even patients with high literate and numeracy can have difficulty in appreciating differences in risk. Evidence-based practices for communicating probabilistic information is available3 and should be used to improve the quality of information exchange. This includes the use of frequencies over percentages in describing probability. Patients are more likely to understand and appreciate a probability of “5 out of hundred” rather than “5% of all patients.” In addition, patients understand absolute risk reduction better than relative risk reduction, although use of the latter can lead to higher treatment uptake rates.4 This makes practical sense when you consider that relative risk reduction often involves larger numbers and may influence patients’ decision about the overall benefit. Rather than describe risks verbally, physicians may be more successful in conveying risks by graphically illustrating them using an icon array, which visually displays proportions of different outcomes. Some websites (eg, www.iconarray.com) allow users to develop their own icon arrays to educate patients by entering the relevant data.
In spite of these considerations, all the information in the world may not be enough when patients are beset with hard choices. Even the most capable physician using evidence-based risk communication tools, working with the most numerate, literate, and well-informed patient, may still struggle with the uncertainty of risk. Although physicians cannot eliminate risk, they can serve as an interpreter who guides patients to articulate their values, preferences, and concerns, and make it easier for patients to make better decisions.
David J. Alfandre MD, MSPH, is a healthcare ethicist for the National Center for Ethics in Health Care (NCEHC) at the Department of Veterans Affairs (VA) and an Associate Professor in the Department of Medicine and the Department of Population Health at the NYU School of Medicine in New York. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the NCEHC or the VA.
- Morgan DJ, Scherer LD, Korenstein D. Improving physician communication about treatment decisions: Reconsideration of “risks vs benefits” [published online March 9, 2020]. JAMA. doi: 10.1001/jama.2020.0354
- Freeman, Alexandra LJ. How to communicate evidence to patients. Drug Ther Bull. 2019;57:119-124. doi: 10.1136/dtb.2019.000008
- Zipkin DA, Umscheid CA, Keating NL, et al. Evidence-based risk communication: a systematic review. Ann Intern Med. 2014;161:270-280. doi: 10.7326/M14-0295
- Schrager SB. Five ways to communicate risks so that patients understand. Fam Pract Manag. 2018;25:28-31.