Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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How not to motivate in risk communication
- Jim Malloy (26 September 2003)
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Trust and communication
- David F Danson, Dr W Tong, Mr T Clark (26 September 2003)
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Oncological Terrain and other Biophysical-Semeiotics Constitutions, theme issue for BMJ?
- Sergio Stagnaro (26 September 2003)
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communicating risk is a risky business.
- manan vasenwala (26 September 2003)
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Communicating risk
- Christopher Buttery (26 September 2003)
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Communicating Risk
- David L Bisset (26 September 2003)
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Establishing good rapport &empathising with the patient will improve doctor-patient relationship.
- A.K. Al-Sheikhli (26 September 2003)
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Doctors: Are you Emotionally Intelligent?
- Anil Pandit (28 September 2003)
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Communication, Choice and Responsibility
- Marcy Koltun-Crilley (28 September 2003)
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Risk and lay epidemiology
- Gordon Pledger (30 September 2003)
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The Risks of Critical Illness
- Stephen J Gordon (30 September 2003)
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Re: communicating risk is a risky business.
- Samantha McCormick (30 September 2003)
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do as I say......
- john main (1 October 2003)
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One in a thousand?
- Craig Skinner (2 October 2003)
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The risks of demystifying risk
- Andrew L Ashford (3 October 2003)
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Jim Malloy, general manager Air Flow Products Ltd. PO Box 1485, Wellington, NZ
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I recently relocated and enroled with a new doctor. On attending after a preliminary examination I was advised that "It's not a matter of 'if' but 'when' you become diabetic and I intend to prevent this for as long as possible. Doctors must learn to "sell" the benefits of personal health management through motivation and not fear. Competing interests: None declared |
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David F Danson, Director Binfield Berkshire. RG42 4EZ, Dr W Tong, Mr T Clark
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It is becoming increasingly difficult for patients to ‘trust’ their doctors and the NHS. This is due in the main to the media focusing in on the very small percentage of medical issues that create emotion and sell papers. However, most patients do trust their own GP. See answers to question number 5 on this poll completed by patients of a general practice in Berkshire:
http://www.mygeneralpractice.co.uk/csPoller/csPoller.cgi?command=sr&pid=47&cid=4&t=2
In fact, after members of their family, it is one’s GP who is most trusted by the public at large. So the trust between a patient and their GP is established but is there sufficient time for communication? Not when GPs are using much of their time on unnecessary consultations thus reducing the available resource for the more complex diagnosis and the critically ill. Communicating risk is clearly important as is communication in general. Communication is essential to maintaining the trusting relationship and reducing the distress caused by the scaremongering and destructive media activities (MMR issue to name but one) but this clearly needs to be a continuous interaction and not just during a consultation. One such communication facility is being used successfully by a Binfield, Berkshire practice. By delivering medical information and administrative procedures in the form of ‘InfoMed’, patients are benefiting and so are the GPs. A copy of a typical InfoMed bulletin can be seen at: http://www.mygeneralpractice.com . Again, one can look at the answer to question 4 in the above poll to see that patients highly value this form of interaction. Trust is the key to communication and regular communication is the key to gaining trust. In a world where people are inundated with negative media messages, GPs need to be responsible for maintaining and developing their privileged patient relationship. Competing interests: None declared |
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Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseases. Researcher in Biophysical Semeiotics. Via Erasmo Piaggio 23/8. 16037 Riva Trigoso (Genoa) Italy.
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Sir, I agree almost completely with your statement: “Many doctors are not good at communicating about risk—-yet increasingly it is one of their central tasks” (1). In addition, nowadays there is certainly a need for numbers, and many doctors don't feel easy with numbers. However, as regards the difficulty in overcoming the problems of uncertainty and of moving from populations to individuals, thanks to precise information given at the bed side by Biophysical Semeiotics (See web site HONCode 233736, http://digilander.libero.it/semeioticabiofisica), and particularly by the present array of individual’s constitutions (2), (if necessary, "some" English colleagues may understand what “constitution” does mean, by reading Oxford Advanced Learner’s Dictionary, Oxford University Press 1990!), doctors can utilize at the bed side both the EBM and SBM (Single Patient Based Medicine) (3). At this point,I must clarify my concepts with two examples: fasting glucose blood level of 120 mg/dl. is surely warning of type 2 diabetes, exclusively in a patient affected by both “diabetic” and “dyslipidemic” (Joslin was right) biophysical- semeiotic constitution, as I demonstrated in above-cited web site (See: Diabetes, 6 articles). On the contrary, the same fasting glycemia is devoid of importance, i.e., it is not worthy of further examinations, in an individual, wherein above-mentioned constitutions (predispositions, if you like) are absent. Finally, PSA values above 4ng are always insignificant and trivial in absence of “Oncological Terrain” (4), whereas further investigations are unavoidable in a subject affected by such as constitution and, particularly important, presenting the “real risk” of cancer in a prostatic lobe, apart from possible “normal” PSA value (5). I suggest these biophysical-semeiotic constitutions to BMJ as a topic for future issues. 1) Smith R. Communicating risk: the main work of doctors. BMJ 2003;327 (27 September) 2) Stagnaro S. Biophysical Semeiotic Constitutions: http://digilander.libero.it/semeioticabiofisica/constitutions.htm 3) Stagnaro S. Single Patient Based Medicine” versus EBM. BMJ Rapid Response: http://bmj.com/cgi/eletters/326/7398/1048#32299 (16 May 2003). 4) Stagnaro S. Oncological Terrain. Primary Prevention of Malignancies. http://digilander.libero.it/semeioticabiofisica/oncological.htm 5) Stagnaro S. Paramount Bias in all Cancer screening.BMJ Rapid Response: http://bmj.com/cgi/eletters/327/7406/101#34283 Competing interests: None declared |
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manan vasenwala, consultant-cardiologist (non-invasive) k.k.heart center, aligarh-202002.india
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communicating risk to the patient is a risky business. when you are in private practice this is understood better. private practice is a service which comes under the consumer redressal system in india. communicating risk to the patient is a double edged sword. in majority of diseases, the risk factor is arbitrary and very much related to facilities and staff available. sometimes it is required to minimise the risk and at other times one needs to exaggerate for one's safety, usually the latter. for instance , if a patient has a myocardial infarction and is stable, it would be unwise to announce that all is well. medicine is so unpredictable and more so are the patients. they are many occasions when you give a clean bill of health to the patient and after five minutes he is no more. it would be more prudent to have told the patient's relatives that he is making progress but is still serious. to say for example that there is 7 out 10 chance of getting better is fine. but preferable in practice is to say that there is 3 chance in ten of dying. the first option is human, while the second option is wisdom. the first option is what the patient want to hear while the second option is what the beseiged doctor wants to convey and what insurance people want to hear you say. Competing interests: None declared |
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Christopher Buttery, Adjunct Professor of Public Health Virginia Commonwaealth University-USA
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Thank you for putting this issue together. As I tell my students, the most important task for physicians, specially public health physicians, is to tell people about health hazards in succinct and clear ways that leave as little doubt as possible. The most important caveate is, don't get people stirred about problems for which there is no solution. This is important when advocating screening. There is a tendency to screen for many things for which we have no good interventions. I remember about 20 years ago reading an excellent paper which stated then when you screen for more than 5 items, one will usually show up as abnormal. However, this is more likely due to chance error rather than a real abnormality. Now you have to spend time and money retesting everything, which will usually turn out to be normal! Competing interests: None declared |
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David L Bisset, Consultant Histopathologist Royal Bolton Hospital BL40JR
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"can you explain why a test with 95% sensitivity might identify only 1% of affected people in the general population?" No I can't, and I struggled to find an answer, until I realised it was the wrong question. if you apply a test with 95% sensitivity to a population it will identify 95% of those with the disease, but, depending on the specificity and the disease prevalence, they may make up only 1% of those individuals with a positive test result. This is not the same as having identified 1% of those with the disease. The true positives may thus be swamped by false positives and leave you in the position of not having identified any of the affected people sufficiently reliably to allow them to be treated. It is sobering to do the calculations for cervical screening cytology. However I would say that the article is the best coverage of sensitivity and specificity I have seen. Competing interests: None declared |
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A.K. Al-Sheikhli, Loc.Consultant Psychiatrist Medical centre,Nuneaton,UK.
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26th,Sept,2003. EDITOR-It was interesting to read Editor's choice,Communicating risk:the main work of doctors,by Smith(BMJ,2003;327:0-f),my comment that,doctors ought to learn how to empathise and establish good rapport with their patients,how they can look not only into somatic issues,but also psychological and social issues too,try to learn the art of not only looking into verbal ways of communication,but also into non-verbal ways of communication, Thanking you, Yours sincerely, A.K.Al-Sheikhli Competing interests: None declared |
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Anil Pandit, Medical Officer MIDAT CLINIC, Langakhel , Patan, Nepal
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Just numbers and academics not enough. The Editor "Emotional intelligence" refers to the capacity for recognizing and managing our own feelings and those of others. It describes abilities distinct from, but complementary to, academic intelligence, the purely cognitive capacities measured by IQ.(1) Emotional Intelligence seems to be a new concept for us. However,it's well known to psychologist. The human beings with this competency are self-aware, self- confident, and self-controlled. They can initiate and accept changes. They are empathic and socially competent.(1) Medical profession is still a novel and respected field in most part of the world. Doctor-patient relationship is vital for medical practice. With advances in information technologies, world has become very narrow. Patients know more about their disease than his doctor knows. They may have other sources of information, someone they may trust more than doctors.(2) Doctor-patient relationship is ever changing(2). It's norms, values and standards in the next century will differ radically from those valued today. Communicating risks, taking informed consent, and educating patient about their diseases weren't on the radar 50 years ago. Now they matter a lot. Every human being has right for information. This law holds perfect when it comes to medical profession. Patient and /or patients next of keen should be informed every thing about the patients suffering and possible solutions which includes treatment and management. There are several instances where patient's management being misled or underdone or overdone due to poor communication between doctor and patient. While communicating with patients, just communicating numbers (statistics) and academics is not enough. Doctor's job is not over by just "transferring information" to the patient. Information should be given in palatable way, at the same time its gravity shouldn't be disturbed. Some doctors would like communicating risks by "Breaking Bad News". See the irony. Surely, art of communicating and emotional intelligence are vital for this. How can we make doctors for the new- world? For future doctors, this includes an education in art of communication and emotional literacy. For those who have already become doctors, start cultivating emotional competence. Dr Anil Pandit Reference: 1. Goleman, D. Emotional Intelligence. Bantam Books, New York, 1995. 2. Smith, R. Communicating Risk; Main work of doctors. BMJ 2003; 327. Competing interests: None declared |
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Marcy Koltun-Crilley, R.N. Kihei, Hawaii
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Risk Communication and informed choice is about Risk Communication and informed choice. Not about convincing people that they are wrong and the Doctor is right. If information is provided by a physician and it is information that the physician has personally researched and believes himself, then he has done an excellent job, regardless of the choice that is made. The problem seems to be be more about people not making the "correct choices" which in this case is the choice the physician believes is correct and the one he or she would make themselves. So really are we talking about coercion and persuasion even if it is based on what we believe to be in others best interest? Is it the responsibility of the medical profession to educate, inform, and allow people to make choices about their health or is it their responsibility to convince them what they believe is wrong if it is not the same as what the medical profession believes. Perhaps if we allowed people to really make their own choices without judgment, change in many areas including malpractice, patient responsibility and trust might occur as a pleasant side effect. Competing interests: None declared |
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Gordon Pledger, retired Director of Public Health Morpeth,Northumberland,NE61 3PN
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I am interested in risk assessment but I found the theme issue hard going. It encouraged me to try to analyse my own situation, a 72 year old male who eats bran and drinks red wine; who takes aspirin, indapamide, and the dog for a walK daily; who drives 25000 miles a year; who flies gliders and light aircraft; and who sustained a fracture of L4 in a flying accident 5 years ago. My assessment of risk does not go beyond feeling that some of what I do is mildly beneficial in terms of reducing the risk of an episode of CHD or stroke, and that my recreation is somewhat more risky than walking around a shopping mall or garden centre. I choose myself to do slightly risky activities rather than having them imposed on my by the Government or an employer, and I enjoy them, so I am probably discounting their risk by a considerable amount. I am also conscious that life is a sexually transmitted disease with 100% case fatality rate! Although I aM a retired health profesional I recognise that I am applying "lay epidemiology" rather than "science" to my personal risk assessment Perhaps the most important point to come out of the theme issue is that clinicians can only give a rough indication of absolute and relative risks, and need to point out that it is up to each individual patient to make up their own mind in relation to their personal life and goals Competing interests: None declared |
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Stephen J Gordon, Specialist Registar in Urology Brighton & Sussex NHS Trust, BN2 5BE
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Your recent issue regarding risk communication is extremely interesting particularly when you consider the specific condition of prostate cancer and this is for two reasons. Firstly, the Department of Health feel they have quite clearly considered the risks and benefits associated with screening of prostate cancer using the currently available evidence. They have found that at the current time the benefits of PSA screening of the general population do not outweigh the risks. Instead they have drawn up the Prostate Cancer Risk Management Programme (PCRMP) which was officially launched on 4 July 2001. The Programme was established to ensure that men considering a prostate specific antigen (PSA) test for prostate cancer were given information concerning the benefits, limitations and risks associated with receiving a test. Patients can then individually make an informed choice. Ultimately even if prostate cancer is diagnosed the best management option is not known. However, patients who have been diagnosed with prostate cancer are likely to be offered the options of radical surgery, radiotherapy or active monitoring. Even though the cancer may be asymptomatic these treatment options obviously cause varying degrees of associated risk including impotence, incontinence, decreased libido and anxiety. The second reason for interest is that risk assessment is possibly most often performed by the insurance industry. The Association of British Insurers (ABI) states on their website that, “Insurance companies assess the risk of any eventuality and the potential downside associated with it. Then, based on past experience and their own expertise, insurance companies calculate the 'premium' that a customer needs to pay to provide ‘cover’ against injury or loss. When the insured event happens, the company pays out the agreed level of ‘claim’.” Critical illness insurance was developed in 1983 by Dr. Marius Barnard, brother of Christian Barnard. Dr. Barnard realised the need for an insurance that paid a benefit to those surviving a potentially fatal illness. The risk of suffering a condition before the age 65 which keeps patients off work for prolonged periods of time is significantly far greater than that of dying. Premiums for critical illness insurance have been rising and additionally further exclusion clauses have recently been added to policies. In particular, concern has arisen by the recommendation by the ABI that, “All tumours of the prostate unless histologically classified as having a Gleason score greater than 6 or having progressed to at least TNM classification T2N0M0” should be excluded. This excludes patients who are more likely to survive prostate cancer but still have potentially fatal disease. A screening programme currently does not exist in the UK but more ‘early’ prostate cancers would be discovered if it did. Certainly these patients currently would be given the option of treatment including radical prostatectomy and radiotherapy or active surveillance. These treatments and their associated side-effects are well known and mentioned above. This is unfair treatment by the insurance industry of those men who have shown a concern regarding their risk of having prostate cancer. Why should men with prostate cancer which is moderately differentiated and non -palpable disease be refused the benefits of critical illness insurance? Why does the insurance industry not feel that prostate cancer is a critical illness? Does it have more information than the doctors treating patients? The benefits or early detection of prostate cancer are yet to be determined but patients with non-palpable disease may be the only ones who would benefit from conventional treatments with curative intent. The long term evidence for this however is not yet available although the insurance industry has already made up its mind. Imagine a man or woman in their 50’s diagnosed with cancer at its early stages and offered curative treatment based on the best currently available evidence. The treatment may improve the chance of survival but as a consequence would possibly cause incontinence and probably take away the will and ability to have sex. Several months would also be required before returning to work. Currently the ABI would recommend refusing to recognise this as a critical illness if an early prostate cancer was the cause. This is purely because they foresee a further increase in the number of men diagnosed with prostate cancer ans subsequent rise in claims. Is this a reason to exclude the condition? Surely this is wrong and not what Dr Barnard envisaged for critical illness insurance. Competing interests: None declared |
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Samantha McCormick, Midwife Ottawa, IL 61301 US
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Editors, this is a response to the cardiologist from india's rapid response Sir you seem to have very unstable "clients" .... <<< perhaps it is because I practice obstetrics and gynecology and not
cardiology, but I cannot imagine any practitioner of any experience making
such an absurd statement. If your "clean bill of health" doesn't predict
the patient being alive five minutes hence, perhaps you should clean the
wax out of your stethescope.
Perhaps you were using hyperbole to point out the obvious --whatever
the risk for a "population", when something happens to a particular
person, they experience the risk as 100%.
We must never forget that our clients are individuals and oddball
events happen every day.
Considering the astonishingly low probability, I was pretty shocked when a young woman client, whose risk would be expected to be very low
due to her age, having had numerous pregnancies and having breastfed all of her children for a year, was diagnosed with breast
cancer.
In the US, a common phrase is "bodies don't read textbooks", low
probability events occur all the time. After all, despite the odds,
someone always seems to wins the lottery.
Samantha McCormick, CNM (Certified Nurse Midwife)
Competing interests:
None declared |
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john main, kidney doctor james cook university hospital, middlesbrough
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Oh dear Dr Smith. You (or possibly your reviewers) need to take some of your own advice and read this week's issue of the BMJ rather more carefully than normally. The reason not one reader in a thousand could explain why a test with 95% specificity might identify only 1% of affected people is that the statement is simply untrue. I suspect that rather more of your readers than you imagine might well be aware that a test with any appreciable false negative rate will reveal more false than true positives if used indiscriminately in a general population with a low incidence of the disease in question. Or is this some sort of trendy BMJ audit to see if anyone is actually paying attention while reading your journal? Competing interests: None declared |
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Craig Skinner, Consultant PHysician 305 Blossomfield Road Solihull B91 1TE
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The editor guesses that not one reader in a thousand could "explain why a test with 95% sensitivity might identify only 1% of affected people in the general population?". Eager to be one of the elect, I thought about it, but concluded that, by definition, such a test would identify 95% of those affected. Turning to the relevant article (p716), I found that this was indeed the case (positive test in 31 of 33 affected people), but, because the target disorder was so rare, the false positives vastly outnumbered the 31 true positives, so that the positive predictive value of the test was only 1% in that population. An important, but different, point. Competing interests: None declared |
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Andrew L Ashford, GP Principal The Limes Medical Centre, The Plain, Epping, ESSEX CM16 6TL
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EDITOR - It must be sublimely ironic that an edition of the BMJ devoted to increasing the understanding of aspects of risk itself contains the sort of mix-up generated by the opening question of Tze-Wey Loong's otherwise clear and helpful article on sensitivity and specificity. In "Editor's choice" you quite rightly pick up on the difficulty most would face in answering the question, though you fail to point out that this is because it is the wrong question! Tze-Wey Loong's review helps to explain the answer to the following question: "Can you explain why a test with 95% sensitivity might correctly identify affected people in the general population only 1% of the time?" The question as published is self-contradictory, as by definition a test with 95% sensitivity will identify 95% of affected people - the problem, as Loong elegantly demonstrates, is with all the unaffected people who also test positive. Has the published question been teasingly and knowingly posed by Tze- Why Loong himself to test us all, is he still mixed up himself, or is it someone else's (editorial) question? Or could it demonstrate the inherent risks of translation? Competing interests: None declared |
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