Intended for healthcare professionals

Education And Debate

Risk communication in practice: the contribution of decision aids

BMJ 2003; 327 doi: (Published 25 September 2003) Cite this as: BMJ 2003;327:736
  1. Annette M O'Connor, professor (,
  2. France Légaré, clinical teacher2,
  3. Dawn Stacey, doctoral candidate1
  1. 1Ottawa Health Research Institute, Ottawa Hospital, Civic Campus, C4-1053 Carling Ave, Ottawa, ON, Canada K1Y 4E9
  2. 2Department of Family Medicine, Laval University, Quebec, QC, Canada G1K 7P4
  1. Correspondence to: A O'Connor

    As patients want to participate more in decision making, and as the range of medical options expands, clinicians are challenged to improve their communication of risk and supportive skills. Are practitioners' counselling skills up to the job?

    Different decisions require different strategies to communicate risk and support decisions, and we consider that two broad classes of decisions exist for patients. The first class lies in the area of “effective” health services, in which the benefits are large compared with harms–the participation of patients improves control of chronic conditions1 and the widespread underuse of these beneficial options.2 The second is in “preference sensitive” health services, in which the ratios of benefit to harm are either uncertain or dependent on patient values2–participation of patients improves quality of decisions and prevents overuse in the subset of informed patients who don't value the options.3

    View this table:

    Differences in decision support for effective versus preference sensitive medical options

    We investigated practical and effective approaches that doctors and practitioners can use when counselling patients about these two classes of decisions. Box 1 shows the sources we used. These approaches should help patients to understand options, benefits, harms, probabilities, and scientific uncertainties; clarify the personal value of the ratio of benefit to harm; and participate in decision making according to needs.

    “Effective” versus “preference sensitive” decisions

    The goal in decision making is to select health services that increase the chances of valued health outcomes and that minimise the chances of undesired consequences according to the best available scientific evidence. w3 w7

    In some cases, the best strategy is clear to both practitioners and patients because the scientific evidence of benefits and harms is known and the harms are minimal relative to the benefits. Most informed clinicians would recommend the options and most informed patients would agree that the benefits …

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