Intended for healthcare professionals


Relative risk

BMJ 2007; 335 doi: (Published 27 September 2007) Cite this as: BMJ 2007;335:666
  1. Stephen J Hanna, GP registrar, department of elderly medicine, York District Hospital, York
  1. sjhanna{at}

    “It was a tight pain, around my chest, just like when I had my heart attack 40 years ago.” He went on to give a textbook history of cardiac chest pain, which had kept him awake all night two nights previously. When I asked him why he had not sought help sooner, he told me that he had been looking after his son's pets while he was away for an important job interview: “If I wasn't there to look after them, he couldn't have gone to the interview, and he really needs the job.”

    I proceeded to ask about risk factors for ischaemic heart disease, starting with smoking. “Yes, I did smoke, but then again, everyone did then … you would have too.”

    Intrigued, I asked what he meant. “I was a Spitfire pilot during the war. Not the normal planes, but the ones on the aircraft carriers. The landing deck was only about 300 feet [about 100 m] long and about 75 feet wide. What made it even harder was that it was a moving target in rough seas. When you've done that, chest pain doesn't seem quite so bad.”

    His blood troponin concentration was elevated at 1.73 µg/l, and we advised hospital admission for observation and optimisation of his medication. “No thanks, doc,” he replied, “It's the Bowls Club Christmas dinner tonight—I don't want to miss it.” We counselled him as to the risks, but he would not stay. It was all we could do to stop him walking the short distance home, rather than waiting for transport.

    Although I was initially concerned by his refusal to stay, on reflection, I think he made the correct decision. We work in a risk averse environment and often lose perspective. For him, the risk of another ischaemic event or arrhythmia was taken in the context of what he had been through all those years ago. He could not contemplate the possibility of his son missing out on a valuable job opportunity, or not catching up with his friends at their annual dinner, just so that he could stay in hospital.

    He has taught me a valuable lesson—risk is relative.

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