Assessing risk can be difficult for patients

MEDICAL MATTERS:Surgeons encouraged to put focus on dangers

IMAGINE YOU have been told your child needs surgery to clear fluid from behind her eardrums. This will involve a general anaesthetic and the insertion of small tubes in the eardrums to allow the gluey substance that is interfering with her hearing to drain away. You are aware of a cousin who had the procedure performed and all had gone well.

Her surgeon tells you there is a 2 per cent risk of something going wrong. How do you respond? Do you think, “Well that means there is a 98 per cent chance all will be well”? Or do you begin to focus on the two in 100 chance of a complication and ask the surgeon to explain these risks in more detail?

Humans vary enormously in how we perceive and assess individual risk. But it does seem that percentage rates are more opaque and more difficult to personalise. Surgeons are now encouraged to explain risk in terms of the number in 100 who may have an adverse event. So for an operation with a one in 100 risk of complications, the surgeon might say, “If you are that one patient in 100, you may have to live with the consequences.” In this way, patients are encouraged to focus more on the potential risk to them and less on the 99 people whose operation went swimmingly.

A study just published describes how difficult it has been for the US Food and Drug Administration (FDA) to communicate risk to consumers in an effective and predictable way. The researchers sorted FDA risk communications from the past 20 years into four categories: warnings about serious adverse events; recommendations against use in specific patient populations; preventing harmful drug-drug interactions; and calls for increased laboratory or clinical monitoring.

The most effective notices were those warning the public about potential serious adverse events, but even these varied in their impact. For example, several studies found that patients shifted away from the diabetes drug rosiglitazone after an FDA alert noted an increased risk of cardiovascular events with this drug. This led to decreased use of the drug and increased use of other, less risky diabetes medications.

Recommendations that specific groups of patients avoid certain medications sometimes decreased use, but they also produced unintended consequences.

The most notable was a series of advisories about the use of antidepressants among children and adolescents. The widely publicised alerts significantly decreased use of these medications by adults as well as children, with one study suggesting an unexpected increase in suicides among children and adolescents due to increases in untreated depression.

“Communicating risk to large groups of people is a complex science,” said study director G Caleb Alexander, associate professor of medicine at the University of Chicago. “But success or failure at this can have significant consequences.”

The most effective communications were the simplest, those that were specific, where alternatives were offered, and where the messaging was reinforced over time, the researchers concluded.

A 2005 EU study found quite a variation between countries in people’s risk perception. Scandinavian countries and Austria have the most trust in medicine, while people in Italy, Cyprus and Poland were more concerned about medical errors and have less trust in health professionals.

Significantly, people’s awareness of the issue differed from their actual experience. While almost four out of five respondents said they had heard or read about medical error, less than one in five indicated they had either personal or family experience of medical error in a hospital.

And while most of those surveyed said it was the responsibility of the healthcare system to ensure the quality of treatment, a substantial number recognised that patients have a role to play in avoiding medical error.

Some of us calculate risk, while others are sensitive to hazards. The next time you are offered medical treatment, you may find it helpful to reflect on which end of that continuum you inhabit.