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Medical risk: What does 1 in a million mean?

Dermatology patients often seek treatment for skin conditions that may be uncomfortable but are not life threatening. Some of the medications used to treat such conditions may be toxic.

Emory dermatologists Robert Swerlick and Benjamin Stoff began to wonder whether their patients fully understood what they were telling them about risk.

To explore the question, they have designed a research project that has implications well beyond their specialty. With the help of Emory medical students Lucy Fu and Aaron Rosado, they are analyzing how doctors communicate with patients and each other, what language they use in doing so, and how effective those communications are.

"Sometimes even though the legal standards for communicating risk are met, ethical standards are not,” Stoff says. "As doctors, our language often is not specific.”

He points to a 1991 research project [Merz, Druzdzel, and Mazur] in which investigators collected information about the ways doctors conveyed patient risk while testifying in court. The doctors who testified often used "low” or "high” to identify the level of risk, but later when asked to quantify what they meant, they differed wildly on meaning. By "low risk,” some doctors had in mind one patient in 10, while others thought low meant one patient in 10 billion. The numbers for "low” risk overlapped with "high.”

The observation led Swerlick and Stoff to other questions: Do verbal terms really mean anything? How prevalent is this problem? Can patients differentiate between risks deemed rare vs. common, likely vs. unlikely, or frequent vs. infrequent? "If the terms lack standard definitions, then I think we need a paradigm shift from verbal expression to one that has more meaning,” Stoff says.

He and Swerlick have identified barriers that potentially can interfere with patients' understanding of what their doctors are communicating, including poor comprehension of numbers, imprecise language, and risk framing (providing a context). "Patients, especially the elderly, have difficulty understanding probabilities, particularly those expressed as fractions or percentages, which is a format often used by health care providers,” Stoff says. A misunderstanding of the numbers can compromise an accurate interpretation of risk.


Emory dermatologists Robert Swerlick and Benjamin Stoff


Framing also plays an important role, says Swerlick, the Alicia Leizman Stonecipher Chair of Dermatology. "Depending on how I present options to any given patient, I basically can talk anyone into anything. However, if all patients within a given clinical context whom I counsel make the same decision, I believe I am not communicating in a way that presents them with any real choice.”

Stoff compares patients' perceptions of risk to their fears of dying in an airplane crash or an automobile accident. "Even though the risk of death from driving is more than 100 times greater than dying in a plane crash, that risk often seems more tolerable to people because driving is a part of everyday life and is under greater control of the individual.”

By identifying where language and current communications tools fall short in the health care environment, the researchers hope to address these limitations to promote the ability of patients to be more self-directed agents. After all, patients who achieve this autonomy in decision-making, working together with caregivers who effectively frame and communicate risk, together can make the best decisions and get the best outcomes.

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