From chance to choice: The use of a verbal analogy in the communication of risk

A qualitative exploration of clinicians' strategies to communicate risks to patients in the complex reality of clinical practice

BACKGROUND

Risk communication, situated in the model of shared decision making (SDM), is an essential element in daily clinical practice. The scientific literature makes a number of generic recommendations. Yet the application of risk communication remains a challenge in patient-clinician encounters. How clinicians actually communicate risk during consultations is not well understood. We aimed to explore the risk communication strategies used by clinicians and extract narratives and visualizations of those strategies to help inform medical education.

METHODS

In this qualitative descriptive study, we interviewed fifteen purposely sampled clinicians from several medical disciplines, who were familiar with the concept of SDM. Deductive and inductive content analysis was used during an iterative data collection and analyses process.

RESULTS

Our study identified various strategies reported to be used by clinicians to address the complexities of risk communication such as dealing with uncertainty. These included verbal, numerical and visual risk communication and framing. Clinicians were familiar with recommended risk formats such as natural frequencies and population pictograms. However, it became clear that clinicians' expertise and communication goals also play an important role in the risk talk. Clinicians try to lay a foundation for balanced decision-making and to incorporate patient preferences while faced with several challenges such as the dilemma of raising awareness but triggering anxiety or fan fear in patients. Consequently, they also use communication goals such as influencing mindset and reassuring patients. Additionally, clinicians frequently have to account for the illusion of certainty in the risk talk.

CONCLUSION

Risk communication is a multi-faceted construct that cannot be dealt with in isolation from the clinical context. For future research we recommend considering a more practical framework within the clinical setting and to take a goal-directed approach into account when investigating and teaching the topic. The patient perspective should also be addressed in further research.

Effects of Message Framing on Patients' Perceptions and Willingness to Change to a Biosimilar in a Hypothetical Drug Switch

OBJECTIVE

Patients often hold negative perceptions toward biosimilars that can create barriers to their uptake. Physicians also report uncertainty in how best to explain biosimilars. The aim of this study was to measure the effect of differently framed explanations on patients' perceptions of and willingness to change to a biosimilar in a hypothetical drug switch.

METHODS

Ninety-six patients with rheumatic diseases taking an originator biologic were randomized to receive 1 of 4 biosimilar explanations: positive framing with and without an analogy, and negative framing with and without an analogy. Willingness to switch to a biosimilar, perceptions about biosimilars, and the effectiveness of the explanation were measured after the information delivery.

RESULTS

Positive framing led to more participants being willing to switch (67%) than negative framing (46%). Framing significantly predicted willingness to switch to a biosimilar, with participants in the positive framing group being 2.36 times more willing to switch (P = 0.041). The positive framing group also reported significantly greater perceived efficacy of biosimilars (P = 0.046) and thought the explanation was more convincing (P = 0.030). The analogy did not enhance willingness to switch or increase understanding (P > 0.05).

CONCLUSION

Positive framing can improve perceptions of and willingness to switch to a biosimilar in patients currently taking biologic treatments.

Providing information promotes greater public support for potable recycled water

In spite of the clear need to address water security through sourcing new and alternative water supplies, there has been marked resistance from some communities to the introduction of recycled water for potable use. The present studies tested the effectiveness of providing relatively brief information about the recycled water process and the safety of recycled water on cognitive, emotional and behavioral responses. Three information conditions (basic information or basic information plus information about pollutants in the water, or information that puts the risk of chemicals in the water in perspective) were compared to a no information control condition. Across three experiments there was general support for the hypothesis that providing information would result in more positive cognitive, emotional, and behavioral responses to recycled water. Information increased comfort with potable recycled water and, in general, participants in the information conditions expressed more positive emotions (Experiment 1 & 3), less negative emotions (Experiment 3), more support (Experiment 1 & 3), and lower risk perceptions (Experiment 1 & 3) than those in the no information control condition. Participants who received information also drank more recycled water than control participants (Experiment 1 & 2, although the differences between conditions was not statistically significant) and were significantly more likely to vote in favor of the introduction of a recycled water scheme (Experiment 3). There was evidence, however, that providing information about the level of pollutants in recycled water may lead to ambivalent responses.

Using Comparison Scenarios to Improve Prenatal Risk Communication

The present research provides empirical evidence of whether communicating the prenatal risk of chromosomal anomalies using comparison scenarios influences women’s ability to distinguish between different risk levels. In 2 experiments, participants read a description of a hypothetical woman who was learning of the risk of chromosomal anomaly as a result of a prenatal screening test. Both experiments used a 3 (risk level) × 3 (scenario) full between-subjects design. In accordance with the experimental condition, participants were presented with a low (e.g., 1 in 5390), a medium (e.g., 1 in 770), or a high risk value (e.g., 1 in 110). Such risk values were presented either on their own or along with additional information illustrating a comparison scenario that provided 2 numerical comparison points. Participants were asked to evaluate the risk of chromosomal anomaly. In Experiment 2, participants’ numeracy skills were also assessed. Results showed that the use of comparison scenarios results in significant differences in perceived risk across risk levels whereas such differences are not significant without the comparison scenario, but such a technique has differential effects according to participants’ capacity to deal with numbers. Although the technique is beneficial for high-numerate participants, it has no effect on low-numerate participants.

The 1-in-X effect on the subjective assessment of medical probabilities

Among numerical formats available to express probability, ratios are extensively used in risk communication, perhaps because of the health professional's intuitive sense of their clarity and simplicity. Moreover, health professionals, in the attempt to make the data more meaningful, tend to prefer proportions with a numerator of 1 and shifting denominators (e.g., 1 in 200) rather than equivalent rates of disease per unit of population exposed to the threat (e.g., 5 in 1000). However, in a series of 7 experiments, it is shown that individual subjective assessments of the same probability presented through proportions rather than rates vary significantly. A 1-in-X format (e.g., 1 in 200) is subjectively perceived as bigger and more alarming than an N-in-X*N format (e.g., 5 in 1000). The 1-in-X effect generalizes to different populations, probabilities, and medical conditions. Further-more, the effect is not attenuated by a communicative intervention (verbal analogy), but it disappears with an icon array visual aid.