Chapter 23. How to communicate risks involved in management?

Dr. Yeshwanth K. Amdekar, DCH, MD (Pediatrics), FIAP

As the world becomes more digital place, we cannot forget

about the human connection

                                                                        Albert Einstein

Effective communication depends on trust and trust

depends on trustworthiness

                                                                        Steven Covey

Concept of “risk”

Risk refers to a chance of unacceptable outcome of any action. Life itself is a series of taking risks as every step has a margin of risk, however small it may be. No outcome is 100% certain or safe and so there is always a fear of uncertainty. Infact, medicine is a science of uncertainty and doctors have to depend on art of probability. Therefore, it always involves some risk. Moreover, outcome of medical treatment depends on many variables, of which most unpredictable variable is individual patient’s response to treatment. Doctor has no control over patient’s response as much as teacher has no control over student’s response and therefore outcome is not in the hands of a doctor. Even the best of the treatment may not guarantee best outcome.

Risk management

It is a process of identifying, monitoring and managing potential risk situation in order to minimize negative impact. As every act has a potential risk, doctor must evaluate risk-benefit ratio. One has to weigh pros and cons. First consider what may happen naturally if no action is taken. After all no action may be apparently safer than any action as in case of minor trauma that heals by itself or a viral infection that is self-limiting. However, in a curable bacterial infection, antibiotic should not be withheld just because there is a possibility of side effects of an antibiotic. In such a situation, side effects of antibiotic are so minor as compared to benefit of cure of bacterial infection which otherwise may endanger life. So clearly benefit outweighs risk and so such a risk is worth taking. In such a situation, it is best not to talk upfront about side effects. When asked by the patient, one should highlight safety of the drug with rarely minimum and inconsequential temporary side effect. Many patients are well informed through “google-doctor” and have read more about side effects than effects. Let patients know that youare responsible for correct information and google-God information is not necessarily applicable to everyone. To a very inquisitive patient who talks only about side effects, I often given them an example that makes them understand a point. I ask them whether it is safe to sit in my clinic under a roof that may collapse anytime. Well, there is always a possibility of collapse to a pessimist but optimist never thinks about it and he is mostly right. Every day one hears about fatal accidents on road and even then, no one stops travelling, simply because risk is negligible. However, situation where in chance of risk and benefit are equal decision is difficult and should be taken together with the patient. For example, treatment of some cancers may be equally dangerous to life as cancer itself. Besides, side effects of treatment may be unbearable requiring repeated hospitalization as against natural sinking that may be less painful. An individual patient’s mind-set should decide best possible action. But there is always a hope for improvement and so many may be ready to take a risk. Calculated risk is a need to achieve a goal but the final decision must come from the patient.

Use communication skills

Communication refers to giving relevant information to the patient. Relevance must be appropriate to the situation. Information not only should be truthful but at the same time it should not discourage the patient to lose hopes of improvement. One needs to be tactful. Most important is the fact that patient should not feel doctor is hiding some information. Such a suspicion leads to despair. So best is to explain to relatives in front of a patient. Always emphasise on positives first. Even in a dire situation that holds significant risk, once you decide that risk is worth taking, talk to the patient about negative impact of not taking a risk. It may amount to a definite disaster while taking a risk may have equal chances of success. It is a good idea to describe your own experience about similar patients who have done well. At times such stories could be fictitious but bring in hopes. Mind plays a significant role in recovery. Doctor must imbibe confidence in a patient that success is always a possibility and so risk is worth taking. Finally, universal faith on almighty is embedded in our culture, especially in high-risk situations. So, it is appropriate  to convince a patient that you will leave nothing undone and  Put-up best efforts. After all outcome depends on luck and luck favors the brave. So, patient must pray and keep mind cool while you as a doctor do your best.

Personal notes

I recall an incidence when a child was admitted with acute appendicitis for whom I suggested urgent surgery. Parents took few hours to decide and meanwhile child’s abdominal pain disappeared but patient had started deteriorating. This child had developed gangrene (meaning appendix became dead due to loss of blood supply and so pain disappeared but child deteriorated). I explained in details to make them aware that child’s life was in danger but they would not agree. In that situation, I asked them to sign a document that they had chosen to disregard my advice and so would be responsible for the outcome. At that stage, parents agreed and child was saved after surgery. I have faced similar situation when a child suffering from pneumonia was breathing faster and required hospitalization but parents refused as their doctor had opined against. I refused to treat this child and left them to decide what suited them.

Take home message

Risk is involved in every step of life. A drug that has an effect also has a side effect, there is no drug without a side effect. It is always right to take a risk when benefit clearly outweighs risk. Even in such a favorable situation, there exists a risk that should be downplayed. Doctor has to be tactful to communicate when risk is high but must be taken for hopeful outcome as against not taking a risk that is a sure disaster. It should be communicated in a way to offer hope. Your experience about stories of success in similar situations helps to boost morale of the patient. It has a positive impact that improves chance of success.

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