“Very rarely a chance of heart attack or death” – Wait, what?

Jeffrey L. Greenwald, MD

Photo courtesy of Dr Greenwald 

‘We work with our colleagues to conduct detailed assessments of risk for a specific patient to determine the level of risk to proceed as well as the level of risk not to do so,’ said co-presenter Jeffrey L. Greenwald, MD, of the Medicine Consult Service Team of Massachusetts General Hospital in Boston. ‘We discuss risk with our patients and assume that the patient understands what we are talking about. But do they? And does this change the outcome? Almost never. The patient goes to surgery regardless, yet shared decision making between patient and physician(s) should be central to this process.’ 

Co-presenter Douglas E. Wright, MD, PhD, director of Mass General’s Medicine Consult Services, said he was jolted into awareness of the ambiguity of meaning of risk statements when he was reviewing a consent form for a cardiac stress test he was about to take while sitting in an empty waiting room at 0600 hours. The risks that could occur from taking the test included the statement: “very rarely a chance of heart attack or death”. What precisely did this mean? The technician did not know, and Dr Wright had the test without incidence. 

Interpretations may vary

Dr Wright and Dr Greenwald subsequently discussed the incident and pondered how a patient would interpret the phrase “slight risk of complications” versus “10% risk of complications”. Researching the subject, they discovered that there is no easy answer. People individually define risk differently. Preconceived notions, shared experiences, cultural and society influences, emotional states, and for some, innumeracy, make interpretation of even the most carefully crafted description of a specific medical risk assessment difficult and unpredictable. 

As an example, they cited a study presented at the 2019 Annual Congress of the Association of Anesthetists conducted at Sheffield Teaching Hospital NHS Trust in the United Kingdom. It evaluated how 57 clinicians and 290 patients interpreted seven probability expressions of risk relating to the occurrence of a major peri-operative complication.¹ 

Not only was there a wide variation among all participants, but patients tended to assign a much higher risk probability than clinicians meant. The study also confirmed the influence of education and the ability to understand numeric probability when assessing risk. Other research studies published in peer-review journals reveal that risk assessment interpretation is highly individualized. 

Dos and Don’ts

Because of these and other data, the presenters recommend that hospitalists prepare in advance for a meeting with a patient and/or family. 

They suggest that doctors should: 

• recognize that information provided about risk of tests, treatments, or procedures may be misunderstood and that the patient may become very emotional. 
• determine their patient’s understanding of the medical situation. Identify their goals and priorities, specifically what they are hoping for and what they are worried about, such as prior experience with similar situations. Identify if there are language, literacy, or numeracy issues and assume that these are present unless proven otherwise. 
• not impose their own beliefs, preferences, and biases on the patient. 
• select a combination of language, visual representations, and numerics (such as percentage) that they think will best convey their message in a way that the patient will understand. 
• ask the patient to explain in their own words what they (the doctor) said. 
• document the content of their interaction with the patient. 

‘In situations where clinical specialists have differing opinions about a patient’s risk, be diplomatic yet frank if you are put in the position of a mediator,’ Dr Greenwald advised. ‘Hospitalists are generalists. Specialists may be experts in their field, but they may not have evaluated the “bigger picture” with respect to totality of the patient’s clinical record. That is our job,’ he commented. 

When Healthcare in Europe asked Dr Greenwald what he personally experienced at Massachusetts General Hospital, a prestigious academic research hospital, he advised that most patients accept the risk information as presented. ‘I think that receptivity of risk information is based on the knowledge and trust of the physicians,’ he said. 

Does risk assessment vary by country?

Benjamin P. Geisler, MD

Photo courtesy of Dr Geisler 

Co-author Benjamin P. Geisler, MD, a Doctoral Research Fellow at the Department of Health Management and Health Economics at the University of Oslo, Norway, comments, ‘I definitely think that the issue exists in other countries too. Language and culture undoubtedly have an impact on these discussions. The clinician-patient relationship may be different on where you are in the world, say Scandinavia or Russia. Risk assessment discussions in Europe may have an even greater technical detail than in the US or alternatively, be discussed only very briefly with the authority and recommendations of the physician unquestioned.’ 

The presenters concluded with this tongue-in-cheek comment. ‘In summation, what do you tell your patients? “You’ll be fine. Probably.”’ 

Reference: 

1. Wiles MD, Duffy A, Neill K. “The numerical translation of verbal probability expressions by patients and clinicians in the context of peri-operative risk communication.” Anaesthesia. 2020 Jan;75 Suppl 1:e39-e45. doi: 10.1111/anae.14871. 

Profiles: 

Jeffrey L. Greenwald, MD, is a teaching hospitalist and a member of the Core Educator Faculty of the Department of Medicine at Massachusetts General Hospital (MGH) and is an Associate Professor of Medicine at Harvard Medical School. He serves on the MGH Medicine Consult Team. Having served as the lead physician for Mass General Brigham’s High Performance Medicine Team on Readmissions, Dr Greenwald works with the MGH Readmissions Care Redesign Committee, and was a principal developer of a novel readmission risk indicator currently used by MGH. He also works on the hospital’s Palliative Care Continuum Project, whose goal is to expand primary palliative care skills and education to clinicians. 

Douglas E. Wright, MD, PhD, is an Assistant Professor of Medicine at Harvard Medical School. He is the Director of the Medicine Consult Team of Massachusetts General Hospital (MGH) and a member of the Core Educator Faculty of the Department of Medicine at MGH. In his role as a clinician educator, Dr Wright attends for five months per year on inpatient medical services, where he focuses on physical diagnosis, bedside teaching, diagnostic reasoning, and perioperative medicine. 

Benjamin P. Geisler, MD, is currently a Doctoral Research Fellow at the Department of Health Management and Health Economics at the University of Oslo. He practices hospitalist medicine at Massachusetts General Hospital, and is particularly interested in cardiovascular diseases, antimicrobial prescribing, rare diseases, and diagnostic dilemmas across medical sub-specialties. Dr Geisler is also a health services research, decision-analytic modeler, and heath economist. 

29.09.2025

• patient management (265)