Explaining without scaring

Medical Matters: Explaining risks to patients has become a central part of medical practice. Whether you are a surgeon preparing to operate, or a family doctor deciding on the best medication for your patient, the ability to communicate the risks and benefits of various decisions is a critical element of good doctor-patient communication.

For prescribing decisions, assessing the benefit/harm balance at the person's bedside poses practical problems.

Flourishing a product data sheet, with a lengthy list of potential side effects, is likely to scare the patient into one inescapable conclusion: the cure is worse than the aliment. Nor is it realistic, even with the help of computerised notebooks and PDAs, to share a lengthy review of randomised controlled trials on the subject.

Yet the physician has a duty to share fully complicated information with his patient. How is he to achieve this without carrying out an exhaustive safety analysis for every treatment decision?

One possible solution is to make more use of decision aids in practice. Canadian specialists from the University of Ottawa have come up with the concept of written patient education decision aid packages.

Take the case of a 64-year-old woman who was concerned about taking paracetemol after learning that it could cause liver damage when taken with alcohol at the high dose she required. Her conundrum was whether to change to a non-steroidal anti-inflammatory drug (NSAID) or remain on the paracetemol.

The decision aid helps her clarify the question. It invites her to consider the pros and cons of taking NSAIDs, with a score given to each. The woman then returns to her GP with the decision aid where both make a joint decision on her future treatment.

Decision aids may not appeal to all patients or their physicians. But they have been shown to be useful, especially in clarifying overall risk as well as an individual's tolerance for a particular risk factor.

An area that is crying out for good risk communication at present is the issue of MRSA infection in Irish hospitals.

The Irish Times recently published a report outlining the number of so-called superbugs detected in hospitals here in 2004. Although the overall numbers showed close to 7,000 in 30 hospitals were infected by MRSA, the report went on to clarify that this figure represented a combination of patients with actual MRSA infections (in the region of 500) with the remainder made up of patients who were "colonised" by the bug. Colonisation refers to the presence of a bacteria on the skin or in the nose, where it lives without causing any harm to the person.

Significantly, the MRSA figures were obtained under the Freedom of Information Act, rather than published by the Health Service Executive. This immediately creates the impression in the mind of the public that the data was not freely available. It then begs the question: what are the authorities trying to hide?

In fact, based on the rates of actual blood infection with MRSA, there was little difference between the previous estimate of 500 for 2004 and the actual figure obtained by The Irish Times. And while the colonisation numbers appear alarming, for the majority of people bugs such as staph aureus, whether methicillin resistant or not, live on our skins, without ever causing any illness.

But because of the vacuum of information on MRSA prevalence, health authorities can look as if they are involved in a cover-up. Not just that, but they have lost an opportunity to explain to the public the apparently high rates of MRSA infection in the bloodstream in some hospitals.

The reasons are complex, but relate to the types of disease treated, whether the hospital takes complicated referrals from other hospitals, and its bed occupancy rates, among other factors.

In fact, the individual risk of serious MRSA infection for particular patients is quite low, and is certainly less than 1 per cent. But because of a failure to communicate risk adequately, the public perception of MRSA is of a serious infection multiplying in Irish hospitals at a cumulative rate.

So what can be done to remedy the situation?

The HSE must plan and adequately fund a comprehensive surveillance system for all hospital-acquired infections. Only then will we get robust data that will allow a true comparison in MRSA rates between hospitals.

There is also a need to acknowledge our low cultural tolerance for risk and to develop our ability to communicate healthcare risk in a way that acknowledges this cultural reality.

Transparency, in the form of communication that is candid, easily understood, complete and factually accurate, will allow the public to "view" the risk assessment and decision-making processes. This is the only way to build and maintain trust.

People have a right to know what risks they face when attending a particular hospital or choosing new treatments. The health service needs to improve its methods of risk communication for this need to be met.

Dr Muiris Houston is pleased to hear from readers at mhouston@irish-times.ie but regrets he cannot answer individual queries.