Both statistics and manner matter to patients

Experts say this finding confirms that the way a physician communicates is important, but it's unclear how a doctor should say what to which patient.

By Victoria Stagg Elliott — Posted July 9, 2007

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Studies are showing what many physicians long have suspected: What a doctor says matters, and how a doctor explains information counts.

"Communication between a doctor and a patient can literally save a life," said Norman Jensen, MD, MS, president-elect of the American Academy on Communication in Healthcare.

For instance, a study in the June 19 Annals of Internal Medicine found that patients were more likely to accept a daily preventive medication if a physician explained its benefit in terms of the number of illnesses prevented rather than in the length of the time delay before developing the illness.

Researchers at Nordlys Legesenter, a health center in Alta, Norway, randomized several thousand participants in a community health survey to receive a written description of a hypothetical medication that would prevent heart attack or hip fracture. The magnitude of the effect of the situations described were equivalent.

Those who received an explanation that the drug prevented disease in a few but not all of the people who took it were more likely to consent to treatment than those who received a description that said the medication delayed the onset of illness for a short period of time in all people who took it. The first group of patients also were more likely to agree to the treatment than those told that the drug delays the illness for a greater amount of time for a smaller group of people.

"This result suggests that the description of the anticipated outcome may influence the patient's willingness to accept a recommended intervention," the authors wrote.

Experts said this study was sound, but that it was less about proving that one way of explaining statistics should be preferred over another. Rather, it demonstrated that the way data are presented is important.

"It does show the wording makes a difference, but you cannot draw any other conclusions," said Anthony Suchman, MD, an internist and consultant on relationship-centered care, based in Rochester, N.Y.

Careful communication

Patient-physician communication experts also cautioned that preferring one communication strategy over another to influence a patient's choice could be ethically questionable. An accompanying editorial advocated presenting a patient with several descriptions to reach a shared decision and avoid the possibility that a patient would feel deceived.

"Doctors need to be careful when we are presenting decision-making information," said Paul Haidet, MD, MPH, a general internist at Michael E. DeBakey Veterans Affairs Medical Center in Houston. "Our responsibility as physicians is to make the best determination of the best course of action, and our responsibility is to communicate that to patients. But we cannot stop there. The best decisions are decisions that we make together going back and forth."

There is also the question of why these different scenarios had the effect that they did. Researchers suspect that one heart attack or hip fracture prevented, even though many who took the drug did not get this benefit, was preferable to a small amount of time gained without this medical condition, albeit a benefit enjoyed by all. The possibility of winning a "big prize" had a lot of appeal.

"That makes perfect sense, because the time benefit is so short in the span of a person's life," said Dr. Haidet, who is also an assistant professor at Baylor College of Medicine.

But the results of this study also highlight the challenge of having patients truly understand to what they are consenting. These scenarios produced differing consent rates, but a large number of patients didn't understand the statistics and said they would go ahead with treatment anyway.

"Sometimes patients want to please their doctors and will agree and not let them know they don't understand," said Elizabeth Rider, MSW, MD, director of faculty development for the Institute for Professionalism and Ethical Practice at Children's Hospital, Boston.

Many experts also questioned how the specifics of this study could be generalized to real-world practice. Participants were presented with hypothetical scenarios but were not actually in a situation where they had to decide whether to take a daily medication. These scenarios also were written, and, while data increasingly are conveyed in this format, in the health care setting, the most likely means of communication would be verbal. There also are other factors that affect a patient's decision to take a preventive medication such as cost and other priorities.

Many doctors pointed out that saying the right thing to the right patient and the patient-physician relationship were far more important than finding the one right thing to say to all.

"Words matter, but that's only the beginning," said Dr. Rider, who is also the director of programs for communication skills at the Stoeckle Center for Primary Care Innovation at Massachusetts General Hospital. "This study is a good start for physicians to know that our words do matter, but they matter in relationship with a patient. And the patient's perspective about what is said to them is important, too."

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What makes patients say yes?

[download pdf]

A study in the June 19 Annals of Internal Medicine suggests that the type of statistics a physician uses to explain a drug's ability to prevent disease may affect patient willingness to consent. Researchers randomized 1,754 participants in a general community health survey to be presented one of three hypothetical scenarios about a drug that could prevent heart attacks, and another thousand to scenarios about a medication that reduced the risk of osteoporosis. Here is how the various methods of presenting the numbers compare:

Survey situation 1: If a doctor says --

"For one heart attack to be prevented, 13 patients have to take this drug for five years."
76% of patients would "certainly" or "probably" consent.
55% thought these numbers were understandable.

"The drug may not completely prevent heart attacks. It postpones heart attacks for a while, and all who take it for five years will live about two months longer before having one."
54% would "certainly" or "probably" consent.
47% thought these numbers were understandable.

"The drug may not completely prevent heart attacks. It postpones heart attacks for a while. One of four patients who take the drug for five years will live about eight months longer before having one. Others will have no benefit."
63% would "certainly" or "probably" consent.
51% thought these numbers were understandable.

Survey situation 2: If a doctor says --

"For one hip fracture to be prevented, 57 patients have to take the drug for five years."
63% of patients would "certainly" or "probably" consent.
35% thought these numbers were understandable.

"The drug may not completely prevent hip fractures. It postpones them for a while, and all who take it for five years will live 16 days longer before they have one."
29% would "certainly" or "probably" consent.
40% thought these numbers were understandable.

"The drug may not completely prevent hip fractures. It postpones them for a while. Three out of a hundred patients who take the drug for five years will live about 16 months longer before they have one. Others will have no benefit."
44% would "certainly" or "probably" consent.
39% thought these numbers were understandable.

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External links

"Different Ways to Describe the Benefits of Risk-Reducing Treatments," abstract, Annals of Internal Medicine, June 19 (link)

"Straight Talk about Disease Prevention," Annals of Internal Medicine, June 19 (link)

American Academy on Communication in Healthcare (link)

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