“IT'S LIKE JAYWALKING ACROSS A BUSY STREET WITH YOUR EYES CLOSED, YOU'RE TAKING A CHANCE”: RISK COMMUNICATION AND VALUES CLARIFICATION IN A RADIATION ONCOLOGY CLINIC
Candidate for the Lee B. Lusted Student Prize Competition
Methods: During 4 weeks in 2013, we invited a convenience sample of clinicians and patients in a radiation oncology clinic to participate in a mixed methods study. Prior to consultations, clinicians and patients completed self-administered questionnaires to assess their subjective numeracy and decision-making style preferences. We audio-recorded consultations, transcribed them verbatim, and conducted qualitative content analysis using a combined inductive and deductive approach with triangulation of researchers. Patients also completed a questionnaire immediately post-consultation to report their recall of risks discussed and their perceptions of the consultations.
Results: Of those invited, 29/30 clinicians (97%) and 40/46 patients (87%) participated. Clinicians included 11 radiation oncologists, 4 residents, and 14 nurses. Patients were 22 men, 18 women, mean age 64 (range 41-78), 22/39 (56%) with no postsecondary degree. Patients had a variety of cancers; 12/40 (30%) had been referred for palliative (not curative) radiotherapy.
During consultations (mean length 45 minutes, SD 16), clinicians presented a mean of 8.3 risks (SD 3.8), using verbal labels alone 83% of the time (e.g., “very rare”), verbal labels with numbers 16% of the time, and numbers alone 1% of the time. They used diverse strategies to convey the inherent uncertainty in medical evidence. Patients recalled significantly fewer risks than clinicians presented (mean recall 2.1, SD 1.8, t=9.29, p<.001). Better recall was associated with higher patient numeracy (F(1,31)=6.75, p=.01) and having risks repeated by a nurse (F(1,31)=6.24, p=.02).
Clinicians and patients indicated preferences for shared decision-making, and patient-reported scores of shared decision-making during the consultations were high (median 49 out of possible 54). Yet 17/39 patients (42%) reported that they had not been asked what was important to them. Indeed, while discussions of risks and benefits were largely initiated by clinicians, discussions of values were largely initiated by patients or their families (Chi-squared(1)=37.8, p<.001).
Conclusions: Clinicians use diverse strategies to communicate risks; these may not meaningfully inform patients. Furthermore, a substantial proportion of patients are not asked about what is important to them. Better strategies must be implemented to help patients understand and retain information about risks and benefits, clarify and integrate their values into the decision-making process, and thus make informed decisions about their health.