Human life became very controversial and speedy for the last decades. This high velocity of nowadays has numerous advantages, such as developing science and technologies. However, contemporary lifestyle brings some definite weaknesses.
One of the most serious problems of modern world is posed by the increased percentage of various risks in our life. Risk is the phenomenon that occurs rather often. Every field of human activity is exposed to risk to more or less extent. In everyday life people are always facing situations when appropriate decisions should be made concerning various risks. Of no doubt, the spheres related to medicine and health are subjected to numerous types of risks more than others. Thus, the attention paid to medicine and healthcare risks can never be too intense. Risks may appear on several major levels, such as organizational (macro-level), and individual (micro-level). In the present paper we will analyze the risks and risk-related factors on the individual level.
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One of the most significant processes related to risks is risk assessment. It is not easy to accurately evaluate the degree of risk in every particular case.
This process is essential, however, for decisions that person may take concerning risks they face. Let us illustrate the sketchy situation. The patient turns to a doctor in order to find out more about his illness and to determine an appropriate treatment. The doctor may offer several types of treatment with different effectiveness, side effects, and consequences. Who must decide what type of treatment to take? Of course the patient must decide for himself, as he is the only one who is fully responsible for his health and life. On the other hand, doctor has some serious responsibilities as well. The doctor must accurately and clearly explain what every type of treatment brings. As for every treatment program is related to different degree of various kinds of risks, the doctor must inform the patient objectively and specifically about them. When the patient chooses a treatment based on the doctor’s explanation, he makes the essential decision about his health and life. Hence, the processes of risk assessment, description and explanation are vital for the patient decision-making.
Of course medical professionals have numerous times faced the situations when they had to assess risks of patient’s decisions. Therefore, the experience of healthcare system and medicine science on this sphere is vast. The studies and theories of risk of medical intervention and patient decision-making are very useful in such situations. However, every case remains individual as for every patient is a unique person with his original story. Thus it is of great importance to provide the patient with adequate information about probable risk, to evaluate the consequences accurately, and to help the patient to make proper decision in order to make the optimal choice about his health and as a result quality of life. Let us try to consistently and carefully analyze these factors.
First of all we should determine what is risk. Various theorists determine risk differently. One of the well-known definitions of risk belongs to the Royal Society, “the probability that a particular adverse event occurs during a stated period of time, or results from particular challenge”, where risk comes from the outer world. There is also the definition of risk made by Heyman as “the projection of a degree of uncertainty about the future onto external world” (1998), where the author considers a person responsible for the risk. Another definition of the Yates describes risk as a possibility of some form of loss. To me personally the latter definition of risk is the most capacious and accurate.
To sum up all these definitions, we will have the description of risk as a probability of occurrence of some unwanted event that may lead to some form of loss and bring some degree of uncertainty about the future and the quality of life. Although this combination of different definitions of risk may seem rather cumbersome, it reflects the description of risk quite accurately. Indeed risk always is related to loss, whether it is loss of life, vision, or comfort. Still the impact of various degrees of loss may be very different from patient to patient. The perception of risk and related loss varies according to various factors.
One of the determining factors in the patient decision making process regarding risk is a patient characteristic by the role in medical decision-making. There are several categories of patients whose attitude to risk is distinct. The “deferrers” are those patients who easily accept whatever treatment the medical professionals offer to them. The “delayers” prefer to briefly analyze the options provided and then make their choice. The “deliberators” analyze all the information about risk provided, including risk assessment and probability, relevant prior experience, and other data available to make the conclusion. Therefore, one of the factors that influence the decision-making about medical risk is the category of the patient who has to choose.
There exist many other factors that affect the decision-making process of the patient considering risk. Age, intelligence, prior experience, severity of illness, and other variables play significant role as well. However even more important for patient decision-making is the approach of medical professionals (doctor, nurse, consultant, etc.) to the process of evaluating and describing risks. They must be informative, clear, but also objective. Subjective impressions about the patient may have an improper effect on the doctor’s judgement. This can lead to biased opinion and may cause potential errors.
Therefore, doctors should involve the patient in the process of risk assessment and decision-making about treatment in order to choose the optimal option.
In order to present the information about potential risks to the patient accurately doctors should consider various so-called “dimensions of risks” (Mazur & Hickam, 1997), the standpoints from which the information concerning risky intervention should be investigated. First of risk dimensions is the identification of appropriate unwanted result, the discussion of potential adverse outcomes of risky medical intervention. As long as the levels of risk may vary soundly, the outcomes of treatment may as well be different. Unwanted results may range from death (the worst outcome) to loss of sensation (moderate outcome) or a wave of nausea (minor outcome). Besides, some kinds of treatment may cause dual risks, such as either benefit or loss. Moreover, in some situations the extent of risk may be undefined or difficult to estimate. This dimension of risk is probably the most important, as for the outcome of treatment oftentimes defines the decision about it. The second dimension of risk is the permanency of unwanted result, which means whether the adverse outcome will last or disappear in some time. This factor is important as well, as for patients would rather choose a treatment that leads to temporary unwanted effect (pain, loss of mobility) than permanent one. The timing of unwanted result is the third dimension of risk that influences the patient decision about medical intervention. This factor involves a decision about a period of time when unwanted changes in life occur. Patient must decide whether have discomfort in short-term or long-term period. For instance, they may decide to have some discomfort now in order to benefit in future. The next dimension of risk is the probability of occurrence of unwanted effect. This dimension is the most controversial for the patient, as for it is rather difficult to assess risk accurately and to present it adequately to the patient. We will come back to this process later in this paper. Finally, the last dimension of risk describes how much is the outcome important for the patient. This dimension is also called the value assessment and represents the information from all the other risk dimensions projected onto the subjective perception of particular patient.
According to Slovic (1987) value assessment of risk depends on the degree of uncertainty concerning particular event. From this standpoint the treatment with unknown outcome is seldom selected by the patient, as they prefer to be aware of risk value they face. To sum up the information about risk dimensions, I want to mention that it is sometimes useful to break risk of medical intervention to several parts. For instance risks for treatment may be separated to risk for anesthesia, risk for surgical operation, risk for medication course, and so on.
In the process of decision-making about particular treatment risk it is very important to consider all factors. The decision-making process of the patient involves numerous psychological factors that influence the final decision. As in any communicative process, various characteristics play significant roles, like verbal and non-verbal communication, atmosphere, gestures and body language, and the presentation of information. Hence, in order to help the patient to come to the right decision it is essential to present the information properly. This may be rather difficult as for people perceive the information differently. As we already mentioned, risk is probability of loss. Therefore, the problem may lie in the way the probability is illustrated. There exist several approaches for presenting the information about value of risk to the patient.
The most popular presentations of probability are quantitative (3 of 10, 30%), qualitative (very seldom, often), and combined. When drawing a quantitative presentation, there are several methods to choose from, such as natural frequency (12 of 67), probability (2 of 10), or percentage (18%). Although the same number or relation represented in different ways does not change its mathematical meaning, it may be perceived differently by different people. For instance statistical information presented in natural frequency is easier to understand (Hoffrage, 2000) than the same information presented in regular probability form. Thus, medical professionals should consider appropriate presentation of risk assessment before providing information to patients.
Nevertheless it is not only the presentation of risk value that affects the patient decision about treatment. It is of great importance to the doctor to assess the risk properly and avoid under- or overestimating. Very frequently the risk value (the probability of occurrence of unwanted outcome) appears relatively small.
This may lead the patient to improper perception of potential risk. For example, if the risk probability is 1 of 40 and the patient faces the patient on next bed having the same unwanted outcome, then he may decide that this “1 of 40 cases” already happened to his neighbor and will not affect himself. Such perception “it will not happen to me” is unfortunately rather common. Therefore, it is of great importance to explain to the patient that the probability of occurrence of negative outcome is the same for every particular case, and other patients suffering from unwanted event will never reduce the risk. It is necessary to avoid the situation when the patient may misunderstand the information and underestimate the potential risk of treatment.
The psychological processes that occur when the person makes decision play significant role in the resulted conclusion. Therefore, it is useful to look at the psychological theory of heuristics, or rules of thumb (Tversky & Kahneman, 1974), that may help understand psychology of patient making decision about medical treatment. Representativeness refers to the approach when the probability is illustrated through the degree of which one event is representative to another. This heuristic may be not relevant, as for factual and statistical information is not considered her, hence the patient may make improper judgement about risk probability. For example, if event A is loss of vision and event B is stomach ulcer, than a person may think that A is not representative of B and possibility of A caused by B is low. Such approach may lead the patient to underestimating risk and making biased decision. The second psychological process while making risk-based decisions refers to availability of information about unwanted effect. This heuristic is also very important to consider, as prior knowledge and experience of the patient about particular treatment may lead him to biased decision. For instance, if the person knows somebody who took the same treatment and had positive effect, he would rather choose this treatment regardless of potential risks. On the other hand, the patient may overestimate risk if he knows somebody who had negative outcome following the same treatment. Imaginability is another availability heuristic that influences the patient risk-based decision. If a treatment is associated with some negative effect (for instance through television program), the patient will rather decline this treatment, and vice versa. The last availability heuristic is illusory correlation. It means that a person may incorrectly consider one event to be related to another event, which may also cause biased decision. Finally the third heuristic involved in the decision-making process of a patient about risk is anchoring. It means evaluating particular risk from the standpoint of another risk. In this case the patient again may mistake dramatically, as for two different risk are not always connected. Thinking about value assessment of one risk in terms of another risk may lead to dangerous errors, because the patient may not recognize the distinction between two risks and make biased decision. Therefore, it is extremely important that the doctors should provide adequate information about risk assessment in order to avoid biased decision of the patient described above.
There is another important theory in risk decision-making suggested by Tversky and Kahneman (1981). They discovered that the patient subconsciously reacts to the mode of risk value presentation. This reaction was called framing. During framing, the patient responses to the presented information differently, depending on the form of presentation. This theory demonstrated that individuals might subconsciously change their decision about treatment depending on the mode of risk assessment information that was presented to them. Moreover, Bogardus (1999) found that the patient perceives the same information differently if it is presented according to his preferences. For instance, when talking about the risk value “1 negative outcome of 20 cases”, for some patients it will be more convenient if information is presented as “19 positive outcomes out of 20”.
Besides, some patients would prefer the same information to be represented as “5 out of 100” or “5%” negative outcomes. Depending on their preferences, patients may perceive the same information differently, which can either reduce or increase the probability of choosing particular treatment. Therefore, these theories should be considered when providing the patient with risk assessment information in order to avoid biased decision.
The number of various processes that occur while making decision about risk is enormous. It is of great importance to consider all of them when talking to the patient about risky medical intervention. As long as psychological processes play one of the most significant roles in decision-making, psychological theories may appear very useful and helpful. According to psychological studies described in this paper, the complex process of making risk-based decision the patient undergoes involves numerous important factors. Therefore, the medical professional should be aware of all the possible difficulties connected to them.
When the patient makes the decision about future treatment, it affects his health and as the result quality of life. Hence, doctor’s responsibility is to provide the patient with accurate information about risk value in order to help making important unbiased decision.
Bibliography
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Holmes-Rovner, M. & Rovner, D. (2000). Measuring improved patient choice. Journal of Evaluation in Medical Practice, 6.
Hoffrage, U. & Lindsey, S. (2000). Communicating statistical information. Science, 290.
Wills, T. (1981). Downward comparison principles in social psychology. Psychological Bulletin, 97.
Perloff, L. (1983). Perceptions of vulnerability to victimization. Journal of Social Issues, 39.
Tversky, A. & Kahneman, D. (1974). Judgement under uncertainty: heuristics and biases. Science, 185.
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