When the times get rough, you can ease your patients' minds

As front-line health communicators, primary care physicians can help patients keep frightening news stories in perspective and put risks of life today into context.

By Susan J. Landers, amednews staff. March 24/31, 2003.

Washington -- Think West Nile virus, terrorist attacks with lethal biological or chemical agents, antibiotic resistance.

These dangers are looming in patients' minds, and the need to address them is layered on top of physicians' existing responsibility to educate and advise about well-known health risks.

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It's a daunting challenge. And for physicians, meeting it is absorbing more of every office visit. But public health experts say there are common methods that can help tackle these tasks. And taking advantage of them can ease the pressure for both doctor and patient.

Former Surgeon General David Satcher, MD, is quick to underscore one of the first, most basic elements of risk communication: "Understand your audience. Understand their levels of concern and anxieties."

And it is important to keep in mind that patients' responses are triggered by what they are seeing and hearing from other sources. It makes critical the doctors' charge of putting information in context. It is also important to quantify those rare risks that have seized the patient's imagination, said David Weber, MD, professor of medicine/pediatrics and epidemiology at the University of North Carolina-Chapel Hill. Explain, for example, "The risk of contracting anthrax is on the order of being eaten by a shark."

Most patients will calm down when the risk is put into perspective. But people tend to "overperceive" rare risks and to "underperceive" common risks, Dr. Weber said. While the example of the safety of air travel compared with travel by car is well-known, he added, many people who are afraid to fly won't put on a seat belt for a drive to the store.

People tend to overestimate the possibility of rare risks and underestimate common risks.

When it comes to communicating messages related to everyday public health problems, AMA Trustee Ronald Davis, MD, offered additional tips.

First, "avoid jargon," advised Dr. Davis, who has long worked on smoking cessation issues. Rather than telling male smokers: "In epidemiological terms your relative risk for dying of lung cancer is 22," tell them, "You have a 22 times increased risk of dying from lung cancer compared to someone who has never smoked." And make the numbers real. For example, instead of saying "More than 400,000 Americans are killed by smoking each year," say, "More people die from smoking each year than die from homicide, suicide, alcohol, cocaine, heroin, motor vehicle accidents and AIDS combined."

People also accept voluntary risk much more readily than involuntary risk, pointed out Dr. Davis. "They tend to ignore or rationalize their own risky behaviors like smoking or not wearing a seat belt, but an involuntary risk like a little bit of lead in the soil or pollution in the air will make them think they are in grave danger."

Context is also key in helping patients understand risks when frightening stories -- such as the threat of smallpox and the possible risk of the vaccine -- become commonplace. Jonathan Fielding, MD, MPH, director of Los Angeles County's Dept. of Health Services, said that after doing some checking he found that an individual's commute to work can be much riskier than is receiving a smallpox vaccine.

It can also be helpful to give patients actions to take to be more in control. "Tell people what they can do to reduce their risk and improve their situations," explained Dr. Fielding. For example, advise them to assemble an emergency kit with sufficient water, food and medications for three days. "That's a positive step."

The trusted face

Beyond the office visit, on the macro level, recent experiences underscore ways to maximize communication with patients.

Jean Malecki, MD, MPH, director of the Palm Beach County, Fla. Health Dept., has some advice on what not to do -- especially in situations that involve significant levels of fear among the public. Dr. Malecki was the face the people saw when the county's risk-communication program moved into high gear after the first case of anthrax occurred in Palm Beach County in October 2001.

Commuting to work is riskier than receiving a smallpox vaccination.

However, shortly after the federal government took charge of the investigation, the local-level communicators were no longer in evidence. "From a risk-communication standpoint, removing the trusted face from the camera and replacing it with people who did not know what was going on was not of value at all," she said. Panic and distrust developed. "The local people who begin the investigation and are involved in it and are leading it should always be a part of the risk-communication strategies."

While there was a decided need for security then, Dr. Malecki maintains that a criminal investigation led by federal authorities could have been carried out alongside a locally led risk-communication campaign.

To avoid such missteps in the future, the Centers for Disease Control and Prevention has put together a Crisis and Emergency Risk Communication Training Program that is intended for use during any "intense public health emergency."

The agency is now taking its program on the road to state health departments and has exported it to Canada where it is being taught to physicians and other health care practitioners and communicators.

The course is as relevant to primary care physicians as it is to representatives of public health departments. "Often family physicians will be the first line of defense on some of this communication," said Barbara Reynolds, a CDC crisis and risk-communication specialist.

Physicians already communicate risks

Although the course considers risk communication in the pressure-cooker atmosphere of a crisis, "it's the same type of communication physicians may be doing automatically and might not even realize it," Reynolds said.

Among the most important elements of the course: Build trust and credibility by expressing empathy and caring, competence and expertise; don't overreassure; acknowledge uncertainty; and tell the truth.

Physicians are the most trusted sources of information about health crises.

Research has shown over and over again that physicians are the most trusted sources of information regarding health crises. Whether communicating to a single patient or to the larger public, physicians have credibility, said Jeffrey Levi, PhD, associate research professor at George Washington University in St. Louis.

"Having the Secretary of Health and Human Services, however well-meaning and decent a person he may be, trying to articulate levels of risk just doesn't carry the same weight as someone who has established some credibility as a straight-shooting scientist," said Dr. Levi.

As far as communicating to individual patients, "medical history has a huge impact on what should or should not be done," said Dr. Levi.

Many physicians have patients fill out a detailed health history, noted Dr. Weber. They are asked where they live, what they do, whether they drink alcohol or smoke, exercises they do, sports or hobbies. The health inventory becomes a part of a patient's record and allows the physician to focus on relevant risks, said Dr. Weber.

To reinforce a message, Dr. Weber recommends that, at the conclusion of a visit, a physician ask a patient to "repeat back to me what I just said."

"Patients don't mind," he said, "They expect to get lectured when they go to see their doctors."