Use of standard terms is unlikely to result in standard communication

EDITOR,—Kenneth C Calman proposes a language of risk that seeks to introduce standardisation into our communication with patients about risks.1 The debate that he calls for must address three fundamental issues. Firstly, is it feasible or theoretically justifiable to translate estimates of risk derived from populations to individuals? Secondly, does current communication about risks meet patients' requirements and is it relevant to them? Thirdly, if we continue with a pragmatic approach to communication about risk, developing it in terms of language, how is this best manifested in practice?

Understanding of risk differs among epidemiologists, clinicians, and lay people. In epidemiology, risk expresses as a statistical measure the association between a characteristic and a disease in a defined population. Tension exists, however, between this perspective, which derives most closely from the “frequentist” interpretation of probability, and the lay perspective.2 The lay perspective corresponds with the “subjectivist” interpretation of probability, reflecting the context and our expectations and observations of events.2

Clinicians may view themselves as trying to mediate between these two, using epidemiological data about groups to help individual decision making in practice. But communication about clinical risks is not straightforward, which perhaps suggests that estimates of risk derived from populations are unhelpful in the individual setting (as the subjectivist perspective holds) and that current practice in communicating risks fails to meet patients' needs. People often have an “all or nothing” perspective of harm or risk (and may therefore, for example, continue to smoke, or not take any risk with a new drug or an operation), showing that epidemiologically derived estimates of risk are often irrelevant to them.3

We still need to know more about what information about risks patients require. Perhaps our language for communicating risks should not be complicated by the uncertainty of applying population estimates to individuals, or perhaps we should continue to bridge this gap from population to individual. This is where a consistent and standardised language could help, but we must address other aspects too. Use of standard terms in the assessment of risk is unlikely to result in standard communication because the interpretation of the language of risks by patients and doctors varies4 5 and because of other contributions to the communication process: non-verbal elements, mental images, past experiences, and discussion about the meaning of risk to individuals. Standard terms would have to be sufficiently flexible to accommodate these contributions. Research to improve communication about risks may need to consider innovation in all these areas and identify whether patient oriented outcome measures are improved by the new processes.