How can physicians better understand and communicate the risks associated with medications and treatments?
Dr. Schwarzenberger is the physician editor of DermWorld. She interviews the author of a recent study each month.
By Kathryn Schwarzenberger, MD, FAAD, January 1, 2024
In this month’s Clinical Applications column, DermWorld Physician Editor Kathryn Schwarzenberger, MD, FAAD, talks with John E. Harris, MD, PhD, FAAD, about his JAAD paper, ‘Assessing risk amid uncertainty inside and outside the dermatology clinic.’
DermWorld: Thank you for your thought-provoking research letter on perceptions of risk. For those who may not have read your article, can you offer a summary of your letter?
Dr. Harris: We wanted to discuss the need for dermatologists and other physicians to both understand risks associated with medications and other medical decisions that we make in the clinic, as well as to communicate these risks with patients. To do this, we put known medical risks in the context of other everyday risks that we encounter, such as the annual risk of death in a car crash, choking on food, bee sting, in an earthquake, or while riding a bicycle. We provided a handy figure comparing the risks that can be shared directly with patients to make this communication easier.
DermWorld: Why take on risk? What made you think of writing this article?
Dr. Harris: We tend to overestimate small risks when it comes to potentially catastrophic outcomes, such as dying in a plane crash or from a terrorist attack. This is also the case when prescribing (as a physician) or being prescribed (as a patient) medications, such as the dermatologist’s bias against Bactrim as an antibiotic, because we are most frequently called when this medication causes SJS/TEN. I have had conversations with patients in the past about taking systemic steroids to treat alopecia areata or taking terbinafine to treat nail fungus. When reviewing the risks of these medications, such as avascular necrosis for steroids or liver toxicity with terbinafine, patients would often comment, ‘It isn’t worth breaking my hip to regrow my hair,’ or ‘…losing my liver for better-looking toenails.’ But then I realized that they had taken a significant risk just driving in their car to see me for their appointment for these issues and thought that I needed to find a way to better put the risks into context. My goal is to never talk someone into taking a medicine for their condition, but rather to help them understand better so that they can make informed decisions about their health.
DermWorld: Were you surprised by any of your observations?
Dr. Harris: No, I wasn’t. I guess I had thought a lot about risks in the past even outside of medicine, and I realized that we make daily decisions about risk and don’t even realize it. We find it acceptable to risk death in order to enjoy a bike ride or sometimes jump out of a plane for fun, as well as injury in order to play basketball with our friends. But then sometimes we avoid things like flying in a plane, despite the convenience of travel, because of a very low risk of dying in a crash.
DermWorld: Is it fair to compare medication risks to unrelated risks, such as a motor vehicle accident? Is there a risk of confusing our patients with these comparisons?
Dr. Harris: I am fond of using allegory and other common comparisons when counseling patients. I believe they better connect when medical discussions are put into context of something familiar that they understand. So, I often compare our immune system to a military, when discussing its role in protecting us from infection or cancer, balanced with its role in driving inflammation or autoimmune disease. I don’t find comparing medical risks with everyday risks confusing for patients at all, but on the contrary, it appears to simplify the concept so that patients and their doctors can grasp these difficult concepts and make more educated decisions. Without a familiar metric like everyday risks, it is very difficult to understand the very unfamiliar risks of medical decisions. It is even harder to explain risks of NOT taking action, such as not taking a medicine to avoid long-term risks like heart disease from high blood pressure or even from uncontrolled psoriasis.
DermWorld: Do you think most physicians appreciate these relative risks themselves? You cited a study that shows that physicians overestimate treatment side effects. Could this be part of the problem?
Dr. Harris: I don't think so. In fact I think we as physicians are just as bad at putting medical risks into context as our patients, so sometimes it is the blind leading the blind. That is part of the problem, and it is why we wanted to write this article.
DermWorld: Has doing this study impacted how you and your fellow authors interact with patients?
Dr. Harris: I have been using this approach for many years with my patients and recognized that it was very helpful for them and enabled them to make more educated decisions about their disease management. So, it was more my experiences counseling patients that drove why we wrote the article. And it was fun!
John E. Harris, MD, PhD, FAAD, is professor and chair of the Department of Dermatology, founding director of the Vitiligo Clinic and Research Center, and founding director of the Autoimmune Therapeutics Institute at UMass Chan Medical School. His paper appeared in JAAD. Dr. Harris has no relevant financial and/or commercial conflicts of interest.
Disclaimer: The views and opinions expressed in this article do not necessarily reflect those of DermWorld.
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