The need for doctors to have proficient communication skills is well recognised,¹ but teaching students how to communicate risk to patients seems to have received little attention in the undergraduate medical curriculum. Primarily, it is statisticians who teach the concept of probability. This ultimately translates into the communication of risk that informs the clinical consultation. Although students need to appreciate the basics of statistical methods and know the different ways to convey risk,² it is particularly important that they have the opportunity to practise these skills under safe conditions and receive constructive feedback.^{1 3}

The recently established graduate entry programme at St George's Hospital Medical School, London, has an integrated curriculum across all years.⁴ The course is delivered by using problem based learning whereby students use triggers from a problem case or scenario to identify their own learning issues.⁵ It has been suggested that students are more motivated by such an approach, where the practical problems they experience act as a stimulus for learning.⁶ Despite the best efforts of teachers, however, students tend to see medical statistics as inherently mathematical and irrelevant.⁷ Within the graduate entry programme integrating the teaching of medical statistics with communication skills has enabled students to see the relevance of medical statistics, in particular the need to communicate risk effectively to patients.

Various techniques can be used to raise students' awareness about the problems that may occur when communicating risk, not only for the patient but also the doctor. Qualitative expressions of probability, such as "unlikely," "a chance," "occasionally," and "probably" are used all the time in clinical medicine to describe risk. A useful approach is to ask students individually to rate such expressions as a numerical proportion,⁸ placed in relation to an event occurring, such as a child being born with Down's syndrome. The results of this exercise enable students to compare their own interpretations with those of their peers. Typically, the interpretation varies widely,⁹ and some students find it impossible to ascribe a single value to a qualitative expression of probability. Ideally, this awareness raising exercise encourages students to think carefully about how their patients might interpret such descriptive statements of probability, and clarify if necessary.

Role playing consultations between patient and doctor plus small group discussions play a valuable part in the students' general education.¹⁰ These teaching methods develop the skills of listening, presenting ideas, decision making, and working as part of a team. They help the student appreciate that one of the biggest problems that clinicians face is how to interpret results from epidemiological studies or clinical trials in ways that have meaning to the individual patient sitting in front of them. The patient will either develop a disease or not, and it is not obvious how the patient's view of their outcome is altered by any risk the clinician ascribes. After feedback the key message that students take away is to tailor information to what the patient wishes to know and to verify his or her understanding.

Most risks given are approximate.

Sources:

• Calman K, Royston G. Risk language and dialects. BMJ 1997;315:939-42.
• Adams A, Smith A. Risk perception and communication: recent developments and implications for anaesthesia.Anaesthesia 2001;56:745-55.
• Best Treatments (www.besttreatments.org).

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