Risks
Joyousd1
Richter.pdf
RESEARCH ARTICLE
A qualitative exploration of clinicians’
strategies to communicate risks to patients in
the complex reality of clinical practice
Romy RichterID 1*, Esther Giroldi1,2, Jesse Jansen1, Trudy van der Weijden1
1 Department of Family Medicine, School Care and Public Health Research Institute (CAPHRI), Faculty of
Health Medicine and Life Sciences (FHML), Maastricht University, Maastricht, Limburg, Netherlands,
2 Department of Educational Development and Research, School of Health Professions Education (SHE),
Faculty of Health Medicine and Life Sciences (FHML), Maastricht University, Maastricht, Limburg,
Netherlands
Abstract
Background
Risk communication, situated in the model of shared decision making (SDM), is an essential
element in daily clinical practice. The scientific literature makes a number of generic recom-
mendations. Yet the application of risk communication remains a challenge in patient-clini-
cian encounters. How clinicians actually communicate risk during consultations is not well
understood. We aimed to explore the risk communication strategies used by clinicians and
extract narratives and visualizations of those strategies to help inform medical education.
Methods
In this qualitative descriptive study, we interviewed fifteen purposely sampled clinicians from
several medical disciplines, who were familiar with the concept of SDM. Deductive and
inductive content analysis was used during an iterative data collection and analyses
process.
Results
Our study identified various strategies reported to be used by clinicians to address the com-
plexities of risk communication such as dealing with uncertainty. These included verbal,
numerical and visual risk communication and framing. Clinicians were familiar with recom-
mended risk formats such as natural frequencies and population pictograms. However, it
became clear that clinicians’ expertise and communication goals also play an important role
in the risk talk. Clinicians try to lay a foundation for balanced decision-making and to incorpo-
rate patient preferences while faced with several challenges such as the dilemma of raising
awareness but triggering anxiety or fan fear in patients. Consequently, they also use com-
munication goals such as influencing mindset and reassuring patients. Additionally, clini-
cians frequently have to account for the illusion of certainty in the risk talk.
PLOS ONE
PLOS ONE | https://doi.org/10.1371/journal.pone.0236751 August 13, 2020 1 / 22
a1111111111
a1111111111
a1111111111
a1111111111
a1111111111
OPEN ACCESS
Citation: Richter R, Giroldi E, Jansen J, van der
Weijden T (2020) A qualitative exploration of
clinicians’ strategies to communicate risks to
patients in the complex reality of clinical practice.
PLoS ONE 15(8): e0236751. https://doi.org/
10.1371/journal.pone.0236751
Editor: Andrew Soundy, University of Birmingham,
UNITED KINGDOM
Received: March 4, 2020
Accepted: July 13, 2020
Published: August 13, 2020
Peer Review History: PLOS recognizes the
benefits of transparency in the peer review
process; therefore, we enable the publication of
all of the content of peer review and author
responses alongside final, published articles. The
editorial history of this article is available here:
https://doi.org/10.1371/journal.pone.0236751
Copyright: © 2020 Richter et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the manuscript and its supporting
Information files. Due to ethical restrictions on
sharing data which contain potentially personally
Conclusion
Risk communication is a multi-faceted construct that cannot be dealt with in isolation from
the clinical context. For future research we recommend considering a more practical frame-
work within the clinical setting and to take a goal-directed approach into account when inves-
tigating and teaching the topic. The patient perspective should also be addressed in further
research.
Background
Modern healthcare faces the shift from the paternalistic model of doctor-patient communica-
tion (“doctors know best”) to a model of shared decision making (SDM) based on sharing
information and incorporating patient preferences and values into decision-making [1–4].
The latter concept is based on an iterative approach comprising three phases: team talk, option
talk and decision talk. The communication of risks and benefits (risk communication) is an
essential part of the option talk in which various screening, diagnostic, treatment or palliative
alternatives are compared [2,4–9].
In recent years, the focus has increasingly been on the varying formats and methods of
communicating risks to patients in an effective way [10–12]. It has been established that cer-
tain risk formats affect the perception of risk and subsequent decisions [13–18]. Broadly speak-
ing, three formats of communicating risk can be distinguished: verbal, numerical and
graphical. Verbal risk communication refers to the use of descriptive labels such as “high risk”
or “low risk”. This qualitative description of risks leaves room for interpretation and thus leads
to ambiguity of definition [19,20]. Consequently, a growing body of scientific evidence points
to the communication of risk in numerical terms. Numerical formats include percentages, e.g.
20% probability of a heart attack, and natural frequencies, e.g. 20 in 100 cases. Natural frequen-
cies seem to be easier to understand than percentages [6,10,21,22]. Notwithstanding the grow-
ing supportive body of evidence for numeric risk communication formats, risk
communication faces challenges. Numerical health illiteracy has been shown in patients, and
also in many clinicians [10,12,21,23,24]. In recent years, a number of researchers have
addressed the graphical display of risks by methods such as population pictographs (icon
arrays), bar charts and risk ladders [5,25–28]. While pictograms have been proven useful in
clinical conversations [20,29,30], however, overall the understanding of graphical risk presen-
tation remains unclear [31,32].
Risk information can be given in a number of ways; this is known as framing [12,33]. Risk
messages can be framed in terms of gain versus loss (goal framing). For instance, taking a medi-
cation will increase the chance of not getting a disease versus not taking the medication will
increase the chance of getting the disease. Another approach is to describe the information in
terms of positive versus negative framing (attribute framing), e.g. a patient can either be told
there is an 80% chance of survival or a 20% chance of dying [12,33,34]. Choice of framing influ-
ences the perception of risks and hence the decision made during a clinical consultation [15].
An inherent part of risk communication is uncertainty, which can take multiple forms. A
number of frameworks have classified uncertainty [35,36], however, there is still no consensus
on a uniform categorization of uncertainty [12,37,38]. Looking at the judgement and decision-
making literature, two dimensions of uncertainty are often distinguished: aleatoric and episte-
mic. Aleatoric uncertainty refers to the natural randomness in a process (stochastic uncer-
tainty). Each time an experiment is conducted under similar conditions, the outcome may
PLOS ONE Clinicians’ risk communication strategies in daily clinical practice
PLOS ONE | https://doi.org/10.1371/journal.pone.0236751 August 13, 2020 2 / 22
identifiable information, the transcribed interviews
are available on request.
Funding: The author(s) received no specific
funding for this work.
Competing interests: The authors have declared
that no competing interests exist.
differ. Epistemic uncertainty results from limited data and knowledge of a fact (that is either
true or not true) [39]. Humans in general, thus patients and doctors, are faced with the illusion
of certainty in daily and clinical life. A clear presentation of uncertainty seems to be one of the
most difficult parts of communicating risks [12,37]. Presentation formats can vary from verbal
to numerical or visual. The effect of communicating uncertainty has not been well studied,
hence it is unclear what types of uncertainty should be communicated and to what extent
[38,40]. Efficient ways to communicate uncertainty are still under debate and there is little
guidance on best practice approaches [12,37,38].
Despite theoretical insights into recommendations for preferred risk communication for-
mats [10,12,21,34,41,42], risk communication remains a major challenge [9,12,21,23]. The var-
ious medical disciplines with their different contexts demand clinicians to nuance the risk talk
sensitively to specific aspects of their discipline. For example, in clinical genetics risk commu-
nication needs to address predictive testing such as the small chance of getting a false positive
test result or the small chance of miscarriage in invasive testing [43]. Thus, clinical geneticists
often have to deal with communicating small and difficult to imagine risks that could have a
great impact in the future of the patient. General practitioners often counsel the patient for
more general problems in the present, while doctor and patient usually have a closer and con-
tinuous relationship with repetitive opportunities for a dialogue and reassurance of the patient.
Whereas surgeons often have to communicate the side effects and consequences of severe sur-
gical procedures under time pressure while having seen the patient one or two times in the
hospital. On the other hand, oncologists often have to consider the communication of over-
treatment and overdiagnosis when discussing screening and treatment options, especially
when dealing with frail elderly patients. Undoubtedly, risk communication is a core skill for
clinical counsellors in various medical disciplines. However, as far as we know, the literature
mainly provides formalistic or standardized language on written communication of numerical
and visual risk communication formats and lacks practical and illustrative examples of how to
communicate risks to patients in daily clinical practice. Research emphasizes that trainees are
in need of concrete illustrations of meaningful language and graphical examples in order to
acquire complex communication skills [44,45]. The provision of illustrative risk communica-
tion strategies in the SDM concept could support educational training programs. Altogether,
this points to a potential gap between theoretical recommendations in literature and ease of
application in clinical practice.
The aim is to add to the existing literature on risk communication by gaining a deeper
understanding of the clinician’s actual strategies in communicating risk in daily clinical prac-
tice. A comprehensive insight into the best practice approaches of a sample of clinicians who
have experience of, or are at least familiar with, the concept of SDM, may provide valuable
examples of real life risk communication strategies, which could support trainees in the pro-
cess of acquiring SDM skills [44]. In line with Lingard´s theory on communities of expertise,
we took the view that as members of a community, clinicians have developed a certain profes-
sional expertise on how to communicate risk to patients [46,47]. To promote the development
of risk communication training for trainees, we explored the strategies used by clinicians to
communicate risk to patients and aimed to extract illustrative examples (narratives) and visu-
alizations of these strategies.
Methods
Study design
We conducted a qualitative descriptive study with semi-structured interviews. We took the
ontological orientation of relativism, which holds the view that multiple subjective realities
PLOS ONE Clinicians’ risk communication strategies in daily clinical practice
PLOS ONE | https://doi.org/10.1371/journal.pone.0236751 August 13, 2020 3 / 22
exist. Consequently, we chose the epistemological orientation of subjectivism referring to the
existence of many interpretations of reality, and to clinicians’ risk communication strategies
being subjectively developed in relation to the clinical situation [48]. The consolidated criteria
for reporting qualitative research (COREQ) has been used to guide reporting of the research
[49].
Ethical approval and informed consent
The NVMO Ethical Review Board granted approval for our study. Clinicians were informed
about the study via e-mail. In this e-mail the research was described, and the goal was stated,
and the clinicians were asked whether they like to participate in a qualitative interview. Subse-
quently, clinicians gave written informed consent (via e-mail) whether they were willing to
participate. Further, verbal consent was obtained before the start of the interview, just before
the audiotape had been started. Verbal informed consent was given for audiotaping and using
the data for publication in a scientific journal. Verbatim transcripts of the recorded interviews
were anonymized with codes.
Conceptual framework
Risk communication is defined as: “The open, two-way exchange of information and opinion
about risk, leading to a better understanding of the risk in question, and promoting better
(clinical) decisions about management” [34,50]. We sited risk communication as the so-called
“risk talk” within the option talk in accordance with one of the models of SDM [2,9]. In order
to display a theoretical foundation and establish the current state of knowledge regarding risk
communication strategies [10,12,34,41] a deductive conceptual framework based on a litera-
ture review was generated (Fig 1). This framework steadily guided the data collection and anal-
ysis process. Other risk communication strategies, clinician goals, content and contextual
Fig 1. Framework Risk Communication (RC). AR(R) = Absolute Risk (Reduction), RR(R) = Relative Risk
(Reduction), NNT = Number Needed to Treat.
https://doi.org/10.1371/journal.pone.0236751.g001
PLOS ONE Clinicians’ risk communication strategies in daily clinical practice
PLOS ONE | https://doi.org/10.1371/journal.pone.0236751 August 13, 2020 4 / 22
factors (patient, clinician, consultation) and challenges of risk communication were captured
during the data collection process using an inductive approach. Subsequently, we created a
new framework with the aim of reflecting the complexity of risk communication in daily clini-
cal practice (Fig 2, Results section).
Study population and sampling strategy
We used convenience sampling facilitated by the research team’s network in Germany and the
Netherlands to identify clinicians who were (a) experienced or at least familiar with the con-
cept of SDM, and (b) known to regularly need to communicate risks to their patients. In order
to obtain a broad spectrum of perspectives, sampling was based on gender, age, experience
and clinical field (general practice, gynecology, nephrology, neurology, genetics, surgery and
orthopedics) [51]. We invited 16 clinicians via e-mail, one of whom declined due to lack of
time. The final sample consisted of 15 experts. Sampling was part of the iterative process of
data collection and analysis and was stopped once data saturation was reached.
Data collection method
The primary female researcher (RR) carried out semi-structured qualitative interviews [52] at
a location preferred by the interviewee. The participants were not known to the primary re-
searcher (RR). Based on the literature review, a semi-structured interview guide (S1 Appendix)
Fig 2. Framework clinicians’ communication goals and challenges in Risk Communication (RC) and influencing Contextual Factors (CF).
https://doi.org/10.1371/journal.pone.0236751.g002
PLOS ONE Clinicians’ risk communication strategies in daily clinical practice
PLOS ONE | https://doi.org/10.1371/journal.pone.0236751 August 13, 2020 5 / 22
with open-ended questions was developed. In the introduction section of the interview partici-
pants were again informed about the goal of the research and consequently asked whether they
would like to participate (S1 Appendix). Verbal consent was obtained in the interview session
just before the audiotape was started. A pilot interview was conducted to test the preliminary
interview guide [52]. Firstly, background information about the professional role was obtained.
Interviewees were asked to give their definition of risk communication. Initially interviewees
were asked to illustrate their risk communication strategies using pre-existing cardiovascular
disease (CVD) or oncology patient cases. After two interviews it became obvious that the best
approach to reveal authentic strategies was induced through self-chosen patient cases. Ques-
tions were posed according to the five risk communication categories (Fig 1). Insight accrued
during the course of data collection led to minor adjustments in the interview guide.
Data analysis
All interviews were audiotaped and transcribed verbatim. Additionally, drawings made by
interviewees were added to the transcript. We started with a deductive content analysis to
gather risk communication strategies according to the categories described in the framework.
Collaterally, the inductive approach was used to capture and group new aspects concerning cli-
nician goals, challenges and dilemmas, risk communication strategies and content and con-
text-related factors with no preconceived ideas [53]. Text fragments were coded in the
software program QUIRKOS. During the data analysis process a schematic table presenting an
overview of risk communication strategies with illustrative example sentences (narratives) and
influencing contextual factors was created. Risk communication narratives were defined as
illustrative example sentences that were used in the consultation room. Two researchers (RR
and EG or TW) independently analyzed the transcripts. Their backgrounds are PhD (EG) and
MA (RR) in health sciences and PhD in medicine (TW). The researchers reached consensus
on the coding through discussion. Detailed information on the analysis can be found in the
AUDIT trail (S4 Appendix).
Techniques to enhance trustworthiness
The data collection was constantly driven by the research question. The theoretical framework
based on the literature review was critically verified, reflected upon and adjusted. Diversity
and richness of data was enhanced by including participants from a range of clinician back-
grounds. A pilot interview verified the relevance of content of the preliminary interview guide
and revealed the need for reformulation and adjustment. The semi-structured interview guide
comprising broad questions left enough latitude for the interviewee to answer [52]. The itera-
tive process of data collection and analysis allowed the researcher to steadily inform data col-
lection by refining the focus in subsequent interviews. Moreover, re-examining the data in the
iterative data analysis led to a continuous meaning making. A member check enabled the par-
ticipants to comment on the interview transcripts and the first version of the article thus
strengthening the credibility of data [54–58]. Transcripts were always independently coded by
two researchers (RR and EG or RR and TW) and discussed. Analysis and interpretation were
additionally discussed in the research team (investigator triangulation) [57,58].
Results
Sample characteristics
The sample consisted of ten female and five male clinicians of varying ages. Twelve of the 15
interviewees worked in the Netherlands and three in Germany. Among the clinicians were two
PLOS ONE Clinicians’ risk communication strategies in daily clinical practice
PLOS ONE | https://doi.org/10.1371/journal.pone.0236751 August 13, 2020 6 / 22
nurses, three specialist-in-training and ten physicians. Table 1 gives a detailed description of
their characteristics.
Interviews
The average length of interviews was 34 minutes. Eleven interviews were conducted face-to-face
in a relaxed office setting and four were conducted over the telephone. One doctor was on-call
during the interview, for this reason the interview was interrupted three times. Obtaining narra-
tives for the applied risk communication strategies in clinical practice was more difficult to
achieve in some interviews than others. However, by asking prompting questions it was possible
to elicit narratives at every interview. Giving the interviewee latitude to choose their own patient
case was especially valuable in assuring elicitation of risk communication strategies that are actu-
ally used on a routine basis. After 15 interviews saturation of data was reached as no new strategies
emerged according to the categories of the framework (Fig 1). In some interviews we were able to
obtain more detailed patient cases, which illustrated the routine of risk communication in an
exemplary fashion (S2 Appendix). The strong link between SDM and risk communication
became evident as interviewees frequently gave comprehensive statements and illustrations, not
only concerning the risk communication format itself, but also for choice or option talk.
Types of risk
Due to the heterogeneous sample, the interviewees covered a variety of diseases and disorders
of varying degrees of severity, duration of treatment and impact. These ranged from a number
of types of cancer, cardiovascular risk, chronic diseases such as diabetes and multiple sclerosis,
and risk-related to parental-diagnostic and embryology/in-vitro fertilization. These diseases
and disorders were perceived as being related to various different types of risk (Table 2) that
influence the risk communication process.
Main findings
The main findings will be presented, comprising the clinician communication goals and chal-
lenges they face in risk communication and the risk communication strategies they utilize.
Table 1. Characteristics of the interviewees.
Clinician Gender Age category Profession discipline Country Interview language
C01 male 60–69 General Practice NL English
C02 female 40–49 General Practice-Elderly Care NL English
C03 female 40–49 General Practice NL Dutch
C04 male 50–59 General Practice NL Dutch
C05 female 40–49 Gynecology NL Dutch
C06 female 50–59 Radiotherapy—Oncology NL English
C07 female 40–49 Internal Medicine—Nephrology NL English
C08 male 30–39 Internal Medicine—Hematology NL Dutch
C09 male 60–69 Head and Neck Surgery—Oncology NL English
C10 female 30–39 Neurology GE German
C11 female 30–39 Neurology GE German
C12 female 40–49 Neurology GE German
C13 female 60–69 Clinical Genetics NL English
C14 female 50–59 Clinical Genetics NL Dutch
C15 male 30–39 Orthopedics NL Dutch
https://doi.org/10.1371/journal.pone.0236751.t001
PLOS ONE Clinicians’ risk communication strategies in daily clinical practice
PLOS ONE | https://doi.org/10.1371/journal.pone.0236751 August 13, 2020 7 / 22
Contextual factors that shape the risk talk will also be introduced. Fig 2 shows the interaction
between those elements with contextual factors (at clinician and patient level) shaping risk
communication in daily clinical practice (grey circle). Clinicians apply different risk commu-
nication strategies (dark blue gearwheel, Fig 2) that are linked to certain communication goals
(medium blue gearwheel, Fig 2). During the process of communicating risk, clinicians face
multiple challenges (light blue gearwheel, Fig 2). Hence, the three gearwheels interact in risk
communication. The results will be described in an interactive way as the Fig 2 illustrates.
Findings will be described and underpinned with illustrative quotes and drawings. The narra-
tives in the quotes are presented in italics. Additional narratives and drawings can be found in
S3 Appendix. For ease of reading the keywords used in Fig 2 are highlighted in bold in the
results section.
Overall, participants regarded risk communication as an integral part of SDM that allows
for balanced decision-making, and to which appropriate time and consideration should be
given.
We are actually moving pretty quickly from risk communication to “Well, these are your options—and what are we going to do?”. So [. . .] going too quickly through the circle of
shared decision-making. While [. . .] if people understand this [risk communication] well, I
think they are more receptive to the following steps [of shared decision making].
—Interview C04 General Practice—
Thus, in this sample of clinicians, it was not questioned whether or not to conduct a ‘risk
talk’ but rather how to communicate risks when facing each unique patient and situation. The
participants emphasized that the complex process of risk communication is highly dependent
on a number of contextual factors related to the consultation and patient (grey circle, Fig 2).
Clinicians stated that the consultation setting whether in a hospital or other type of practice
and the availability of tools and time for the risk talk may shape the risk communication.
Table 2. Types of risk.
Risk of disease/event
• in a healthy patient with an unknown risk, e.g. CVD, cancer
• in an unborn child or embryo
Risk of recurrence of disease/event
• in a patient already diagnosed with e.g. CVD or cancer
Risk of deterioration of symptoms /condition/ quality of life
• in a patient with a chronic condition e.g. Chronic kidney disease, cancer
Risk of dying and end-of life
• in a frail patient or one with a chronic condition e.g. chronic kidney disease, cancer
Risk of side effects of treatment
• in invasive treatment such as surgery
• in patients with acute or chronic disease
Risk of treatment or diagnostic burden
• e.g. in surgery, drug treatment with high number of doses per day
• e.g. in invasive, painful or frightening diagnostic procedure
Risk of overtreatment
• e.g. resuscitation in cardiac events
• e.g. screening for disease in healthy persons
https://doi.org/10.1371/journal.pone.0236751.t002
PLOS ONE Clinicians’ risk communication strategies in daily clinical practice
PLOS ONE | https://doi.org/10.1371/journal.pone.0236751 August 13, 2020 8 / 22
They agreed that risk communication is highly dependent on the patient’s unique context
(such as patient and family history and his/her physical and mental condition). Clinicians
consistently named health literacy as an important factor in influencing the risk talk. Overall,
interviewees viewed a certain minimum level of health literacy as conditional for effective risk
communication. Some clinicians deliberately skipped the risk talk in patients with a low level
of literacy. One doctor emphasized the use of a stepwise approach: first estimate the health lit-
eracy level of the patient and subsequently adjust the risk talk.
First, I check for [level of] health literacy. If that is low, I will skip most of my [risk] talks
and try to reach them on their level, somewhere. [. . .] for risk communication there needs
to be some kind of standard or platform that people are on already.
—Interview C04 General Practice—
During the course of data collection, it became evident that risk communication is clearly
shaped by clinicians’ own risk communication strategies and their communication goals. The
clinicians frequently aimed to tailor the risk talk to the preferences of the patient for certain
medical options. This approach was reported to have an impact on whether clinicians go into
detail when giving information about a certain medical option. One doctor mentioned that tai-
loring the risk talk to the preferences of the patient reduces the amount of risk information to
deliver. That goal was to counteract the challenge of selective listening by the patient due to
the amount of information delivered.
So, I put a lot of effort in discussing with the patient what is important for them. What are
their goals for the short term and for the long term? And [. . .] when I know what is impor-
tant [for them], only after that I start discussing risk. [. . .] And then I explain, "Well I’ll tell you about this treatment and that treatment. I haven’t told you a lot about this third treat- ment because what I understand from you is that you don't want an operation”–an MRI for
example. [. . .] And that helps me a lot with my risk communication because then the
amount of risks that need to be discussed will decrease.
—Interview C02 General Practice—
By means of the risk talk clinicians seek to lay a foundation for a balanced decision-mak-
ing. Participants reported that they applied different risk communication formats in their con-
sultations, such as verbal and numerical risk communication. Overall, clinicians agreed that
communication in verbal terms only leads to ambiguity in definition of the risk size. Nonethe-
less, some clinicians reported that they describe the risk in verbal terms only in situations
where numbers were not available due to lack of knowledge for example, or the non-applica-
tion of a tool that could have provided information about the size of the risk. Another justifica-
tion for verbal phrasing of risks was situations in which clinicians passed on information
about a very small or a very high risk.
But sometimes, I must admit that I do use those words occasionally. [. . .] I let myself be
tempted to say there is a very small chance [. . .] especially if the odds are very high or very
low, then I say so. So, if 95% of people recover, I don’t say, 19 of the 20 recover but then I
often say, “Almost everyone recovers.”
—Interview C08 Internal Medicine—Hematology—
PLOS ONE Clinicians’ risk communication strategies in daily clinical practice
PLOS ONE | https://doi.org/10.1371/journal.pone.0236751 August 13, 2020 9 / 22
Most clinicians stated that they prefer natural frequencies instead of percentages because
natural frequencies are easier for patients to understand. A small number of clinicians reported
that they only use percentages to communicate a risk estimate. Interviewees said that their
choice to use this format was influenced if in their estimation the patient had a higher level of
numeracy. Some clinicians reported using both percentages and natural frequencies. Most par-
ticipants felt that percentages are quite abstract and should be avoided.
Then I say, “And now there is a side effect that, do not be afraid, it sounds now a bit scary,
but it is very rare, however it is very dangerous, and you have to know that it exists. Namely
in XX of 1000 people, a [. . .] encephalitis can occur [. . .].”
—Interview C11 Neurology—
If a change in risk was reported, the participants stated that they had a preference for abso-
lute risk since the presentation of relative risk alone can lead to biased perception of risk size as
the reference value is missing. Interviewees seldom mentioned the concept of number needed
to treat (NNT).
But the absolute [risk] is much more important than the percentage, I think. With that [rel-
ative risk] you can impress a patient: ’You have a 50% risk reduction.’ But it depends on
how big the baseline risk is and what the absolute risk is. So, I think the relative risk reduc-
tion is not so exciting.
—Interview C03 General Practice—
In the process of achieving their goal of laying a balanced foundation for decision-making,
clinicians encounter a number of challenges in daily clinical practice. They repeatedly stated
that it is difficult for patients to comprehend abstract risk estimates. Some clinicians talked
about the influence of the risk size that imposes additional challenges to risk communication,
as it impacts on the patient’s risk perception. For example, some participants stated that the
patient´s emotional arousal may influence their perception of risk, and potentially their inter-
pretation of the size of the risk, therefore the right time point for risk communication should
be carefully chosen. Some clinicians reported that the indirect experiences of the patient’s sig-
nificant others seem to have an impact on the patient’s perception of risk. Clinicians observed
that the occurrence of disease can bias the patient´s sense of risk size towards 100%. They also
mentioned that patients apparently do not always relate the population-based risk estimate to
themselves or may deny having been informed about a certain risk at an earlier consultation—
in the setting of clinical genetics for example—when a small risk of a serious outcome had
indeed been communicated by a clinician. Furthermore, in the process of informing the
patient, clinicians reported that they are frequently confronted with the challenge of “raising
awareness of a risk versus fanning fear and anxiety in patients”. This aspect seems difficult
to balance for the clinicians, as on the one hand they aim to inform patients that real risks do
exist and on the other hand, they do not want to frighten the patient.
You want to do it in a way that is understandable, you want them to understand that there
are real risks, but you also don’t want to make them too anxious and to scare them, because
sometimes you can also induce fright through risk communication.
—Interview C15 Orthopedics—
PLOS ONE Clinicians’ risk communication strategies in daily clinical practice
PLOS ONE | https://doi.org/10.1371/journal.pone.0236751 August 13, 2020 10 / 22
Hence, the framing of risk messages was regarded as important. Clinicians reported trying
to use both positive and negative framing, but only a few clinicians stated that they always
applied the two strategies in order to be as neutral as possible. One clinician had a clear prefer-
ence for positive framing, which the interviewee explained was related to their own personal-
ity. Interviewees said that their choice of strategy was influenced by the context, i.e. if the
patient was healthy or suffering from a disease, the size of the risk, and patient emotions and
patient preferences. Clinicians described using negative framing in high-risk patients such as
those with CVD in order to illustrate and emphasize the risk of a heart attack through smok-
ing. Positive framing was also reported as one means of reassuring patients.
For example, recently on the ward someone said, “Oh I’m scared that next month I will have the disease back”. I knew that the chance that the lady would have the disease back in the fol-
lowing month was very small. But it wasn’t zero. And if I had said to her “You have a 1 in 10 chance that you will have the disease back next month”, she would have been worried the
whole evening. But I said to her “Well the chance is 9 in 10 that it will all go well” and she
was reassured. Then I was actually using risk communication [. . .] framed to the patient
and to also support her a little bit.
—Interview C08 Internal Medicine—Hematology—
Furthermore, clinicians said that they tried to reassure the patient by putting the risk into
perspective. In risk talks about small risks some clinicians reported that they related the small
risk to experiences with similar cases, or in general to highlight the high chance of a positive
outcome. One clinician also used the illustration of the natural fluctuation in organ function to
comfort the patient.
[. . .] people don’t understand that 0.0001%. But what kind of chance is that? [. . .] what I lit-
erally say is, “I have to tell this number to you but in my experience in my practice I haven't seen or I've only seen one or two patients who lost their kidney because of a bleeding after a kidney biopsy I would do many many kidney biopsies and it almost always goes good [. . .].”
—Interview C07 Internal Medicine—Nephrology—
Overall, clinicians considered graphical support to be very helpful for putting risks into per-
spective, often in relation to time (e.g. 10-year risk, lifetime risk). Clinicians most frequently
reported using population pictograms to illustrate the occurrence of a certain outcome or of
side effects. Another tool that was repeatedly mentioned by GPs was a color-coded table of car-
diovascular disease risk that illustrates the 10-year absolute risks for various high and low risk
categories [52]. Another tool interviewees reported to use was bar charts. A smaller number of
clinicians also said they used self-made drawings. Two examples are shown here (for further
examples see S3 Appendix). Fig 3 shows an illustration by an oncologist of the likelihood of
dying over time in which stem cell transplantation treatment is compared with the natural
course of leukemia to make the patient aware of the risk of treatment (Fig 3). Another clinician
illustrated the peak age of breast cancer in a diagram (Fig 3).
A few clinicians said they used metaphors or visual analogues to put the risk into perspec-
tive. As a reason for using metaphors, one clinician mentioned that metaphors support a
patient’s comprehension because the picture of a certain item allows them to grasp the size of a
certain risk better than abstract numbers alone would. One example of putting a risk into per-
spective was making a comparison with the lottery. To illustrate risk size, another clinician
depicted a 50:50 risk by using weighing scales or the odds of having a son or a daughter. To
PLOS ONE Clinicians’ risk communication strategies in daily clinical practice
PLOS ONE | https://doi.org/10.1371/journal.pone.0236751 August 13, 2020 11 / 22
visualize the concept of uncertainty one clinician explained to utilize the picture of a crystal
ball. Another reported using the metaphor of an umbrella to visualize the uncertainty that is
inevitably part of life and each individual’s subjectivity that leads to differences in risk percep-
tion and risk seeking.
If you look up at a cloudy sky, and you ask ten people if they want to take an umbrella or
not, then some of them will always take an umbrella, some never will, and some may,
depending on how cloudy the sky is. [. . .] But it is not about whether I would like to take an
umbrella, it is about, “Do you want to take an umbrella?” [. . .] one person might not mind
walking around carrying an umbrella the whole day for nothing, because she definitely
doesn’t want to have her new perm spoiled. And the other person thinks ’I’m really not
going to walk around all day with that umbrella.’
—Interview C05 Gynecology—
Uncertainty is inherent in the whole risk communication process and clinicians repeatedly
spoke of challenges in dealing with this complex concept in their daily clinical practice. Some
clinicians reported that they communicated epistemic uncertainty in general descriptive verbal
terms in situations where there is a lack of evidence.
Fig 3. Self-drawn diagrams of interviewees to visually support risk communication.
https://doi.org/10.1371/journal.pone.0236751.g003
PLOS ONE Clinicians’ risk communication strategies in daily clinical practice
PLOS ONE | https://doi.org/10.1371/journal.pone.0236751 August 13, 2020 12 / 22
Yeah, I communicated it [uncertainty] a little bit more open. I say, “In your case we don’t
know exactly what is going to work because there isn’t a lot of research supporting therapies
or treatments for your disease or for your case. So, we need to have trial and error what is
working for you.”—Interview C02 General Practice—
All clinicians stated that they communicate aleatoric uncertainty verbally. The use of confi-
dence intervals was regarded as too difficult for patients to understand. Two clinicians who are
frequently involved in communication on the prognosis of serious disease reported using the
strategy of giving a range instead of a precise risk estimate. These interviewees explained that
this approach helps to prevent patients holding on to a fixed deadline which has a strong emo-
tional impact as the patient then expects to die at the forecasted time. Therefore, one clinician
only spoke of an average life expectancy if directly asked by the patient.
In this case [concerning average survival] [. . .] I don´t find it useful for people to know an
exact number. And when people ask: ‘Can you tell me what the average survival is?’ Well
then, I have to say approximately six months, but I try not to do that at the beginning,. [. . .]
I find it very unpleasant to give a set time. Because there just isn’t one. We only know the
average of 100 comparable patients.
—Interview C08 Internal Medicine—Hematology—
I have seen patients with chance of 95% for cure. And they die. And the other way around,
patients incurable and they survive. [. . .] You never know. [. . .] if you have 1000 patients
[. . .]. 90% will survive or 90% will die. [. . .] “But then again that doesn’t say anything about you.We don’t know.” [. . .] doctors who say: ’Ok you have [. . .] three months because if you
have 1000 patients with the same disease, one patient will survive one hour, and one will
survive 10 years and the mean is three months.’ [. . .] But I never use these kinds of indica-
tions. Because I think it’s harmful. Because I had patients and then they said: ’Ok, I was
with the medical Oncology and he said I have two months to go.’ And then [they think] it’s
the last visit. And then they said goodbye. And this lady [. . .] she came back in December,
still in a good condition. And we were just a bit talking and [she] said yeah: ’The problem is
I gave all my stuff for Christmas away. What shall I do?’, I say, “Yeah, you have to ask it back.”[. . .] And she died next year in in June.
—Interview C09 Head and Neck Surgery—Oncology—
Some clinicians reported that they aimed to influence the mindset of the patient. One
interviewee who is involved in the treatment of severe disorders tried to make patients aware
that death is an undeniable fact of life, and that treatment does not necessarily result in cure.
Therefore, that clinician emphasized that it is important to accept death and to make treatment
choices that are not based on fear, but based on life choices consistent with the patient’s own
values.
[. . .] as soon as you accept that you will die, then a lot of uncertainty and a lot of anxiety is
gone. Because the death is always behind you. So, if you turn around and say, “Okay, I know I know you are there. So, one day you win.” [. . .] Because if you are afraid to die and if that’
the reason to have the surgery than you take the wrong decision because you will die any-
way. Better to get used to the idea that you will die.
—Interview C09 Head and Neck Surgery—Oncology—
PLOS ONE Clinicians’ risk communication strategies in daily clinical practice
PLOS ONE | https://doi.org/10.1371/journal.pone.0236751 August 13, 2020 13 / 22
The clinicians said they wanted their patients to understand that despite treatment, the risk
or risk reduction usually does not approach 0%. In situations related to a medical test such as
screening in asymptomatic patients, clinicians might want patients to understand that the test
may also lead to additional risks related to overtreatment. Another aspect of risk communica-
tion, which clinicians repeatedly mentioned as challenging to communicate to patients, is the
treatment burden in relation to the challenge of “quality versus quantity of life”. Quality and
quantity were regarded as problematic to weigh against one another since concrete numbers
for individual patients are lacking. Therefore, clinicians aimed to influence the patients’ mind-
set by making them thoroughly consider the trade-off between quality and quantity of life. Pre-
dominantly in situations related to impactful treatment clinicians aimed to draw the patients’
attention to the fact that the treatment might have a negative effect that could lead to a decline
in quality of life. This awareness potentially supports the laying of the foundation for balanced
decision-making for the patient.
And if you have tried all kinds of different statins then you also try to put it into perspective
and look at it this way “But how much quality of life have you lost due to the side effects you have?” And that cannot be expressed as a single estimate, as it is related to the experience of
the patient. “And suppose you belong to that group of patients who have been taking it all these years, but actually do not benefit from it, because it’s only some of the 100 people who benefit from it, does that still affect your decision to continue or not?” [. . .]
—Interview C03 General Practice—
In the complex risk talk the experiences and expertise of the clinicians play an important
role. Some clinicians reported the goal of steering the patient towards a certain decision.
This approach is manifested by the clinician emphasizing a certain risk more than other out-
comes. It was reported to be used in situations such as the choice for elective surgery where on
the basis on his sound medical insights and experiences with similar cases, the doctor deemed
a patient as not such a good candidate for surgery. Thus, this goal was not related to steering
the patient towards the doctor’s treatment preference but to make high risk patients thor-
oughly consider the side effects of treatment.
[. . .] in a patient when you explain a certain surgical therapy. But you think that the patient
is not entirely eligible for it, or that he or she behaves in a certain way, or has a certain other
comorbidity [. . .] then you also use risk communication to emphasize that there really is [a
risk]–thus you make those risks a little bit bigger in your explanation.
—Interview C15 Orthopedics—
Discussion
Main findings
The aim of this study is to give an overview of clinician’s strategies to communicate risk in
daily clinical practice with illustrative examples. Risk communication in this study is shaped
by various contextual factors at the consultation and patient level, as well as clinicians’ specific
communication goals. When communicating risk to patients, clinicians face various challenges
and uncertainties that may go beyond choosing the appropriate risk format. The majority of
risk communication literature seems to focus on examining different risk communication for-
mats that are often isolated from the daily clinical context. [5,10–13,17,22]. Our findings reveal
PLOS ONE Clinicians’ risk communication strategies in daily clinical practice
PLOS ONE | https://doi.org/10.1371/journal.pone.0236751 August 13, 2020 14 / 22
what actually shapes risk communication in clinical practice, thereby elucidating the interac-
tion between the expertise of clinicians and their specific communication goals, the choice of a
certain strategy and the challenges they face in daily practice.
Clinicians apply a number of risk communication strategies in order to lay a foundation for
balanced decision-making. Consequently, clinicians make the patient aware of a certain risk.
As pointed out by the extensive literature on judgement and decision-making, the risk com-
munication process is prone to heuristics and biases [59–63]. Raised awareness of the risk
through a risk talk leads to further challenges for clinicians to address. The patient´s risk per-
ception plays a major role: a small risk of a severe disorder or a medium risk of a mild disorder
can be perceived differently. Depending on the context, in the field of embryology for example,
the communication of small -but nonetheless impactful- risks can strongly affect the emotional
impact on the patient. Thus, clinicians are repeatedly confronted with the challenging dilemma
of raising awareness and fanning fear in patients, emphasizing the importance of phrasing the
risk message sensitively. There seems to be a need for clinicians to develop skills/strategies to
communicate risks without increasing fear [64]. As shown in our study, clinicians repeatedly
tried to reassure patients by putting the risk into perspective by using comparisons with expe-
riences from other cases, or the use of visual formats. Some participants stated to use verbal
analogues or metaphors to put risks into perspective. Although there is not much to be found
in the scientific literature regarding the use of metaphors and visual analogues [65,66], it
seems to be a relevant concept, especially in relation to the illustration of aspects of uncer-
tainty. Clinicians noted that the concept of the uncertainty that is inherently present in life is
challenging to explain to patients. It is difficult for patients to grasp that numbers are only esti-
mates based on a sample of the population. Furthermore, it is important for patients to be
aware of the illusion of certainty, therefore some clinicians tried to influence the mindset of
patients by making them aware of aspects of uncertainty in decision-making and life in gen-
eral: e.g. treatment does not necessarily mean cure and despite the treatment a risk hardly
approaches 0%. Therefore, thorough consideration of the aspects of the quality and quantity of
life in life-threatening treatment decisions for example, is important to patients. It should be
noted that clinicians need to develop a certain expertise concerning the more sensitive aspects
of risk communication such as a patient’s emotions.
Previous literature on doctor-patient communication empirically supports both the con-
text-specific and goal-directed nature of communication [67–71]. As presented in this study,
the risk communication process is influenced by different contextual factors at the consulta-
tion, patient and clinician level. Risk communication has to be sensitive to the context of the
consultation (context-specific), e.g. concerning practical aspects such as time pressure or
patient aspects such as their emotions. Risk communication is also goal-directed as clinicians
apply specific communication goals in the process. Those specific communication goals vary
and might depend on e.g. patient preferences, but they can also be driven by clinicians’ prefer-
ences and expertise. For example, clinicians might aim to influence the lifestyle of the patient
or to make high risk patients thoroughly consider the side effects of a treatment. Clinicians
adapt how they present risk accordingly. Therefore, risk communication is not merely to be
satisfied with a standardized stepwise approach of the “right” risk communication format/
strategy, considering the uniqueness of situations in daily clinical practice. A holistic, context-
specific and goal-directed approach to teaching risk communication seems to be needed.
The complexity of risk communication also became evident during the search for a theory/
framework that could support the data collection and analysis process of this study. There was
little guidance on a framework for risk communication in the clinical consultation setting. A
larger body of scientific literature on risk communication focuses on risk communication con-
cepts in catastrophe or crisis management [72–75]. Research on risk communication in the
PLOS ONE Clinicians’ risk communication strategies in daily clinical practice
PLOS ONE | https://doi.org/10.1371/journal.pone.0236751 August 13, 2020 15 / 22
clinical setting was rather focused on effectiveness of single risk message formats only, and iso-
lated from the context [13,17–19,21,22].
Overall it can be stated that in concordance with findings and recommendations in the lit-
erature, participants used natural frequencies, absolute risk and positive and negative framing
in their risk communication. Some clinicians also reported to use percentages. This approach
is generally not highly recommended in the scientific literature [6,10,21,22], however recent
findings suggest that natural frequencies do not foster better understanding and thus pointing
to an equal performance of percentages and natural frequencies [20,76].
In agreement with scientific recommendations, our participants stated to prefer the presen-
tation of absolute risk since relative risk can be misleading in risk perception [12,20]. Concern-
ing visual tools most clinicians were familiar with population pictograms and applied them on
a regular basis. Overall, all interviewees agreed that a form of visualization is important to sup-
port risk communication, as shown in previous research [28,77–79]. A noteworthy fact is that
clinicians did not consistently specify the time frame around the risk estimates. Concerning
the communication of numbers in words only, a small number of clinicians reported that they
used this approach in some situations, although this is contradictory to the recommendations
in the literature [19,20,41]. Clinicians reported that they dealt with uncertainty in descriptive
verbal terms. Complex approaches such as confidence intervals were not reported to be used.
However, in relation to serious life-threatening illnesses, clinicians gave a range of life expec-
tancy to patients to prevent the negative effects of holding on to a fixed time point.
Strengths and limitations
As far as we know no other study has given a comprehensive insight into risk communication
strategies and narratives that clinicians report to apparently use in practice, in the way that we
have done. We provide a comprehensive overview of a sample of clinicians from the Nether-
lands and Germany. However, as we interviewed a convenience sample of clinicians that are at
least familiar with the concept of SDM, these findings might not be generalizable to clinical
practice in general, as other doctors might be less inclined to use the presented risk communi-
cation strategies. Most of the interviews were conducted in the mother tongue of the partici-
pant (Dutch or German) with the exception of six interviews that were conducted in English.
Using the mother tongue of the interviewee facilitates the elicitation of authentic narratives.
Nevertheless, a drawback might be that the interviewer has only recently learned Dutch. How-
ever, discussing the data in the project team with Dutch speaking team members, strengthened
the credibility and scientific quality. Another drawback is the small sample size. The findings
need to be confirmed in a larger sample size. However, it needs to be considered that qualita-
tive research aims to give a detailed explorative insight rather than confirming specified
hypotheses in a representative sample. We are confident that the results reflect adequately the
information provided by this sample of clinicians as recruitment and data collection took
place until saturation of data was reached. Further, the utilization of interviews to obtain the
risk communication strategies relied on the recall of the clinicians. Observations of consulta-
tions would probably have resulted in additional information. As observations were not feasi-
ble in our study, we believe that using participants’ self-selected patient cases sufficiently
enhanced authentic reflections about their risk communication process. In addition, this study
cannot make any inferences and statements about the effectivity of the illustrated strategies.
Nonetheless, these findings could facilitate specific hypotheses that could be tested in future
experimental and systematic studies. For reasons of feasibility the patient perspective could
not be explored in this study.
PLOS ONE Clinicians’ risk communication strategies in daily clinical practice
PLOS ONE | https://doi.org/10.1371/journal.pone.0236751 August 13, 2020 16 / 22
Conclusion
In conclusion, our study gives an insight into what shapes risk communication and what
authentic risk communication strategies clinicians from different medical disciplines report to
use in daily clinical practice. We illustrated the multi-dimensional nature and complexity of
risk communication which is about more than conveying a risk message in an adequate for-
mat. The risk communication process is inherently incorporated in the interaction with the
unique clinical circumstances. Hence, we conclude that risk communication cannot be taught
without taking the context and the clinicians’ expertise and communication goals into
consideration.
Implication for further research and practice
Undoubtedly, research on effectiveness of certain risk communication formats is important,
but risk communication should be viewed in relation to its context. Further research should
address more practical approaches for a risk communication framework in the clinical setting
to be able to better examine the topic. The challenge for future research is to take the perspec-
tives of clinicians and patients into account and also the contextual situation related to the dis-
ease and type of risk instead of merely focusing on a single format. It could be of interest to
elucidate patient satisfaction concerning the described strategies. Further research needs to
address the aspect of patient´s health literacy and risk communication. The effectiveness of
using illustrative examples of risk communication should be evaluated in a systematic way, as
they might be a good method of supporting risk communication training for trainees. Given
the important role of context in risk communication, providing clinicians with context-spe-
cific risk communication strategies seems important. Hence, the identified strategies can be
used as a starting point for the development of medical curricula that address teaching risk
communication in a more practical illustrative way, e.g. centered in proactive workplace-
learning [44,80], where the expertise of experienced doctors is taken into account. Addition-
ally, the provided risk communication strategies may be of interest to other clinicians.
Supporting information
S1 Appendix. Semi-structured interview guide.
(PDF)
S2 Appendix. Patient cases that illustrate risk communication.
(PDF)
S3 Appendix. Tables risk communication strategies and narratives.
(PDF)
S4 Appendix. AUDIT trail.
(PDF)
S5 Appendix. COREQ checklist.
(PDF)
Acknowledgments
The authors thank Albine Moser for the advice concerning questions on the qualitative meth-
odology, Anke Steckelberg for the contribution to recruitment process and Simona Dumi-
trescu and Simon Voß for the critical input on the manuscript text and figure.
PLOS ONE Clinicians’ risk communication strategies in daily clinical practice
PLOS ONE | https://doi.org/10.1371/journal.pone.0236751 August 13, 2020 17 / 22
Author Contributions
Conceptualization: Romy Richter, Esther Giroldi, Jesse Jansen, Trudy van der Weijden.
Data curation: Romy Richter, Trudy van der Weijden.
Formal analysis: Romy Richter, Esther Giroldi, Trudy van der Weijden.
Investigation: Romy Richter.
Methodology: Romy Richter, Esther Giroldi, Trudy van der Weijden.
Supervision: Trudy van der Weijden.
Visualization: Jesse Jansen.
Writing – original draft: Romy Richter.
Writing – review & editing: Romy Richter, Esther Giroldi, Jesse Jansen, Trudy van der
Weijden.
References 1. Barry MJ, Edgman-Levitan S. Shared decision making—The pinnacle of patient-centered care. New
England Journal of Medicine. 2012 Mar 1; 366(9):780–1. https://doi.org/10.1056/NEJMp1109283
PMID: 22375967
2. Elwyn G, Durand MA, Song J, Aarts J, Barr PJ, Berger Z, et al. A three-talk model for shared decision
making: Multistage consultation process. BMJ (Online). 2017; 359:j4891.
3. Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et al. Shared decision mak-
ing: a model for clinical practice. Journal Of General Internal Medicine. 2012 Oct; 27(10):1361–7. Avail-
able from: http://www.ncbi.nlm.nih.gov/pubmed/22618581 https://doi.org/10.1007/s11606-012-2077-6
PMID: 22618581
4. Elwyn GJ, Edwards A, Kinnersley P, Grol R. Shared decision making and the concept of equipoise: The
competences of involving patients in healthcare choices. British Journal of General Practice. 2000; 50
(460):892–9. PMID: 11141876
5. Paling J. Strategies to help patients understand risk. British Medical Journal. 2003; 327(7417):745–8.
https://doi.org/10.1136/bmj.327.7417.745 PMID: 14512489
6. Godolphin W. The role of risk communication in shared decision making: first lets get to choices. British
Medical Journal. 2003; 327(7417):692–3. https://doi.org/10.1136/bmj.327.7417.692 PMID: 14512449
7. Kirkegaard P, Edwards AGK, Hansen B, Hansen MD, Jensen MSA, Lauritzen T, et al. The RISAP-
study: a complex intervention in risk communication and shared decision-making in general practice.
Risk Communication in General Practice. BMC Fam Pract. 2010; 11:70. https://doi.org/10.1186/1471-
2296-11-70 PMID: 20860820
8. Hoffmann TC, Légaré F, Simmons MB, McNamara K, McCaffery K, Trevena LJ, et al. Shared decision
making: What do clinicians need to know and why should they bother? Medical Journal of Australia.
2014 Jul 7; 201(1):35–9. https://doi.org/10.5694/mja14.00002 PMID: 24999896
9. Han PKJ, Joekes K, Elwyn G, Mazor KM, Thomson R, Sedgwick P, et al. Development and evaluation
of a risk communication curriculum for medical students. Patient Education and Counseling. 2014 Jan;
94(1):43–9. https://doi.org/10.1016/j.pec.2013.09.009 PMID: 24128795
10. Gigerenzer G, Gaissmaier W, Kurz-Milcke E, Schwartz LM, Woloshin S. Helping doctors and patients
make sense of health statistics. Psychological Science in the Public Interest. 2007 Nov; 8(2):53–96.
https://doi.org/10.1111/j.1539-6053.2008.00033.x PMID: 26161749
11. Gigerenzer G, Edwards A. Simple tools for understanding risks: From innumeracy to insight. British
Medical Journal. 2003 Sep 27; 327(7417):741–4. https://doi.org/10.1136/bmj.327.7417.741 PMID:
14512488
12. Ahmed H, Naik G, Willoughby H, Edwards AGK. Communicating risk. BMJ [Internet]. 2012; 344:e3996.
https://doi.org/10.1136/bmj.e3996 PMID: 22709962
13. Lipkus IM. Numeric, verbal, and visual formats of conveying health risks: Suggested best practices and
future recommendations. Medical Decision Making. 2007; 27(5):696–713. https://doi.org/10.1177/
0272989X07307271 PMID: 17873259
PLOS ONE Clinicians’ risk communication strategies in daily clinical practice
PLOS ONE | https://doi.org/10.1371/journal.pone.0236751 August 13, 2020 18 / 22
14. Waldron CA, van der Weijden T, Ludt S, Gallacher J, Elwyn G. What are effective strategies to commu-
nicate cardiovascular risk information to patients? A systematic review. Patient Education and Counsel-
ing. 2011; 82(2):169–81. https://doi.org/10.1016/j.pec.2010.04.014 PMID: 20471766
15. Akl EA, Oxman AD, Herrin J, Vist GE, Terrenato I, Sperati F, et al. Framing of health information mes-
sages. Cochrane Database of Systematic Reviews. 2011 Dec 7;(12):CD006777. https://doi.org/10.
1002/14651858.CD006777.pub2 PMID: 22161408
16. Keller C, Siegrist M. Effect of risk communication formats on risk perception depending on numeracy.
Medical Decision Making. 2009; 29(4):483–90. https://doi.org/10.1177/0272989X09333122 PMID:
19525484
17. Timmermans D, Molewijk B, Stiggelbout A, Kievit J. Different formats for communicating surgical risks
to patients and the effect on choice of treatment. Patient Education and Counseling. 2004 Sep; 54
(3):255–63. https://doi.org/10.1016/S0738-3991(03)00238-6 PMID: 15324976
18. Marteau TM, Saidi G, Goodburn S, Lawton J, Michie S, Bobrow M. Numbers or words? A randomized
controlled trial of presenting screen negative results to pregnant women. Prenatal Diagnosis. 2000; 20
(9):714–8. https://doi.org/10.1002/1097-0223(200009)20:9<714::aid-pd906>3.0.co;2-4 PMID:
11015699
19. Berry DC, Raynor DK, Knapp P. Communicating risk of medication side effects: An empirical evaluation
of EU recommended terminology. Psychology, Health and Medicine. 2010 Aug; 8(3):251–63.
20. Lühnen J, Albrecht M, Mühlhauser I, Steckelberg A. Leitlinie evidenzbasierte Gesundheitsinformation.
Hamburg; 2017.
21. Bodemer N, Meder B, Gigerenzer G. Communicating relative risk changes with baseline risk: Presenta-
tion format and numeracy matter. Medical Decision Making. 2014; 34(5):615–26. https://doi.org/10.
1177/0272989X14526305 PMID: 24803429
22. Gigerenzer G, Galesic M. Why do single event probabilities confuse patients? Statements of frequency
are better for communicating risk. BMJ (Online). 2012; 344(7839):11–3.
23. Petrova D, Kostopoulou O, Delaney BC, Cokely ET, Garcia-Retamero R. Strengths and Gaps in Physi-
cians’ Risk Communication: A Scenario Study of the Influence of Numeracy on Cancer Screening Com-
munication. Medical Decision Making. 2018 Apr 1; 38(3):355–65. https://doi.org/10.1177/
0272989X17729359 PMID: 28884617
24. Koo K, Brackett CD, Eisenberg EH, Kieffer KA, Hyams ES. Impact of numeracy on understanding of
prostate cancer risk reduction in PSA screening. PLoS ONE. 2017 Dec 1; 12(12):e0190357. https://doi.
org/10.1371/journal.pone.0190357 PMID: 29284055
25. Edwards A, Elwyn G, Mulley A. Explaining risks: turning numerical data into meaningful pictures. BMJ.
2002 Apr 6; 324(7341):827–30. https://doi.org/10.1136/bmj.324.7341.827 PMID: 11934777
26. Neuner-Jehle S, Knecht MI, Stey-Steurer C, Senn O. Acceptance and practicability of a visual commu-
nication tool in smoking cessation counselling: A randomised controlled trial. Primary Care Respiratory
Journal. 2013 Dec; 22(4):412–6. https://doi.org/10.4104/pcrj.2013.00086 PMID: 24105269
27. Goodyear-Smith F, Arroll B, Chan L, Jackson R, Wells S, Kenealy T. Patients prefer pictures to num-
bers to express cardiovascular benefit from treatment. Annals of Family Medicine. 2008 May; 6(3):213–
7. https://doi.org/10.1370/afm.795 PMID: 18474883
28. Garcia-Retamero R, Cokely ET. Communicating Health Risks With Visual Aids. Current Directions in
Psychological Science. 2013 Oct 25; 22(5):392–9.
29. Caverly T, Fagerlin A, Larkin K, Zikmund-Fischer B. What is the best way to communicate the benefits
and harms of lung cancer screening? Journal of General Internal Medicine. 2016; 31(2 SUPPL. 1):
S471–2.
30. Hess R, Visschers VHM, Siegrist M. Risk communication with pictographs: The role of numeracy and
graph processing. Judgment and Decision Making. 2011; 6(3):263–74.
31. Schapira MM, Nattinger AB, McHorney CA. Frequency or probability? A qualitative study of risk com-
munication formats used in health care. Medical Decision Making. 2001; 21(6):459–67. https://doi.org/
10.1177/0272989X0102100604 PMID: 11760103
32. Bonner C, McKinn S, Lau A, Jansen J, Doust J, Trevena L, et al. Heuristics and biases in cardiovascular
disease prevention: How can we improve communication about risk, benefits and harms? Patient Edu-
cation and Counseling. 2018 May 1; 101(5):843–53. https://doi.org/10.1016/j.pec.2017.12.003 PMID:
29269097
33. Edwards A, Elwyn G. Understanding risk and lessons for clinical risk communication about treatment
preferences. Quality in Health Care. 2001 Sep; 10(Suppl 1):i9–13.
34. Polak L. Communicating risk to patients and the public. British Journal of General Practice. 2012; 62
(598):240.
PLOS ONE Clinicians’ risk communication strategies in daily clinical practice
PLOS ONE | https://doi.org/10.1371/journal.pone.0236751 August 13, 2020 19 / 22
35. Han PKJ, Klein WMP, Arora NK. Varieties of Uncertainty in Health Care: A Conceptual Taxonomy.
Medical Decision Making. 2011 Nov 1; 31(6):828–38. https://doi.org/10.1177/0272989x11393976
PMID: 22067431
36. Hillen MA, Gutheil CM, Strout TD, Smets EMA, Han PKJ. Tolerance of uncertainty: Conceptual analy-
sis, integrative model, and implications for healthcare. Social Science and Medicine. 2017 May 1;
180:62–75. https://doi.org/10.1016/j.socscimed.2017.03.024 PMID: 28324792
37. Han PKJ. Conceptual, Methodological, and Ethical Problems in Communicating Uncertainty in Clinical
Evidence. Medical Care Research and Review. 2013; 70(1_suppl):14S–36S. https://doi.org/10.1177/
1077558712459361 PMID: 23132891
38. Politi MC, Han PKJ, Col NF. Communicating the uncertainty of harms and benefits of medical interven-
tions. Medical Decision Making. 2007 Sep; 27(5):681–95. https://doi.org/10.1177/0272989X07307270
PMID: 17873256
39. Brun W, Keren G, Kirkebøen G, Montgomery H. Perspectives on thinking, judging, and decisions mak-
ing: A tribute to Karl Halvor Teigen. Oslo: Universitetsforlaget. 2011 [cited 2020 Jan 15]. Available
from: https://research.tilburguniversity.edu/en/publications/perspectives-on-thinking-judging-and-
decisions-making-a-tribute-t
40. Bhise V, Rajan SS, Sittig DF, Morgan RO, Chaudhary P, Singh H. Defining and Measuring Diagnostic
Uncertainty in Medicine: A Systematic Review. Journal of General Internal Medicine. 2018 Jan 1; 33
(1):103–15. https://doi.org/10.1007/s11606-017-4164-1 PMID: 28936618
41. Mühlhauser I, Albrecht M, Steckelberg A. Evidence-based health information and risk competence.
GMS German Medical Science. 2015; 13:1612–3174.
42. Gigerenzer G. What are natural frequencies? BMJ. 2011 Oct 17; 343:d6386. Available from: http://
www.ncbi.nlm.nih.gov/pubmed/22006953 https://doi.org/10.1136/bmj.d6386 PMID: 22006953
43. Dixon SD, Konheim-Kalkstein YL. Risk communication: A complex process. In: LeRoy BS, Veach PM,
Bartels DM, editors. Genetic counseling practice: Advanced concepts and skills. Wiley-Blackwell;
2010. p. 65–94.
44. Giroldi E, Veldhuijzen W, Geelen K, Muris J, Bareman F, Bueving H, et al. Developing skilled doctor–
patient communication in the workplace: a qualitative study of the experiences of trainees and clinical
supervisors. Advances in Health Sciences Education. 2017 Dec 1; 22(5):1263–78. https://doi.org/10.
1007/s10459-017-9765-2 PMID: 28220333
45. van den Eertwegh V, van Dalen J, van Dulmen S, van der Vleuten C, Scherpbier A. Residents’ per-
ceived barriers to communication skills learning: Comparing two medical working contexts in postgradu-
ate training. Patient Education and Counseling. 2014; 95(1):91–7. https://doi.org/10.1016/j.pec.2014.
01.002 PMID: 24468200
46. Hodges BD, Lingard L. The Question of Competence: Reconsidering Medical Education in the Twenty-
First Century. Cornell University Press, ILR Press. 2012. 240.
47. Swanwick Tim. Understanding Medical Education: Evidence, Theory, and Practice. West Sussex:
Wiley-Blackwell; 2013.
48. Bradshaw C, Atkinson S, Doody O. Employing a Qualitative Description Approach in Health Care
Research. Global Qualitative Nursing Research. 2017 Dec 24; 4:233339361774228.
49. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-
item checklist for interviews and focus groups. Int J Qual Health Care. 2007; 19:349–57. https://doi.org/
10.1093/intqhc/mzm042 PMID: 17872937
50. Ahl AS, Acree JA, Gipson PS, Mcdowell RM, Miller L, Mcelvaine MD. Standardization of nomenclature
for animal health risk analysis. Rev. Sci. Tech. 1993 Dec; 12(4):1045–53. https://doi.org/10.20506/rst.
12.4.744 PMID: 8312610
51. Lambert V, Lambert C. Qualitative Descriptive Research: An Acceptable Design. Pacific Rim Interna-
tional Journal of Nursing Research. 2012; 16(4):255–6.
52. Moser A, Korstjens I. Series: Practical guidance to qualitative research. Part 3: Sampling, data collec-
tion and analysis. European Journal of General Practice. 2018 Dec; 24(1):9–18. https://doi.org/10.
1080/13814788.2017.1375091 PMID: 29199486
53. Elo S, Kyngäs H. The qualitative content analysis process. Journal of Advanced Nursing. 2008 Apr; 62
(1):107–15. https://doi.org/10.1111/j.1365-2648.2007.04569.x PMID: 18352969
54. Lincoln YS, Guba EG. Naturalistic inquiry. Newbury Park, CA: Sage Publications; 1985. 416.
55. Koelsch LE. Reconceptualizing the Member Check Interview. International Journal of Qualitative Meth-
ods. 2013 Feb 1; 12(1):168–79.
56. Bradshaw C, Atkinson S, Doody O. Employing a Qualitative Description Approach in Health Care
Research. Global Qualitative Nursing Research. 2017 Nov 21; 4.
PLOS ONE Clinicians’ risk communication strategies in daily clinical practice
PLOS ONE | https://doi.org/10.1371/journal.pone.0236751 August 13, 2020 20 / 22
57. Korstjens I, Moser A. Series: Practical guidance to qualitative research. Part 4: Trustworthiness and
publishing. European Journal of General Practice. 2018 Jan 5; 24(1):120–4. https://doi.org/10.1080/
13814788.2017.1375092 PMID: 29202616
58. Frambach JM, van der Vleuten CPM, Durning S. AM Last Page: Quality Criteria in Qualitative and
Quantitative Research. Academic Medicine. 2013 May; 88(4):552. https://doi.org/10.1097/ACM.
0b013e31828abf7f PMID: 23531762
59. Schwartz S. Heuristics and Biases in Medical Judgment and Decision Making. In: Heath L. et al. (eds)
Applications of Heuristics and Biases to Social Issues. Social Psychological Applications to Social
Issues (Published under the auspices of the Society for the Psychological Study of Social Issues), vol
3. Boston: Springer; 1994. pp. 45–72.
60. Tversky A, Kahneman D. Judgment under uncertainty: Heuristics and biases. Science. 1974; 185
(4157):1124–31. https://doi.org/10.1126/science.185.4157.1124 PMID: 17835457
61. Tversky A, Kahneman D. Availability: A Heuristic for Judging Frequency and Probability122. Cognitive
Psychology. 1973; 5:207–32.
62. Kahneman D. Thinking, fast and slow. New York: Farrar, Straus and Giroux; 2011.
63. Shah AK, Oppenheimer DM. Heuristics Made Easy: An Effort-Reduction Framework. Psychological
Bulletin. 2008 Mar; 134(2):207–22. https://doi.org/10.1037/0033-2909.134.2.207 PMID: 18298269
64. van Wagner V. Risk talk: Using evidence without increasing fear. Midwifery. 2016; 38:21–8. https://doi.
org/10.1016/j.midw.2016.04.009 PMID: 27174012
65. Barilli E, Savadori L, Pighin S, Bonalumi S, Ferrari A, Ferrari M, et al. From chance to choice: The use of
a verbal analogy in the communication of risk. Health, Risk & Society. 2010 Dec 2; 12(6):546–59.
66. Edwards A. Communicating risks through analogies. BMJ. 2003 Sep; 327(7417):749. https://doi.org/
10.1136/bmj.327.7417.749 PMID: 14512490
67. Essers G, Kramer A, Andriesse B, van Weel C, van der Vleuten C, van Dulmen S. Context factors in
general practitioner—Patient encounters and their impact on assessing communication skills—An
exploratory study. BMC Family Practice. 2013; 14.
68. Essers G, van Dulmen S, van Weel C, van der Vleuten C, Kramer A. Identifying context factors explain-
ing physician’s low performance in communication assessment: An explorative study in general prac-
tice. BMC Family Practice. 2011; 12:1–8. https://doi.org/10.1186/1471-2296-12-1
69. Salmon P, Young B. Creativity in clinical communication: From communication skills to skilled commu-
nication. Medical Education. 2011 Mar; 45(3):217–26. https://doi.org/10.1111/j.1365-2923.2010.03801.
x PMID: 21299597
70. Veldhuijzen W. Challenging the patient-centred paradigm: Designing feasible guidelines for doctor–
patient communication. Maastricht: Maastricht University. 2011.
71. Veldhuijzen W, Mogendorff K, Ram P, van der Weijden T, Elwyn G, van der Vleuten C. How doctors
move from generic goals to specific communicative behavior in real practice consultations. Patient Edu-
cation and Counseling. 2013 Feb; 90(2):170–6. https://doi.org/10.1016/j.pec.2012.10.005 PMID:
23218241
72. Eppler MJ, Aeschimann M. A systematic framework for risk visualization in risk management and com-
munication. Risk Management. 2009 Apr; 11(2):67–89.
73. Reynolds B, Quinn SC. Effective Communication During an Influenza Pandemic: The Value of Using a
Crisis and Emergency Risk Communication Framework. Health Promotion Practice. 2008; 9((4
Suppl)):13S–17S. https://doi.org/10.1177/1524839908325267 PMID: 18936255
74. Covello VT. Best Practices in Public Health Risk and Crisis Communication. Journal of Health Commu-
nication. 2003; 8(sup1):5–8.
75. Reynolds BJ, Seeger MW. Crisis and Emergency Risk Communication as an Integrative Model. Journal
of Health Communication. 2005 Feb 23; 10:43–55. https://doi.org/10.1080/10810730590904571 PMID:
15764443
76. Pighin S, Gonzalez M, Savadori L, Girotto V. Natural Frequencies Do Not Foster Public Understanding
of Medical Test Results. Medical Decision Making. 2016 Aug 31; 36(6):686–91. https://doi.org/10.1177/
0272989X16640785 PMID: 27034447
77. Lipkus IM. Numeric, verbal, and visual formats of conveying health risks: Suggested best practices and
future recommendations. Medical Decision Making. 2007 Sep; 27(5):696–713. https://doi.org/10.1177/
0272989X07307271 PMID: 17873259
78. Garcia-Retamero R, Cokely ET. Designing Visual AIDS That Promote Risk Literacy: A Systematic
Review of Health Research and Evidence-Based Design Heuristics. Human Factors. 2017; 59(4):582–
627. https://doi.org/10.1177/0018720817690634 PMID: 28192674
PLOS ONE Clinicians’ risk communication strategies in daily clinical practice
PLOS ONE | https://doi.org/10.1371/journal.pone.0236751 August 13, 2020 21 / 22
79. Pratt M, Searles GE. Using visual aids to enhance physician-patient discussions and increase health lit-
eracy. Journal of Cutaneous Medicine and Surgery. 2017; 21(6):497–501. https://doi.org/10.1177/
1203475417715208 PMID: 28614954
80. Gigerenzer Gerd, Muir Gray JA. Better Doctors, Better Patients, Better Decisions: Envisioning Health
Care 2020. Cambridge: MIT Press; 2011.
PLOS ONE Clinicians’ risk communication strategies in daily clinical practice
PLOS ONE | https://doi.org/10.1371/journal.pone.0236751 August 13, 2020 22 / 22
