. When explaining risk to patients, clinicians are typically focused on providing the facts about the risk (objective information), while patients typically are more interested in knowing how a bad outcome might affect them (subjective information). Patients, of course, also want to know the identity of the risk (death, disability, pain), its timing (early versus late), and the nature of the bad event (temporary, permanent), [JAMA 1999;281:1037-41.] When faced with a situation of conflicting evidence by several national guidelines, the practitioner is faced with a solitary dilemna. What do you do in the face of uncertainty and how do you explain probability. We have recently shown [Do medical students and physicians understand probability?  Quart J Med 2004;97:53-55. ] that physician might be have difficulty with probability and using natural frequancy format might be a better and simpler form of explaining risks.
From the patients stand point the anger comes , from the realisation that, " was in the physicans' office and all the did was talk! They involved me in a whole array of words, numbers, and NNT("again physicians and patients donot understand this consistently). Both the physicians and patient stand to lose sometimes. The patient from lack of understanding and the physician from lack of support from their own colleagues and from others in the event something bad happens.Worse still is the possibility of a bad event happening in the presence of a normal test( false negative).
It risky business of talking about risk is that in an individual case things could go wrong, however being totally risk averse and panicky at these instances leading to a fatalistic approach to medicine and not being evidence-based would be to grave a danger. The only way not to have any of these problems is , ' not to practice medicine, or be a 100% researcher without any patient contact!'. It is a sad thing which happened here, but we would be  equally in the dark if we were to teach our students that medicine is not fraught with uncertainty. Not surprisingly internist and family practitioners( Martha Gerrity's work) handling unceratinty than sub-specialists, though this very quality might land them into similar troubles.

Amit K. Ghosh, MD, FACP
Associate Program Director, General Internal Medicine Research Fellowship
Assistant Professor of Medicine
Mayo Clinic College of Medicine
200 1st Street, SW
Rochester, MN, 55905
Phone: 507-538-1128
Fax: 507-284-4959
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> -----Original Message-----
> From: Paul Glasziou [SMTP:[log in to unmask]]
> Sent: Tuesday, January 20, 2004 11:17 AM
> To:   [log in to unmask]
> Subject:      Re: sad
>
> Dear Martin & Co.,
> I agree this episode is indeed distressing. Far from Dave Sackett's predictation for 2005 - that the Bolem test (of peer practice) would be replaced by the Cochrane test.
> However, this doesn't seem uniform across countries. In Australia, litigation issues for Veteran's affairs had been taken out of court and replaced by an evidence review of possible causality.
> So I think we have steps forward and back, and should welcome and encourage the steps forward,
> Paul Glasziou
>
> At 20/01/2004, Roy Poses wrote:
>
>
>       At 09:42 AM 1/20/04 -0500, you wrote:
>
>
>               The piece by Daniel Merenstein in JAMA vol 291 2004 p15 - 16 was very disturbing. It seems that it is litigiously safer to practice sub-optimal care if that is what is normally practiced rather than to use evidence to improve your care thus making it different from others. If this really does become the case then the legislation of various countries will be ultimately responsible for a lot of harm.
>               How can we change this approach? We seem still to be having the same arguments as were going on 10 years ago.
>               It was really quite depressing reading and I would like to hear stories from others that redress the balance.>
>
>
>       Unfortunately, medicine in the US is increasingly dominated by large organizations whose economic and ideological agenda may conflict with physicians' core values, and what physicians may see as their responsibilities to provide the best possible care to each individual patient.  Evidence-based health care is a particular threat to these organizations since it may produce results that may threaten their vested interests.
>
>       A relevant example was that Yamey and Wilkes who were compared with Joseph Mengele for daring to suggest in public that PSA screening should not be done routinely.  (See Yamey G, Wilkes M. The PSA storm. BMJ 2002; 324: 431.)  The lay men's group that lead the attack against Yamey and Wilkes is mainly funded by the pharmaceutical industry.  (Lenzer J. Lay campaigners for prostate screening are funded by industry.  BMJ 2004; 326: 680.)
>
>       However, pharmaceutical manufacturers are hardly the only such organizations.  (Not to toot my own horn, but for more details, see my article: Poses RM. A cautionary tale: : The dysfunction of American health care.  Eur J Int Med 2003; 14: 123-130.)
>
>       ...............................................................
>       Roy M. Poses MD
>       Director of Research, General Internal Medicine
>       Brown University Center for Primary Care and Prevention
>       Memorial Hospital of Rhode Island
>       111 Brewster St.
>       Pawtucket
>       RI     02860
>       USA
>       401 729-3400
>       fax 401 729-2494
>       [log in to unmask]
>
> Paul Glasziou
> Department of Primary Health Care &
> Director, Centre for Evidence-Based Practice, Oxford
> ph: 44-1865-227055  www.cebm.net <http://www.cebm.net/>