Family Practice Vol. 19, No. 6, 704-707
© Oxford University Press 2002
Risk maps and three dimensional models: a rejoinder to Misselbrook and Armstrong
a Royal Free & UCL Medical School
b University of Hull
Dr Steve Iliffe, Dept. of Primary Care & Population Sciences, RFUCLMS, Royal Free Campus, Rowland Hill St, London NW3 2PF; E-mail: s.ilffe{at}pcps.ucl.ac.uk
The rise of risk as an intriguing subject of medical, health and lay debate seems inexorable. Misselbrook and Armstrong1 have usefully identified its centrality to clinical practice alongside managing risk through clinical governance2 and limiting risks through public policy initiatives like the creation of the Food Standards Agency. Misselbrook and Armstrong suggest that citizens have a bimodal concept of high and low risk that is different from the mathematical risk models used by doctors, and that the task for clinicians is to find ways of constructing a common language to discuss probability. In this response we argue that citizens’ concepts of risk are more complex than those of doctors’, and that medical perceptions of risk are both negative and partial. Before we can develop a common language clinicians need to acquire a broader perspective of risk as a social and subjective construction that is more than the probability of adverse outcome.
It is clear from evidence of patient and lay behaviour that individuals have varying perspectives on risk.3 For example, individuals may over-estimate the risks from infrequent hazards and under-estimate the risks from common hazards. Similarly, the risk of fatal outcome may be judged to be higher than it really is if the causes of death are vivid and imaginable.4 Risks may be seen as highly probable but of low consequence (e.g. measles) or of low probability but high consequence (e.g. autism following MMR immunization). Such risks may be experienced as widespread in modern society, arising from its reflexivity (e.g. contamination of the food chain), from human violence on a mass scale and from the threat of personal meaninglessness.5 Responses to risk may depend on the individual’s relationship to the dominant intellectual culture, with a spectrum stretching from congruence with professional authority at one end to dissenter status, frontier mentality or fatalism at the other.6 We suggest that clinicians might usefully think of risk perceptions in their patients using the three dimensional model shown in Figure 1
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These variations of risk perception may well differ from medical opinion but we now know that they are more than a matter of information deficits, or miscalculations of probabilities. Context and individual constructions of costs and benefits appear to be important. Such constructions are apparent in Graham’s study of mothers who smoked7 and the way in which smoking offered them moments of pleasure, often in a very difficult and stressful context of deprivation and difficult family circumstances. The John Everyman used to illustrate Misselbrook and Armstrong’s arguments may well be aware of the risks of smoking but juggle these in respect of his other, perhaps more immediate and pressing, priorities and preferences.
Professionals readily neglect the positive aspects of risk-taking. Risk is frequently seen as negative, as synonymous with harm or danger8 but if defined as such misses the elements of uncertainty, unpredictability and elation. John Everyman presumably finds benefits or pleasure in smoking. At times, this positive acceptance of risk can be seen as poor judgement, but risk-taking by itself may be an important aspect of individuality, and central to notions of adulthood.9 Within primary care good practice guidance increasingly points to the value of risk-taking for people with dementia, for example.10 The professional emphasis on risk as hazard pathologizes the need to walk as ‘wandering’, but this can be normalized again by accepting walking as desirable, and organizing for it in a safe environment. This points to potential for clinicians to encourage risk: a different approach to both the calculated, factual transfer of information and the ‘pathologizing gaze’ that converts everyday activity into possible hazard.11
Such moves increase the value of Misselbrook and Armstrong’s identification of talk and language as important parts of the doctor: patient transaction around risk. While some patients may seek certainty and calculation, others may wish for information and support with which to inform their own risk-taking. The difficulties of handling uncertainty pose challenges for professionals, for although experts can (by definition) deal with uncertainty, those nearer novice status need rules to guide their thinking and acting. In a service dominated by professionals in training (like the NHS) managing uncertainty, and risk is therefore a major problem. Oversimplifying patients’ needs for knowledge and judgements can lead to negative outcomes, as shown in the Bristol Inquiry,12 which has eloquently set out the range of individual clinical and organizational implications of limited risk awareness and communication. The perceived failure to convey risks at Bristol has helped undermine the medical profession as an authority on risk, and made debate more difficult than it needs to be. Hence the dispute over MMR immunization, in which the rumour of a (high consequence) risk is sufficient to change parental decisions and to provoke angry medical responses about indoctrination, scaremongering and citizens becoming more ‘informed’ by an irresponsible press.13
Conversations are, of course, two way processes and at times involve other people (family) or other practitioners (the team). We may find it helpful to talk less of patients’ rejection of clinical advice and to avoid polarities of acceptance and dismissal. Risk-taking is, after all, pervasive and few of us would claim any superiority in managing or negotiating risks. In this sense we agree with Misselbrook and Armstrong that a map is a useful metaphor for the clinical transaction but it is one in which some areas are relatively uncharted. Much depends on an individual’s preferred route, and, of course, his or her freedom to change direction in some respects. Equally, the map needs to be as accurate as possible, without some features being exaggerated at the expense of others. Smoking is a risk factor for heart disease, but it is less powerful as a risk factor than socio-economic status.14 Does this mean that the conversation about heart disease risk should begin with relative deprivation and only later move on to lifestyle factors? We suspect that most practitioners do not see socio-economic status as tractable in their world, and reduce its significance, possibly to zero. The result is a distortion of medical science itself, through the re-attribution of mortality risk to smoking when it is independently related to education and income15 and also the debasement of policy making on health inequalities.16
Similarly, while receiving a map of an uncertain world is possibly worth the risk of a visit to the doctor (itself a matter of weighing up positive and negative consequences and their likelihood), we may need to accept and work with the imprecision of concepts and language around risk. Searching for common understandings of likelihood in order to clarify ‘messy’ language may have certain attractions but, as Misselbrook and Armstrong demonstrate, patients’ expressions and beliefs may of necessity be indeterminate and so, to an extent, are those of clinicians. Actual risks of ill health may be a function of the inter-relationship of socio-economic status, learned coping strategies, genetic endowment, differential susceptibility17 and the psychosocial environment,18 with chosen lifestyle a minor component. All of us understand this, to some extent, because we know from experience about the prevention paradox—most of those who do risky things get away with it. To be effective, therefore, any map of risk has to be very detailed and personally relevant.
A central element of Misselbrook and Armstrong’s argument is the construction of meaningful exchange between doctors and patients around risk, a task which will become increasingly important if the MMR story is any indication. What could restore trust and make dialogue possible? And how can such dialogue be part of the brief or transitory encounters of clinical practice? In our view there are several ways forward, one being to understand patients’ likely appreciation of risk using a three dimensional model like that in Figure 1
. John Everyman most likely knows the risks for he is subject to ubiquitous health promotion messages and possibly family pressures about smoking risks. If he is not a dissenter or a fatalist, his decisions about smoking may flow from his categorization of smoking risks as low probability (distant in time) even if of high consequence. Discussion with his medical practitioner may need to focus on the benefits of smoking, and what it would take for the long term, seemingly low probability disadvantages to outweigh the short term, high probability benefits. Such a discussion will be different if the benefits of smoking are a gain in social status at minimal personal outlay, or an expensive but accessible pleasure in a highly stressed life.
Detailed knowledge of the positive experiences of risk and the value placed on these are relevant to such conversations. Risk has much to do with values, whether these are choice, individuality or desires for excitement and challenge (or indeed the quiet life). Misselbrook and Armstrong’s perception of a bimodal lay understanding of risk, and some responses to the MMR debate, suggest that professionals’ awareness is limited and unequal to the task. How then can awareness of the context of risk judgements be incorporated into professional education? And finally, to use the image of the map, how will the cartographers of risk know that their projections match reality, and how will they make a sceptical public trust their map-making?
References
1 Misselbrook D, Armstrong D. Thinking about risk. Can doctors and patients talk the same language? Fam Pract 2002; 19: 1–2.
2 NHS Executive. Clinical Governance: Quality in the new NHS. HSC 1999/065. London: Dept of Health, 1999.
3 Finucane M, Slovic P, Mertz CK, Flynn J, Scatterfield TA. Gender, race and perceived risk: the ‘white male’ effect. Health, Risk & Society 2000; 2(2): 159–172.
4 Pidgeon N, Hood C, Jones D, Turer B, Gibson R. Risk perception in The Royal Society (ed.) Risk: analysis, perception and management. Report of a Royal Society study group, The Royal Society, London 1992.
5 Giddens A. The consequences of modernity. Cambridge: Polity Press, 1990.
6 Douglas M. Risk and blame: essays in cultural theory. London: Routledge, 1992.
7 Graham H. When Life’s a Drag: Women, Smoking and Disadvantage. London: Dept of Health, HMSO, 1993.
8 Alaszewski A, Harrison L, Manthorpe J (eds). Risk, Health & Welfare. Buckingham: Open University Press, 1998.
9 Manthorpe J, Walsh M, Alaszewski A, Harrison L. Issues of risk, practice and welfare in learning disability services. Disability and Society 1997; 12(1): 69–82.
10 Clark CL. Risk: constructing care and care environments in dementia. Health, Risk & Society 2000; 2(1): 83–93.
11 Lippman A. Choice as a risk to women’s health. Health, Risk & Society 1999; 1(3): 281–291.
12 Kennedy I. Learning from Bristol: the report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984–1995, CM 5207. London: The Stationery Office, 2001.
13 Barnes N, James E. There is no room for lingering doubt. Br Med J 2002; 324: 734.[Medline]
14 Hertzman C, Frank J, Evans RG. Heterogeneities in health status and the determinants of population health. In Evans RG, Barer ML, Marmor TR. Why are some people healthy and others not?: the determinants of health of populations. New York: Aldine de Gruyter, 1994.
15 Davey Smith F, Shipley MJ. Confounding of occupation and smoking: its magnitude and consequences. Social Science & Medicine 1991; 32(11): 1297–1300.
16 Davey Smith G, Ebrahim S, Frankel S. How policy informs the evidence. Br Med J 2001; 322: 184–185.
17 West P. Rethinking the health selection explanation for health inequalities. Social Science & Medicine 1991; 32(4): 373–384.
18 Marmot M, Theorell T. Social class and cardiovascular disease: the contribution of work. Int Journal of Health Services 1988; 18: 659–674.
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