If you are having an operation or any surgical procedure, an important conversation needs to take place long before you enter the operating theatre. This discussion should include the procedure being recommended, what the alternatives are, what the likely benefits are and, importantly, what could go wrong.
This can sometimes be one of the most difficult conversations in medicine because the concept of risk is surprisingly difficult to grasp. If I tell a patient that there is a one per cent risk of a particular complication, she may think, “That is very unlikely.” Another patient may hear “one per cent” and think, “There is a chance this could happen to me.” Both responses are completely understandable.
Our perception of risk is influenced by many things, including our previous experiences, our fears and how serious we believe the possible consequence to be. Research has shown that patients can have quite different perceptions of surgical risk from the estimates given by their doctors.
We accept risk every day without necessarily thinking about it. When we get into a car and drive to work, we know there is a small possibility of being involved in an accident, but we accept that risk because the benefit of getting to work is important to us. We cross a busy road, knowing there is a risk of being knocked down; we board an aeroplane, despite knowing that flying is not completely risk-free; we go swimming, cycling or running, understanding that injuries can occur.
We make these decisions almost instinctively, weighing the perceived risk against the benefit. Medical decisions are really no different, and often we accept a degree of risk because the risk of not treating the problem is greater.
If an operation has a small risk of a complication but offers a significant chance of treating a cancer, for instance, or preventing a serious health problem, we may decide that the potential benefit justifies accepting that risk. The important difference is that, in medicine, we should not simply assume that a patient will accept the risk—we need to explain it clearly, put it into context and allow them to decide whether the potential benefit is worth it.
Also crucial, our job as doctors is not to promise zero risk. That would be impossible. Our responsibility is to understand the risks, explain them honestly and do everything reasonably possible to minimise them.
This becomes particularly important in patients considered high-risk. Someone who has had previous major surgery, has significant medical conditions, is older or overweight, may have a very different risk profile from another patient having the same procedure.
In these circumstances, I believe the conversation needs to be even more detailed. We should explain not only what we hope to achieve but also what complications might occur, how likely they are and what we would do if they happened.
The way we communicate risk matters enormously. Studies have shown that people often understand absolute numbers better than relative risks, and visual aids can improve understanding. Sometimes I will say, for example, “This happens in about one out of every 100 patients,” rather than simply saying “There is a one per cent risk.”
And you should certainly ask questions.
Ask what happens if something goes wrong. Ask how often the complication occurs. Ask what the alternatives are. Ask about recovery. Ask whether there is anything that makes your particular risk higher or lower. There is no limit to the number of questions you are allowed to ask about your own body.
Finally, even when everything is done correctly, complications can still happen. Surgical experience and technical skill matter enormously. An experienced surgeon can recognise difficult anatomy, anticipate problems, make careful decisions and manage complications when they arise. But surgery is never completely predictable and reducing risk is not the same as eliminating it.
When I recommend an operation, I am essentially weighing two sets of risks: the risks of doing something and the risks of doing nothing. My job is to help my patient understand both.
And this is where risk perception becomes so important. A complication that occurs in one patient in a thousand may feel terrifying to the person sitting in front of me, particularly if she is that one patient.
Conversely, a risk that sounds relatively small on paper may have enormous consequences if it occurs. Statistics can describe risk, but they cannot completely describe what that risk means to an individual person.
That is why I do not believe my role is simply to tell patients the numbers. It is to help them understand what those numbers mean in the context of their health, their operation and their circumstances. We cannot practise medicine without risk. What we can do is recognise it, reduce it wherever possible, communicate it honestly and make decisions together.
