Book Reviews
Health Care and Notions of Risk
Richard C Clark
ISBN: 0-958619-83-2 2004 PB 60 pages North Melbourne: Therapeutic Guidelines Ltd
Michael D. Mehta
Professor and Chair, Sociology of Biotechnology Program, Department of Sociology, University of Saskatchewan, Saskatoon, Canada
Many people who specialise in risk have begun to appreciate a central truism of our times, namely that we live in a 'risk society'. Risk has become a form of currency in the modern world and is being used as a conceptual tool for understanding how a range of actors and institutions respond to new technologies, changing global dynamics, concerns about liability, and the evolving nature of shared decision-making under various kinds of uncertainty. In the realm of health care, risk is seen by many practitioners and policy-makers as an indispensable concept for focusing attention on patient safety. In Health Care and Notions of Risk, Richard Clark reviews the results of a national survey of 1501 Australian adults on their experiences with adverse outcomes (medical mistakes), perceptions and preferences about participating in medical decision-making, and perceptions of risks in health care.
To focus his analysis on these experiential, preferential and perceptual issues, Clark begins by reviewing the history of adverse medical events. In this review Clark reflects on the centrality of risk in health care and provides several examples of how medical errors are under-reported, costly to the health care system as a whole, and challenging in terms of the ethical issues that often arise when risky medical interventions are undertaken. The approach here is refreshing and on-target. Instead of discussing risk only in the abstract, he appropriately combines the growing literature on risk perception with a general sociological analysis of the changing nature of medical decision-making. As many now appreciate, a patient-centered approach to health care creates its own challenges but it will invariably benefit from a more nuanced understanding of how patients perceive the risks and benefits of various treatment options.
In his analysis of the national survey, Clark notes that the health care system is perceived as 'moderately safe' when compared to other hazards including tobacco, chemicals in the environment, food handling and nuclear power. Differences by demographic variables like sex, income, age, level of education and region are included in the analysis to provide a richer understanding of how best to address concerns of patients, and to focus the discussion on the nature of self-reported medical mistakes, and other areas like declared satisfaction with the last medical experience.
Unlike other studies on this topic that gather data from patient satisfaction surveys, law suits and coroners' reports, this study provides new insights into how risks and benefits can be balanced to meet the needs of patients, so as to foster a democratisation of health care that could improve the level of trust patients have in their health care providers. Since many patients now turn to alternative sources of information (the Internet) for guidance on how to manage personal risk, interpret treatment options as outlined by health care providers, and to learn about new therapeutics, the era of the passive recipient of health care is mostly dead. In a sense, Clark's report validates this observation by suggesting that patient perceptions of risk are likely to be magnified when trust is low and patients are kept out of the decision-making process.
Clark's review of the data offers a glimpse into the relationship between patient assessments of risk and self-declared interpretations of adverse outcomes, their causal mechanisms and understandings of how adverse events could have been prevented. Clark reports that the most important way to prevent an adverse outcome is to improve communication between patients and health care providers. Improved communication is likely to create a bond of trust that works to enhance patient compliance with treatment regimes and to foster higher levels of satisfaction in both patients and health care providers. This virtuous circle reinforces the kind of behaviour that will maximise the likelihood not only of compliance but follow-up, greater patient-centered vigilance and perhaps even preventative care. In short, Richard Clark's monograph demonstrates the value of a risk-based approach to health care. However, instead of relying solely upon traditional, scientifically rational conceptions of risk, Clark shows us how patient safety can be improved by building the right kind of social and cultural environment for communicating risks and benefits to patients, and the rewards that may flow from this kind of understanding.
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