Disconnect Exists Between What Patients Hear vs What Clinicians Try to Say

Patients hospitalized for cardiovascular conditions are, in comparison to the physicians providing their care, more likely to underestimate their future risk, according to a recent study conducted in Spain.

Moreover, a disconnect exists between patients and physicians as to whether there’s adequate communication about potential procedural complications and medication side effects, investigators report in Circulation: Cardiovascular Quality and Outcomes.

Earlier research has shown “patients often struggle with understanding medical risks, leading to significant discrepancies between what physicians think they have communicated and what patients actually comprehend,” Juan Górriz-Magaña, MD (Central de la Defensa Gómez-Ulla University Hospital, Madrid, Spain), and colleagues say. “This disconnect can have serious implications, not only for patient satisfaction but also for adherence to treatment and overall outcomes.”

Risk communication, they explain, “goes beyond merely presenting statistical data and probabilities, emphasizing the implementation of effective communication strategies.”

Jared Magnani, MD (University of Pittsburgh School of Medicine, PA), commenting on the new findings for TCTMD, pointed out that in clinical encounters, patients bring with them their own perspectives and “fundamental fabric” as human beings. “If there’s dissonance between what patients are thinking and what we’re thinking as physicians, then it really behooves us to ‘meet patients where they are,’” he stressed.

“In general, we should assume that patients have a limited understanding of their diagnosis and treatments and they bring their [own] personal framework and experience into their care,” Magnani said. “Patients can share a lot about how they experience acute and chronic disease, and we can learn from them in order to address their understanding and integrate those aspects into our treatment and management.”

Though this study addresses an important topic, he added, it does not offer insights into which strategies might be helpful or address the key role of health literacy—people’s capacity to understand and participate in their own care. Education level and other social determinants of health, for example, can impact how individuals interpret information about their own risk. In this study population, Magnani noted, 44% of patients had completed no more than primary education.

“As we have therapies that are more and more complicated, people are living more with multimorbidity, and their treatment regimens are getting more complex, [better communication] is becoming increasingly paramount to us,” he stressed. “If we as doctors can’t partner with our patients, then we’re not going to be able to help them with chronic disease self-management, adherence to treatments, [and] electing treatments.” This in turn, said Magnani, will lead to worse outcomes.

Sadiya Khan, MD (Northwestern University Feinberg School of Medicine, Chicago, IL), who led the development of the PREVENT equations for comprehensively estimating long-term risk of cardiovascular disease, agreed that these are crucial questions to address.

This study “highlights how much more of this type of research that we need on how we communicate risk and how risk is perceived,” she said. In designing risk calculators to be accurate, “we spend so much . . . time thinking about making them right, but they are not useful unless they’re able to be translated and effectively implemented.”

More research should be done to “demonstrate that one way of communicating risk is better than another way” and to assess whether these various approaches sway outcomes, said Khan. It also would be helpful, she suggested, for clinicians and researchers to partner with experts in risk communication when looking at implementation.

Risk Perception—or the Lack Thereof

For the study, researchers included 943 adult patients (mean age 68.2 years; 29.4% women) who had urgent or scheduled hospital stays for cardiovascular conditions across 28 hospitals in Spain over a 6-month period ending in March 2023. The most common reasons for admission were ischemic heart disease (41.3%) and heart failure (18.1%).

Each patient completed a self-administered, paper-based questionnaire based on the American College of Cardiology’s Improving Cardiovascular Risk Communications tool kit during the hospital stay or within 24 hours of discharge. On the same day patients were surveyed, their treating physicians completed a corresponding questionnaire.

Patients and physicians showed “substantial agreement” when it came to identifying the reason for admission, with a Kappa index (KI) of 0.72, the researchers report.

Responses were less well-aligned when it came to potential procedural complications among patients who underwent interventions, for which the weighted KI was 0.34. Around three-quarters (76.9%) said they received this information, 13.4% said they did not, and 9.7% either were uncertain or failed to answer. In contrast, 93.4% of physicians said they had explained the risks. Additionally, of the 199 patients who did experience complications, 69.3% said they hadn’t been warned about them ahead of time.

Similarly, for future cardiovascular risk, 29.4% of patients said they were unaware of their risk and 1.8% didn’t answer the survey question. Among those who did, 24.7% perceived their future risk as high and 9.5% as very high. Among physicians, 20.4% rated their patients as having high risk and 39.2% as very high risk, which resulted in a weighted KI of 0.29.

“This underestimation is particularly problematic in cardiovascular care, where accurate risk perception is crucial for motivating lifestyle changes and adherence to preventive therapies,” Górriz-Magaña et al note.

The questionnaire also revealed discrepancies over communication about what adverse events might accompany new medications, as well as uncertainties about the cause of disease, treatment and prognosis. More than a third of patients reported feeling scared and a quarter said they felt sad, though both older age and having a prior CV hospitalization appeared protective against fear and sadness.

Patients with a history of CVD or those who had been previously hospitalized for a CV event were more likely to regard themselves as having higher risk along the lines of their physician’s ratings, as did those with diabetes. Men tended to gauge their future risk as lower than women.

Communication with patients is not about good intention. . . . There is a skill set that people can acquire. Jared Magnani

“As well-informed patients are more likely to adhere to preventive therapies, tailoring communication strategies to individual patient characteristics could improve understanding and align perceptions with clinical realities, enhancing health outcomes,” the investigators conclude.

Effective communication is “not just about what is said but also how it is said,” they add, highlighting the need to assess patients’ priorities and to engage in shared decision-making based on a clear understanding of risks and benefits.

For clinicians, “communication with patients is not about good intention. . . . There is a skill set that people can acquire and training that people can have in order to bolster their capacity,” Magnani said, adding that simple examples of these skills include being attentive to emotions and not interrupting. “We’re partnering with patients, and we’re embracing the fact that our patients may not understand or appreciate the complexity of their diagnosis.”

These concepts should be integrated into medical training programs and become part of the clinical workflow, wherein physicians can document health literacy and identify gaps in comprehension, he advised. Magnani said it’s also worth noting that the metrics clinicians use to describe risk, such as the CHA₂DS₂-VASc score in atrial fibrillation, might not be intuitive to patients.

“This whole topography is kind of buried by the demands of clinical care,” he said. “We’re really good, I think, at delivering the most contemporary care that is to the best advantage of our patients. We’re very deficient in communication with our patients.”