Public health OSCE

Risk communication

How to tell the patient about it:

Explain importance of source of information. Inform patient to read behind the headlines
for more information, educate: not everything you read in newspaper is true (often facts
are distorted or misinterpreted).
o Also need to note source of where the data was from e.g. surveys or databases?
More important to know limitations / advantages of study design! Rather than what type of
study assess quality if you know the study.
o Tell patient I will also have to read the actual paper itself and get back to you.
Meanwhile you may want to read ___ and take some time to think about what I
have just explained.
o 1 paper = need wider body of experience time lag before evidence implemented
into policy e.g. NICE guidelines.
Clear data explanation in an appropriate format (understandable terms e.g. 3-4 X or %) e.g.
give both RR and OR, dont need to explain why the difference or why they are like that.
Not just that OCP cause increased risk thrombosis many other risk factors.
BG risk. Mentions a comparator: thrombosis risk is increased naturally anyway e.g. in
pregnancy is 4-5X increased while OCP is only 2X of a rare event (draw this or analogy to
illustrate). Risk is much less than a pregnant lady, how many pregnant mum has blood clots
that threatened their life?
o Therefore relative risk (type of risk ratio) is high and something common (incidence
high) = more useful (if not skew data)
Patients life values, goals (context)
Alleviate fear
o Especially if the article is sensationalist e.g. put absolute risk way down in the article,
and put relative risk way up omg 2X more likely (fear-mongering since no
absolute number to compare twice as likely to get blood clots, but the old event is
VERY rare so 2X of very rare event = peanuts).
o Article puts in people who die (and even quote deaths from old pills instead of new).
Risk assessment
o Likelihood x severity (have to COVER BOTH)
Severity = someone died, spreading infectious disease.
Inform patient that results are based on population MAY NOT APPLY TO PATIENT!
Dont say stop the Pill!

Article 1 2 3 4
Risk RR RR RR RR
4X vs norm pop Same
2.5X old vs. new 2X old OCP vs.
norm
Study design Retrospective, but cannot tell if cohort or case-control

Absolute 14 (assumed to be 14 out of 10,000

(attributable) risk out of 1 million
which the article is
wrong!)
Attributable Can be derived.
fraction
NNH Can be derived.
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Key definitions.

Relative risk compared to Y, what is the ratio of cases when I do X.

Absolute/attributable risk already takes into account background rate; how many NEW
/EXTRA cases given I do X.
NNH number of patients exposed before you harm 1 patient.

Case control:

Select based on OUTCOME (who has thrombosis from GP database just need to find from
database who on OCP).
Tends to be OR but in the OCP article, it can be approximated to RR
Because rare outcome of thrombosis = RR ~ OR
Since the outcome is SO RARE case-control is good here
Other advantages can match controls (up to 4 controls to increase the power) + cheap &
quick (already know who has the rare outcome).
Weaknesses?
o Recall bias (but NOT here since use GP databases; but can be MIScoded!)
o Retrospective (no temporal relationship)

Cohort studies:

Select based on EXPOSURE (who was on OCP then search GP database who has DVT).
o Since outcome is SO RARE, you would need lots of people in a retrospective cohort
to meet your exposure e.g. females on Pill = more expensive and time-consuming
esp. if errors in code.
Retrospective cohort look back e.g. white hall study recruited pregnant ladies who gave
birth in 1946 collect the data to answer pre-defined Q e.g. social determinants or now in
2017, I need to answer new questions = can use the same data (retrospective)
Prospective cohort You collect data as you go = not efficient use of resources either since
you need to recruit SO MANY people since outcome is SO RARE. People you recruit also tend
to be younger and older.

Cross-section is merely a snapshot of a period of time or 1 timepoint. Since snapshot, you can never
determine a temporal R/S. For example: fruits + veg consumption & less overweight at my timepoint
ok, but dont tell me their diet in the past. Another disadvantage (also temporal problem =
future) take the Pill = increased risk of thrombosis later in life (but cant determine NOW).
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Calculations

Attributable risk

Incidence of exposed incidence of unexposed (background) = number (out of 10, 000)

This is the key info patient want.

Attributable fraction

AR divided by incidence of exposure = %

Harder to explain, which is why not even in articles.

In this case:

Ie Io = 14 per 10,000.
Ie = 4X
4 Io Io = 14 per 10,000
Io = 14/3 = 4.7 per 10,000
Ie = (14 + 4.7)/10000 = 18.7 per 10,000
AF = (18.7 4.7)/ 18.7 = 75%
Population of study not stratified by group e.g. smoker, obese etc. but was well case-control
matched 1: 5, so confounders probably taken into account.
 Public health OSCE

Screening

Julie is your 52 year old patient who received a letter with screening results of the 1st screening test.
The letter tells her that the test is +ve, and she needs to attend breast assessment clinic for further
investigations in 2 weeks. She is very surprised and is upset by this news, as she has been taking care
of her health and she checks her breast often and have not found any lumps.

She wishes to discuss:

1. Concerns relating to her +ve result
2. Risks and benefits of breast screening
3. False +ve and false ve
4. Controversy of over-Dx and over-Tx
5. Likelihood of the screening results being TP.

Key facts:

4 in 100 +ve result and go for further test

1 in 5 have abnormal result test cancer
Overall, 8 in 1000 pickup rate of cancer
Breast assessment clinic may include O/E, more mammogram, US, needle Bx, FNA
Women who are Dx at earlier possible stage have 9 in 10 chance of surviving at least 5 years
after Dx
4000 out of 15500 will be over Dx, but 1300 lives will be saved.
o This means for 1 live saved, 3 over-Dx

Patient instructions:

You check your breast regularly and have never found any signs or Sx of cancer so why did you
receive a +ve test?

You have read some articles of interest which imply that breast screening is unreliable, WHY is this
the case?
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Student pointers

How are you? Risk factors evaluation.

You dont need to use all information given to you in the sheet but enough to meet the
following points below
o However, you have to be balanced, reassuring yet clear guiding patient to their
preferred choice (their values).
o There is no need to add information off the sheet. If you do so, be CONFIDENT of the
facts.
What do you know so far?
What do you want to know?
Avoid the use of jargon e.g. FP, FN instead explain immediately. Use diagrams if necessary.
o Such as a flow chart
O/E +ve (or straight from offered screening)
Digital mammogram +ve FNA or Bx to assess (invasive)
1000 41 called back of those 8 found to have cancer (1 in 5).
Treatment
ICE
Frame the risk and test SN = reassuring yet clear. E.g. benefits > risk. E.g. strong benefits if
detect early.
KEEP checking with patient
o Do you understand what I am saying so far?
Addresses concern of controversy in over-Dx and over-Rx
Ultimately patient choice (you are just providing the information informed choice)

Actor pointers

Do you think the doctor communicate in a way that you can understand?
Was the doctor reassuring?
Does the doctor address controversial issues regarding the screening?
Explained why tests are not always accurate.
Can you make the choice based on the consultation?