How Risky Conversations Fail for Rheumatologists

Blalock SJ, DeVellis BM, DeVellis RF, et al., Medication Risk Communication During Rheumatology Office Visits. Arthritis Care & Research. 2015;67:161–168. February 2015. Article first published online: 27 JAN 2015. doi: 10.1002/acr.22424. 

How you tell RA patients about medication risks may be almost as important as what you tell them.

During routine office visits, clinicians seem to devote only limited discussion to the risks of rheumatoid arthritis (RA) medications. And when they do discuss risks, doctors and patients often speak different languages, this study shows.

These researchers at the University of North Carolina at Chapel Hill analyzed more than 1,000 taped office visits involving 450 RA patients from two states. They found that most of the time rheumatologists bring up the subject of medication risk only when they are adding or changing drugs.

However, in almost half of cases, patients initiate conversations about the risks of past medications, and about medications being added to their regimens only 10% of the time. Evidently they would prefer to talk about problems they’ve already experienced much more than about side effects they’re likely to have in the future.

In the recorded conversations, when proposing to add a new drug rheumatologists often stressed the importance of catching potential problems early, especially by monitoring with lab tests (e.g., liver and kidney function).

But some patients may interpretthis as suggesting that a medication is dangerous, the authors suggest, and may be reluctant to start the new drug as a result.

Similarly, when discussing risk probability, clinicians used only qualitative terms, such as saying risk of a side effect is “rare.” The doctor means the risk is slight; that’s not what the patient may hear.

“While rheumatologists may have the intention of reassuring patients about medication safety when describing a particular risk as ‘rare,’ it is likely that most patients lack sufficient expertise to interpret such terms in a meaningful way,” the researchers comment. In fact, some patients may misinterpret "rare" as meaning more dangerous, they add.

“Remember that you can get a little bit of hair loss with methotrexate, but it’s very rare," one physician reassures a patient during a recorded conversation. "And, if it happens, we stop it and it comes back.” The doctor minimizes the hair loss, but previous studies reveal that 38% of RA patients are not willing “under any circumstances to accept the risks only associated with cosmetic changes (e.g., acne, alopecia),” the authors note.

The patients in this study, most of them fairly educated Caucasian women older than 61, were seeing by rheumatologists in their mid-40s, most of them men.

The only significant gender-related finding: Physicians were more likely to minimize the risk for severe effects if the patient was male.

A 2014 study found that RA patients may be more fearful of drug side effects than of living with their chronic disease, which makes them reluctant to take some medications. And it gave another reason to be careful how you speak: Learning new information that contradicts what they think they know about their medication may make them even more reluctant to take it.

So how can you say the right thing at the right time? Predictably, the North Carolina authors say more research is needed.