Haslam D. Haslam’s view:Helping our patients to understand risk. Practitioner 2015;259(1786):35

Helping our patients to understand risk

21 Oct 2015


Professor David Haslam CBE FRCGP Chair NICE, Past President BMA, Past President RCGP


The views expressed are those of the author and do not necessarily reflect those of NICE.


On a blisteringly cold and snowy day in the depths of the Fens, I watched what was probably one of the wildest sights I have ever seen. Nature red in tooth and claw, in Tennyson’s famous words.

It was at a wildfowl trust. Welney is home to more than 9,000 migratory whooper and Bewick’s swans. One winter’s day I watched as a fox stalked its way very slowly among them. The swans took almost no notice. The fox picked its way carefully from swan to swan, as if sizing up the most likely meal to take from the buffet, and then without the slightest warning  pounced, killed and dragged off a swan and started to eat it. The red blood on the pure white snow was astonishingly vivid. After a few minutes of profound consternation and panic, the surviving swans settled back to their peaceful lives.

As I watched, I remember being struck by how unconcerned they were about the fox, before it actually attacked. I know I am being excessively anthropomorphic, but it was almost as if they had made a personal calculation: ‘One fox, 9,000 swans. It probably won’t be me, so I’ll keep eating’. Most of them would have been right.

Knowing that something is a risk doesn’t always change behaviour. Indeed, sometimes it shouldn’t. If we all lived our lives terrified of the tiniest risk, we would never go anywhere or do anything.

Sometimes the exact opposite applies. Driving down the motorway you can pass a stationery queue of traffic several miles long, and just before the end of the queue you see cars overtaking riskily in the belief that the risk is going to get them somewhere quicker – only to come to a sudden and lengthy stop. All that adrenaline, risk, and anticipation entirely wasted.

Every GP develops a profound understanding of risk, and of the sudden changes that can impact on anyone at any time. We see patients who are so unnerved by the risks that face them that life becomes impossible. We see patients who take so little notice of risk, that for instance, they smoke, and they smoke only to stop the moment that cancer is diagnosed.

 Helping our patients understand risk, understand when the fox is likely to pounce, and when it can safely be ignored, is a critical part of every doctor’s work. Shared decision tools that make this process more understandable are going to become an increasingly important part of our lives.

Not everyone seems able to take risk management on board.

Some years ago I had a patient who smoked incredibly heavily. When I suggested he stop he came out with the old line about his uncle who had smoked all his life, never had a day’s illness, and had died in his late nineties.

I thought of what I believed was a brilliant analogy. In our practice area there was a crossroads where a minor road crossed a very busy main road. I said, ‘If you blindfolded yourself and drove straight across the main road and managed to get to the other side alive, it wouldn’t prove it was safe, would it?’ Surviving something doesn’t prove it’s safe.’

He looked at me scathingly and said: ‘But I don’t drive.’

Incidentally, at the start I said that the fox attack on the swan was one of the wildest things I had ever witnessed. The wildest event was at a conference. A drug company was giving away free umbrellas from its exhibition stand. I will never forget watching fists fly, genuine hand to hand fighting, punching, pulling, yanking, and anger breaking out, as distinguished delegates fought to get their hands on an ever diminishing supply of umbrellas.

It made Brer Fox look like a softie.