When it’s time for a patient to decide — on a medication, a surgery, or a lifestyle change — how do you tell them about the risks?

Risk communication has been studied for decades. Physicians can consult any number of flow charts, framing choices, and visual aids to present pros and cons.

Yet miscommunication still happens — a lot.

A recent analysis by Italian researchers found that doctors and patients averaged 10 misunderstandings during a 30-minute pancreatic cancer discussion. Many stem from implicit communication, like misconstrued meanings, body language, tone, and questions left hanging and never addressed. Other than the teach-back method, there aren’t a lot of ways to spot them.

“Most communicators don’t realize when they are being misunderstood,” said University of Michigan risk communication expert Brian J. Zikmund-Fisher, PhD, who recently co-authored a report called Making Numbers Meaningful.

Experts suggest a surprising approach: Lean into uncertainty. Admit that nobody knows for sure. When a doctor concedes uncertainty, proponents say, it can lead to more personalized medicine, authentic shared decision-making, and fewer misunderstandings.

This requires a self-aware and self-critical mindset, said Paul Han, MD, a senior scientist and bioethicist at the National Cancer Institute in Bethesda, Maryland — something medical schools don’t teach.

It’s a “metacognition,” he said — a way of thinking about thinking. “It’s a knowledge of your own ignorance.” Knowing the limitations of statistics and risk information can be a positive: “That uncertainty becomes kind of a strength, or a capacity, that will allow [clinicians] to be self-reflective and not sort of go into these conversations thinking that, okay, my job is: ‘I have the truth,’” Han said.

This can be an adjustment for a doctor who has done the homework, marshalled the numbers and, after all, has done this before.

But going a step further — talking about what the numbers can’t tell us — may be beneficial for you and your patients.

Uncertainty and Communication

It’s hard to recognize a misunderstanding in real time, said the lead researcher of the Italian study, Monica Consolandi, PhD, a philosopher of applied language in healthcare settings.

They often happen when clinicians embark on extended monologues or when patients are overwhelmed or frightened, Consolandi’s team found. Recognizing these moments may help a doctor realize the limitations of evidence-based medicine and steer the conversation to a more personal level.

What the finding boils down to, she said, is that physicians need to be more active when they listen to patients. Don’t interrupt, and work to keep a neutral state of mind, “because sometimes what we don’t realize — and this is part of the implicit communication — is that we have categories that we unconsciously apply to reality. When physicians listen to their patient, they have some very specific goals in mind, but maybe this is also why sometimes they don’t really understand what the patient is saying.”

A kind of teamwork is called for, Zikmund-Fisher said. “The clinician is an expert in the data of the health outcomes and their likelihoods,” he said. “The patient is the expert in their values and their life and the implications of what it would mean to them if these different things happen to them.”

“Both of those pieces need to be brought together to get a better decision.”

How to Limit Misunderstandings

Embracing uncertainty means acknowledging that “there are fundamental limits to what we know and can know,” Han said. That awareness can prompt physicians to guard against excessive certainty, against dogmatic views, and bring more humility and flexibility to a dialogue that fosters mutual understanding.

It’s a mindset shift away from truth-telling and toward the art of medicine. Now, you and the patient are struggling through these questions together.

“What do we do about you? What do we think about your risk? What is your risk? And because we don’t know what that is and we can never know what that is, there’s fundamental uncertainty,” said Han, who worked as a general internist and practiced palliative medicine before transitioning to research.

Risk estimates can be confusing, and there isn’t one right way of understanding them, Han said. He points to the longstanding tension between science and philosophy, such as the idea that probability does not exist or that there is no frequency of a single event.

Sure, in a study of 5000 people, there can be a 60% probability of an outcome, and that means 60 out of 100 people. Han calls this objective probability, and he says it’s only the first of two levels of probability discussion to have with a patient.

The second is personalized risk, and that is uncertain.

“We need to understand that people can look at the same risk number and come up with different understandings or they might move their own personal probability up or down based on things that they know about themselves that were never studied or measured in a study,” Han said.

“These aren’t in the risk models. These aren’t in the studies. And so it’s anyone’s guess what somebody’s true probability is and also what the right understanding of the probability estimate is when applied to that person and their situation,” he said.

A patient with prediabetes may have an eating disorder history they’d like to discuss before deciding on dietary changes, or someone may want to skip a colonoscopy this year because other life factors have frayed their emotional tolerance for a potential diagnosis.

Some will dismiss a risk number out of optimism and hope, which in medicine is often labeled as “denial.” A classic example is a family’s choice not to remove a loved one from a ventilator.

“We still can’t get rid of the fact that we really don’t know” if the patient will be the one in a million, Han said. “We need a dose of humility about that. And we need to answer these conversations.”

Choose Your Deep Dives

A deep dive into uncertainty requires a clinician’s judgment, Han acknowledged. For big decisions like palliative vs curative therapy, or whether to discontinue life-sustaining therapy, “these conversations are really important.”

“Teach-back is one preliminary step to make sure they understand the objective probabilities,” Han said, “but it should end with a mutual back-and-forth where we are constructing a probability. We’re discovering it. We’re constructing what makes sense for the person.”

Of course, if every clinical conversation was like this, “we would never get any work done as doctors.” But the big decisions require deep discussion.

Try These Approaches When Discussing Risk

Be curious. Many misunderstandings in the Italian study occurred while collecting patient medical history. Actively listen and consider using the teach-back method on yourself, such as saying: “Here’s what I heard you say,” suggested risk communication expert Ellen Peters, PhD, of the University of Oregon, Eugene, Oregon.

Watch for sensitive moments. “We noticed that there are some moments that are even more delicate, maybe because the patient is somehow frightened or overwhelmed,” and misunderstanding was most likely to happen then, oftentimes fueled by implicit communication, Consolandi said.

Don’t go on and on. Consolandi’s team noticed more misunderstanding happened when the physician talked for several minutes straight or more.

Do use numbers and use them well. Patients prefer numbers, and research from Peters and Han shows that providing context helps (“a 6% risk is generally considered poor” or “your risk is 6% and the average risk is 12%”). Use the teach-back technique to confirm understanding.

Acknowledge uncertainty. When discussing statistics, you can say something like, “Estimates of the chance of something happening are only a best guess based on the scientific knowledge we have right now. We do not know your personal real risk because of things about you that have never been studied and we don’t yet understand,” Peters said.