Box 4: Acknowledging the inherent uncertainty of the medical evidence and negotiating a provisional decision
Extract 1: Woman is concerned about taking hormone replacement therapy
Patient: I've been having 'em, HRT patches and in the middle of the year there was a new finding.
Doctor: Right, the scare.
Patient: Right, so when they've finished I thought, I'd try to do without them.
Patient: And I've been considering it and considering it—what I want to know is do you think—what's your opinion on it—when we talked about—when we talked about it earlier we weighed up all the pros and cons.
Doctor: Yes. Yes.
Patient: Is there a history of cancer, is there a history of heart problems—no history of cancer—but a history of heart problems so we decided it offered some a sort of protection to—but it seems to have taken a change—and then when I sort of thought about it later the percentage is quite small really isn't it.
Patient: When we, sort out how many people we're talking about it isn't large so I think that, I think that I'll go ahead with some more. Is that what, is that what you would advise, do you think it isn't—it isn't a big risk.
Doctor: No. It's certainly not a big risk—how long were you been on HRT for?
Patient: Oh not long—less than a year.
Doctor: OK, that's important because there's also risks associated with time that you're on HRT, so basically the longer you're on, the risk goes up, particularly if you're looking at breast cancer, but having said that you're absolutely right, the risk is still very small so any risk that there is only affects a very tiny minority of women and of course it's very difficult to know whether if something happens to you whether it's this or more likely whether it would have happened anyway.
Patient: And I was thinking of the quality of my life as well—my young lad I really need a bit more energy.
Doctor: Well that's important too (laughing).
(The discussion continues and blood pressure is checked. Towards the end of the consultation the doctor says:)
So I'll just give you some more now—and then what we do...if you're happy with them you can either come and see one of us or see (practice nurse) in six months for the next lot. (General practice, consultation 072)
Extract 2: Consultation to review hormone replacement therapy
Patient: Err my Estraderm patches, I'm getting a new prescription today, now the last time I saw the nurse, she said this would be my last prescription and I wouldn't be able to have any more.
Doctor: Did she mean because...
Patient: Because of my age or something—and I thought well I'll come and see you, because I did funnily enough try to come off patches myself, and I still got very flushed, so I thought I better just pop in and see you while I'm here anyway.
Doctor: Yes, I mean you're 62 and therefore, sort of 10 years beyond a natural menopause but you had a pretty dramatic menopause—you've had your ovaries taken out.
Patient: Oh I've had all sorts.
Doctor: I guess, she may have been thinking in terms of osteoporosis prevention, in that 10 years would be adequate for that and also as you also will know, a longer term use of HRT is associated with breast cancer, however, if you feel that you'd rather carry on, bearing in mind you know the increased risk of breast cancer.
Doctor: You know the big one, then I don't have any particular problem with this.
Patient: What about after this six months I mean obviously it's—would it—if I only say tried one a week instead of two how would that—or don't you do that with HRT.
Doctor: Well, or else what you could well. I'm just looking to see if they come in 25s—if you put one a week on, you'd be fine for the first half of the week and then...
Patient: Sure enough.
Doctor: Yes, they come in 25s so one option might be to draw three months of the 25s to see how you get on.
Patient: Yes, yes.
Doctor: You might find that when you decide to stop you have no hot flushes or you know whatever you got when you last decided to stop.
But I think she probably just felt that that she would flag it up about breast cancer. (General practice, consultation 002)
Extract 3: Consultation with practice nurse
The woman and nurse have discussed the increase in breast cancer risk from taking hormone replacement therapy long term as shown by the US study reported in the media. The woman is feeling well while receiving hormone replacement therapy.
Nurse: But there is still a risk of breast cancer—but there again there is a risk of breast cancer in this age group anyway, but it is increased with long term use of...
Patient: Well when you say long term use of...
Nurse: Long term—10 years plus.
Patient: Oh, I'm getting up to that one now aren't I—8 years isn't it?
Nurse: Yes, that's right—they advise five years, fine, up to 10 years is okay and then to rethink about it.
Patient: Well I mean by then I might be okay we'll just have to wait and see.
Nurse: That's right—blood pressure's fine—but it is something that you've got to be aware of.
Patient: Oh yes, I realise that—yes. (General practice, consultation 083)