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RiskWorld contact: Mary Bryant, associate editor
A Conversation with LTC Charles Engel Jr., M.D., M.P.H., Conference Co-Chairman
The First Annual Conference on Post-Deployment Care
Risk Communication and
Terrorism:
New Clinical Approaches
The attacks on the World Trade Center, the Pentagon and the subsequent and still unresolved anthrax attacks, have ignited a sense of urgency among the nation’s healthcare providers to learn what they can, while at the same time remaining maximally responsive to the needs, fears and concerns of patients.
Exploring clinical risk communication and its application to provider-patient relationships in the context of the “new war” on terrorism, will be the focus of the conference, Risk Communication and Terrorism: New Clinical Approaches, Sept. 9-11 at the Hilton Alexandria Mark Center in Alexandria, VA. This unprecedented three-day forum is sponsored by the Department of Defense, Deployment Health Clinical Center, at Walter Reed Army Medical Center in collaboration with the U.S. Department of Energy.
In this interview, Charles Engel Jr., M.D., M.P.H., co-chairman of the conference, Risk Communication and Terrorism: New Clinical Approaches, discusses why military and civilian healthcare providers should be concerned about responding effectively to potential and emerging biological, environmental and psycho-social health risks; the need for an interagency collaboration to address risk and consequences of the “new war;” and how new technology is making it easier for patients and providers to communicate and be empowered. Dr. Engel is also chief of the Deployment Health Clinical Center at Walter Reed and an associate professor of psychiatry at the Uniformed Services University in Bethesda, Md.
Q. You are presenting the Risk Communication and Terrorism conference September 9 - 11. For many in and outside of the healthcare community or the military, risk communication may be an unfamiliar term. How would you describe it and its relevance and application to healthcare in a post-Sept. 11 world?
A. There are many ways to define risk communication. The way that we’ve chosen to define it for the conference is the notion that risk communication is the purposeful exchange of information between stakeholders, and in the clinical setting it’s the purposeful exchange of information between healthcare providers, patients, and often families. The process of risk communication is designed to help our patients make better health decisions. There is often a perception that risk communication or dialogues about risks amount to statistical information. In healthcare settings, risk communication is about real people with real illnesses making real decisions.
Uncertainty is rampant so, in risk dialogues you have to include discussion of people’s values, concerns and opinions and their treatment or diagnostic options. You can’t just focus on the statistics. You have to bring all these considerations into the discussion in recognition of the fact that a patient’s desire to choose a certain risk over another is based on a lot of very personal issues and concerns. So, in a clinical setting, risk communication also entails dialogues about the risks of therapies, the risks of diagnostic tests, the risks of various health risk factors such as smoking or participation in certain less than OSHA-approved workplaces. It’s about enhancing those dialogues; it’s about developing open information sources that can help both patients and providers to understand these risks better. It’s really about empowering both patients and healthcare providers to discuss risk and creating opportunities for communication around health and environmental risks.
Q. How would you describe its relevance or application during and following the events of September 11?
A. In this “new war” that we’ve been involved in since September 11, there has been a wide range of both environmental and psycho-social health risks that we have encountered, sometimes in person and sometimes from afar-from watching television or from reading about it or hearing about it. I’m a Gulf War veteran. I know that during my time in the Gulf War theater of operations, there were many hazardous exposures and conditions that I wouldn’t have experienced in my everyday life. There were oil wells, smoke, anthrax vaccinations, sand and particulate matters in the air, to name just a few. What’s not surprising to me is that upon returning from the Gulf, there were many people who were concerned about the impact of those kinds of exposures on health.
I think we’re seeing very similar things since Sept. 11. Another example are the recent health concerns emerging from asbestos exposures among rescue and emergency personnel at the World Trade Center to the health concerns about irradiated mail from postal workers. I think that the opportunity for doctors and other healthcare providers to learn how best to frame these sorts of health risks and to discuss them effectively with patients, is a real challenge and something we have to get better at doing.
Q: Is there a greater sense of urgency now among physicians and other healthcare providers in a post-Sept. 11 world to gain and enhance the skills needed to better communicate such risks to patients?
A. I think that what makes it more urgent now is that terror and risk are reaching right into our homes here on American soil. It’s one thing to talk about the health risks we see or experience via television or watching shots being fired in the Persian Gulf. It’s entirely another to see the World Trade Center, an icon of our society, where people who look just like we do, die as a consequence of terrorism. In addition, many emergency responders were affected by the exposures they encountered in the search and rescue operation. It just makes it all that much more immediate. It means that doctors in our civilian sector have to be in tune with these concerns as well, not just those who get called to active military duty or those who serve on active military duty.
Q. Why is it important to host a national conference on risk communication and terrorism nearly a year after Sept. 11 and to include interagency healthcare and public health experts from the federal government, the civilian community and from the military?
A. Now is an excellent time for us to be integrating lessons that have come about as a consequence of the “new war.” One of the lessons that we have been hearing quite a bit about is the importance of interagency collaboration in protecting our homeland. The view of those of us involved in coordinating this conference is that these agencies all need to work together. We can learn together and by collaborating we can develop new communication technologies and strategies. The agencies that will come together at this conference each bring a rich critical mass of expertise. For instance, we will be meeting with representatives from the CDC, NIH, DoD, VA, and DOE at the conference. Each of these organizations has its own rich history of learning about communicating with stakeholders and patients in and out of healthcare settings about health risks and responding to disasters and terrorist events. As a final point, I would say that perspective is everything in communication. Each of these agencies has its own unique historical perspective and expertise that lends itself to efforts to improve the clinical risk communication process. We feel it’s very important to make this a combined effort with lots of perspectives.
Q. Nearly a year after the terrorist attacks of Sept. 11, how would you assess the delivery and dissemination of anthrax information to patients and the public from your role as a physician and public health expert? What are some of the lessons learned?
A. First let me say a word about terrorism and homeland defense. The focus of terrorism is not necessarily those most immediately impacted by terrorist event. The focus is on population disruption and fear. Often the source of that fear is fairly circumscribed. The social, economic, health, political and behavioral repercussions that come out of a terrorist event reverberate a long time after. I think the bioterror events involving anthrax from last fall are classic examples of this. Even though there were really only a handful of people who actually developed anthrax, our country, for a period of time, was greatly slowed and the health and well being of our nation was adversely affected by those events. Communicating on the heels of events like anthrax attacks and bioterrorism-while the process will always be imperfect and there will always be opportunities to improve and learn-the good news is that there are interagency efforts being made to improve communication. This conference is one example of that. In another example, at the Deployment Health Clinical Center (DHCC), we are working on a CDC-funded effort called Health-e VOICE to develop risk communication technologies that can be used to teach primary care clinicians how to communicate risks related to anthrax vaccinations and risk related to unexplained illnesses such as what we experienced after the Gulf War.
Another such collaboration resulted in Operation Solace, the Department of Defense’s (DoD) response to the Pentagon attack. In the years following the Gulf War, the DoD developed a post-deployment clinical health guideline for providing care to people after war or terrorist events. That guideline was modified and is being implemented in the National Capitol Region by Operation Solace. Those of us who’ve been engaged in Operation Solace-the behavioral health community and the Deployment Health Clinical Center-have felt that the existence of such a program has been an important reason why it appears from recent studies, that the Washington, D.C. area has fared better on a national scale, perhaps even better than many areas much less impacted by the events of September 11. So, a year later, I’d say that given that this was a completely unexpected event, the response was understandably imperfect, but at the same time there is a sense of pride in the fact that the things we’ve been involved in over the last decade, have moved us closer to refining a process for providing care after terrorist attacks and threats such as anthrax.
Q. What are some desired outcomes of this three-day conference? What are some of the highlights and what can we look forward to?
A. One desired outcome is process driven. We want to create and launch an interagency dialogue. We want to create interagency relationships between people inside and outside of the government who are thinking about risk and terror. In addition, we’d like to develop a set of recommendations for clinical risk communication that we can bring to the DoD-planning efforts in the areas of research, policy and practice that pertain to clinical aspects of risk communication. In short, we want to learn new and productive ways to bring information to the practice of medicine and to those who are practicing medicine. We can’t go it alone in this new war; I can’t emphasize that point enough. This is a great opportunity for lots of people with common interests, who often don’t have the opportunity to speak together and work together to devise a proactive strategy for improving communication practices in medical care and for responding to terrorism and risk.
Q. Confusion, anger and fright dominated the lives of many people following last year's terrorist attacks and subsequent anthrax exposures. Most turned to their doctors, the professionals that people tend to trust the most, when they sought information and guidance on anthrax. Unfortunately, only a handful of doctors and healthcare providers had ever seen a case of inhalation anthrax. When it comes to communication, how can doctors be proactive and prepared in the event of future exposures?
A. Surprisingly, there are many sources of information out there in this Internet age. One that we are very proud of at the Deployment Health Clinical Center is called PDHealth.mil. The DHCC developed this site, PDHealth.mil, to present relevant information about health and exposures about military populations. Civilian clinicians will also find the site of great interest. Most civilian clinicians will be surprised at the amount of information presented there that is relevant to homeland and environmental health concerns. I know that CDC, DOE, and VA are among just a few other sources of similar information. Lastly, healthcare providers should be attentive to the fact that a large amount of all disease in society is determined socially and behaviorally. It’s crucially important to know about inhalation anthrax and the agents that are most likely to be used in a bioterrorism situation. Healthcare providers should also know what to expect in a crisis situation, as well as the agencies and organizations that will be participating in responses and what the likely behavior and emotions of their patient population will be. It’s those factors that will make for a very chaotic working situation and will make for a difficult communication situation if not planned and thought out.
Q. Who are some of the expert panelists and presenters who will be participating in the conference and what will they bring to the discussion.
A. We have a wide variety of speakers from civilian academia, multiple government agencies dealing with the issue of clinical and population risk communication. Among the speakers that we have is Dr. Maria Pavlova, an expert in risk communication. She is also my co-chair and a medical officer with the U.S. Department of Energy. She’ll be speaking about patient-centered risk concerns. Another speaker who will be joining us is Allard Dembe. Dr. Dembe is from Yale University and is an occupational health services research expert. He’s written extensively on social factors and how they affect how we think about occupationally related diseases and illness. I think that he’s going to do a great job of conveying how information can affect how we conceptualize and respond to illness in both positive and negative ways. We have a wide variety of panel presentations that address new technologies that are gaining interest in the field of risk communication.
The conference will include the use of risk communication scenarios that participants can view and take part in. The scenarios offer a real-time way for healthcare providers to practice and learn how best to respond to a community-based terrorist event or to patients with health concerns related to such an event. In addition, we will be presenting some of the work that has been done over the last 10 years in the DoD including what we’ve been learning about risk communication on the heels of our work with Gulf War veterans, and new clinical practice guidelines on post-deployment health. Similar outcomes, events and best practices from other agencies will also be featured. This conference has much to offer to those who attend and are concerned about communication following terrorist events both in clinical and community-based situations.
Related Links
News release from September 3, 2002
RiskWorld news brief from September 5, 2002
Posted September 5, 2002.
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