Structured pre-op communication linked to better understanding and fewer complications

A structured preoperative communication program was associated with better risk understanding, greater trust in physicians, more treatment acceptance and fewer complications in a two-campus controlled study of 320 adults undergoing elective surgery or invasive procedures at a tertiary hospital in Henan Province, China. Researchers randomly assigned one hospital campus to deliver the intervention and the other to continue routine preoperative communication, with 160 patients at each campus. After adjustment for measured demographic and clinical factors, intervention patients scored 2.001 points higher on a 0–10 risk-understanding scale and 2.703 points higher on a 0–10 trust scale. Complications within 30 days occurred in 11.3% of the intervention group and 26.9% of the control group, corresponding to an adjusted risk ratio of 0.413. The unusually large differences are promising, but they must be interpreted as adjusted between-group associations rather than definitive causal effects because the intervention and campus were inseparable in the design.

The intervention joined two mechanisms designed to address distinct problems in clinical decision-making. Its prospect-theory component focused on how patients evaluate uncertain outcomes, using clear reference points, balanced presentations of benefits and risks, and natural frequencies to explain low-probability complications. This was not a gain-versus-loss persuasion strategy. Instead, it aimed to help patients compare expected benefits, possible losses and the consequences of declining or delaying a procedure without allowing a severe but unlikely event to dominate the discussion. Its ultimatum-game component focused on interactional fairness through a four-stage sequence: a physician proposes a treatment, the patient responds with questions and personal priorities, the physician answers or revises the proposal, and both parties work toward a final shared decision. The two pathways were designed to connect cognitive accuracy, relational trust and decision quality.

Prospect theory provides a technical rationale for the risk-calibration component. It holds that people judge outcomes relative to a subjective reference point, treat losses asymmetrically relative to gains, and assign decision weights to probabilities through a nonlinear transformation. In this setting, the reference point was not monetary: it could be a patient’s baseline health, expected recovery time or clinical outcomes among similar patients. Loss aversion means that a possible complication may receive more psychological weight than an equivalent expected benefit, while nonlinear probability weighting can cause a low-probability event with severe consequences to appear more important than its stated frequency warrants. By presenting treatment benefits, potential harms and the consequences of no treatment together, the protocol sought to make these reference points and trade-offs explicit rather than attempting to steer patients through a preferred frame.

The ultimatum-game analogy supplied a different explanation for why a medically reasonable proposal might still encounter hesitation or refusal. In the classic economic game, a respondent may reject an advantageous offer when it is considered unfair. Clinical care is not an economic bargain, but the interaction has a comparable structure: a proposal, feedback, explanation or adjustment, and a decision. The study’s model operationalized this structure by asking clinicians to identify the procedure’s benefits, risks and alternatives; invite questions concerning risk tolerance, work, family responsibilities and other patient values; respond to the concerns raised; and revise the clinically feasible plan when appropriate. A four-step protocol does not itself prove that procedural fairness caused trust or acceptance to rise, and the study did not directly measure the proposed mediators. It nevertheless converted an abstract principle into steps that physicians could learn, audit and apply consistently.

The primary outcomes were risk understanding and trust in physicians. Risk understanding, rated by an assessor against predefined criteria, averaged 7.87 in the intervention group and 5.86 in the control group, an unadjusted difference of 2.01 points with a 95% confidence interval of 1.89–2.13. The standardized difference was unusually large at Cohen’s d of 3.66. Patient-reported trust averaged 8.41 versus 5.69, also a 2.72-point difference, with a 95% confidence interval of 2.61–2.84 and Cohen’s d of 5.03. Multivariable adjustment changed little: the adjusted coefficients were 2.001 for understanding and 2.703 for trust. Both measures were study-specific 0–10 tools with limited independent psychometric validation, so their numerical effect sizes should not be assumed to generalize to other instruments.

Treatment acceptance was more frequent in the intervention group: 148 of 160 patients, or 92.5%, accepted the proposed treatment, compared with 126 of 160, or 78.8%, under routine communication. The absolute difference was 13.7 percentage points. Adjusted odds of acceptance were 3.491 times those in the control group, with a 95% confidence interval of 1.638–7.442 and P = 0.001. That odds ratio should not be read as an equally large increase in probability, because odds and probability diverge when an outcome is common. Nor should higher acceptance automatically be equated with better decision-making. The intended interpretation is narrower: structured communication may help patients reach clear choices after they understand benefits, risks, alternatives and their own priorities. The study did not report whether increased acceptance represented less coercion, better alignment with patient values, or some combination of those outcomes.

The complication signal extended beyond communication and decision measures. During the 30 days after surgery or an invasive procedure, 18 intervention patients had complications, compared with 43 control patients. The unadjusted risk ratio was 0.419, with a 95% confidence interval of 0.253–0.693, while modified Poisson regression with robust standard errors produced an adjusted risk ratio of 0.413 and a 95% confidence interval of 0.248–0.688. Results remained directionally similar among 255 patients with a recorded procedure type and 173 patients known to have undergone surgery, with adjusted risk ratios of 0.407 and 0.333, respectively. One plausible pathway is that better-informed patients were more prepared for medication changes, postoperative activity, wound care and symptom monitoring, but those behaviors were not measured and therefore were not demonstrated as mediators. The magnitude of the difference is unusually large for a communication-only intervention, raising the possibility that unmeasured differences in physician teams, anesthesia, surgical pathways or perioperative care also contributed.

Medical disputes did not show a statistically supported reduction. Sixteen were recorded within three months—six in the intervention group and 10 in the control group—giving unadjusted rates of 3.8% and 6.3%. The adjusted odds ratio was 0.596, but its wide 95% confidence interval of 0.200–1.773 crossed 1 and the P value was 0.352. The event count was too small to support a firm conclusion, and the study did not distinguish complaints, liability disputes or other forms, or record their causes and resolution. Dispute frequency is also shaped by care quality, financial burden, expectations, complaint handling and mediation systems. The result therefore sets a clear limit to the intervention’s demonstrated reach: better communication may support conflict governance, but it cannot replace formal quality control and dispute-resolution systems.

Several design features also constrain what can be concluded. The study occurred at one hospital, and only two campuses participated, with one assigned to each condition. Because there was no independent randomization within campuses, campus characteristics and the intervention were perfectly aligned; patient-level adjustment could not remove unmeasured differences between sites. Baseline imbalances included payment method, occupation, procedure type and whether a patient had undergone a first procedure, although measured factors were included in the adjusted models. Education, household income, health literacy, physician seniority, team characteristics, communication duration and intervention fidelity were not fully recorded. Subgroup analyses were exploratory and not corrected for multiple comparisons. Although differences remained positive across age, sex and disease-severity groups, a nominal age interaction with risk understanding requires independent replication. Confirmation in multiple hospitals with more independently randomized units, validated outcome scales, longer follow-up and direct measurement of adherence and clinical pathways is needed before the complication association can be treated as causal or the approach can be judged for cost and sustainability in high-volume care.

Subject of Research: A controlled evaluation of structured preoperative physician-patient communication based on prospect theory and procedural-fairness principles.

Article Title: Optimizing physician-patient communication through an integrated perspective of prospect theory and the ultimatum game: a controlled study among patients undergoing elective surgery or invasive procedures in a Chinese tertiary hospital

Article References: Niu, M., & Liu, P. (2026). Optimizing physician-patient communication through an integrated perspective of prospect theory and the ultimatum game: a controlled study among patients undergoing elective surgery or invasive procedures in a Chinese tertiary hospital. Frontiers in Public Health, 14, Article 1937493. https://doi.org/10.3389/fpubh.2026.1937493

Image Credits: AI Generated

DOI: 10.3389/fpubh.2026.1937493

Keywords: preoperative communication, risk understanding, physician-patient trust, treatment acceptance, perioperative complications, prospect theory, shared decision-making, ultimatum game, patient safety, medical disputes, Optimizing, physician-patient