In the paper by King et al (this issue, pp 550–4),¹ an analysis of the communication between neurosurgeons and their patients with unruptured aneurysms was conducted immediately after an outpatient appointment in a neurosurgery clinic. Many patients had an inaccurate understanding of their treatment plan, and an exaggerated sense of the risks of treatments and of the disease. Despite methodological limitations discussed by the authors, the results of this study are consistent with those found in other specialties.

Communication is of special importance whenever there is a choice between two therapeutic options—that is, when the decision depends mainly on the patient’s preference. Practitioners should be sure that their information was correctly understood. This holds true especially when the event we want to prevent is potentially devastating, the therapeutic options invasive and risky, leading to irreversible changes, and the risk of spontaneous occurrence of this event is low. Beside unruptured aneurysms, this situation is also met, for example, in carotid surgery for asymptomatic stenosis, interventional radiology for arteriovenous malformations that have never bled, asymptomatic cavernomas, and asymptomatic meningiomas.

The quality of the information is crucial because the relation between doctors and patients has changed: years ago, doctors used to decide what they felt to be the best option for their patient. Nowadays, when there is no emergency they have to explain the various options and their advantages and disadvantages, and finally the patient decides. This is an improvement for the quality of care, but unfortunately the last step is still missing: it is necessary to check carefully the patient’s level of knowledge before they take a decision, otherwise their decision may be inappropriate.

To increase the quality of the information, seven actions can be recommended: (1) encourage randomised clinical trials for any clinical situation frequent enough, where there is uncertainty, to provide patients with more reliable information; (2) never ask the patient to take a decision immediately when there is no emergency; (3) organise a visit with a practitioner who is not personally involved in the techniques and has neither preference nor reluctance for one or other technique, for instance a neurologist; (4) explain the issue to the general practitioner and involve them in the discussion; (5) check whether patients have really understood the discussion, especially when they have a low level of education; (6) bear in mind that patients are always more pessimistic for their own health and exaggerate the risks of the disease (possibly leading to an inappropriate wish to be treated) and of the treatments (possibly leading to an inappropriate refusal of invasive options); (7) bear in mind that urgent decisions reduce the level of anxiety in the practitioner but are major obstacles to a multidisciplinary approach, which is the best guarantee of providing balanced information.