Patient Safety Tip of the Week
August 10, 2010 It’s Not Always About The Evidence
In the era of evidence-based
medicine we often fall into the trap of evaluating the performance of an
individual provider or a healthcare system by the degree to which they comply
with clinical guidelines or best practices that are grounded in outcomes from
randomized controlled trials. Yet, when we are asked by a friend or family
member about a referral to an individual physician or a hospital, we always
have a few that we preferentially recommend – even though there are others that
perform equally well (or even better) on the measures mentioned above. In
effect, we are taking into account the “art” as well as the “science” of
medicine.
Enter a very humbling paper (Weiner
et al 2010) on “contextual” errors. Contextual errors are those errors
where the clinician “fails to take into account those elements of a patient’s
environment or behavior that are relevant to their care”. Examples of those
elements might be a patient’s financial or employment status, social situation,
health literacy, etc. How many times have you “escalated” a patient’s
antihypertensive regimen, only to realize later that they were never compliant
with any part of that regimen, either because they could not afford those
medications or could not read the labels? That’s an example of a contextual
error.
The study by Weiner et al. puts the
frequency of such contextual errors in perspective and demonstrates why we so
often fail to achieve the desired outcome despite “adhering to the guidelines”.
It’s also a good reminder that the idealized “subjects” in randomized
controlled trials have been carefully selected to weed out many of these
contextual issues and may explain some of the differences between clinical
trial and “real world” outcomes.
The investigators trained actors in
variants of 4 common clinical scenarios and sent them as unannounced
standardized patients into the practices of 111 internal medicine attending physicians.
For each scenario there were “red flags” that required further probing by the
clinician. Red flags were either “contextual” (as above) or “biomedical” (for
example, a nocturnal increase in wheezing or coughing that should prompt
questions about possible esophageal reflux). So each scenario could have no red
flags, a contextual red flag, a biomedical red flag, or both red flags.
As we’d suspect, fewer clinicians
probed further after the “contextual” red flags, but the impact on overall
plans of care was striking. Error-free plans of care occurred in 73% of the
“uncomplicated” (no red flags) cases but in only 38% of the biomedically
complicated cases and 22% of the contextually complicated cases. And of those
with both biomedical and contextual red flags a mere 9% of cases had
error-free plans of care.
What a powerful demonstration that,
as we strive to standardize care, we must not sacrifice the need to
individualize care for each patient.
While we can program electronic
medical records to remind you to add an ACE inhibitor is certain clinical
situations, it is much more difficult to rely on technological solutions to
address contextual issues. We need to do a better job of training our medical
students and residents to consider these contextual issues as they interact
with patients and their families. Most medical schools now include simulations
(using actors or standardized patients) in teaching interview techniques. It
would be easy to add the sort of contextual issues from the Weiner paper to those
simulation training exercises.
But we have some other suggestions
as well. The successful clinician is one who utilizes all members of the
healthcare team in dealing with his or her patients. It is amazing how often a
patient will confide some of these contextual issues to a nurse or clerical
staff but would not disclose them to a physician. Sometimes they are too
embarrassed to discuss them with the physician. Other times they may feel that
the physician is “too busy” and they don’t want to bother them with these
issues. So sometimes it is okay to have one of your other team members broach
the questions for you. (As an aside, we’ve seen many teens who are afraid to
talk about issues like STD’s but will listen to tapes on such topics or even
talk to anonymous sources about such issues. Generation X also freely uses
social media technology to discuss things they would never discuss in person.).
The solution is that you need to have multiple means of communication available
to your patients because they may all communicate in different ways.
Contextual issues can also pop up
when you are doing team meetings in your practices. While most practices focus
on issues such as billing, scheduling, etc. during “team meetings”, that’s also
a good time to say “We’re having trouble getting Mrs. Jones’ diabetes under
control. Does anyone have any insights that might help us better manage her
care?”. You’d be surprised how often your staff will volunteer their insights
and it also helps your staff take pride in helping all your patients.
You also need to include contextual
issues in your plans of care. For example, even if you neglected to probe
contextual issues when you first developed a plan of care, you should always
ask the appropriate contextual questions when a patient has not responded as
expected to a therapeutic intervention. While you should have a clear
understanding about the financial impact of prescribing any new drug for a
patient, it becomes absolutely crucial that you specifically inquire about cost
issues if their blood pressure has not improved or their LDL has not moved a
month after you started them on a new regimen.
It can be a humbling experience when
you achieve a less than desired outcome because you didn’t take the time to
give your patient the individualized care he/she needed. This study by Weiner
et al. is a real reminder that we still take care of patients one at a time and
it’s a real contribution to helping us deliver safe and effective care.
References:
Saul J. Weiner SJ, Schwartz A, Weaver F, et al. Contextual Errors and Failures in Individualizing Patient Care: A Multicenter Study. Ann Intern Med 2010; 153: 69-75
http://www.annals.org/content/153/2/69.abstract?sid=076f5f8a-abf5-4fc5-9963-c795d39a4924
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