They also learn to conduct a contextual history by asking simple, straightforward questions, keeping in mind potential areas of context, including the patient’s emotional state and cultural beliefs (see sidebar, “Cases of Context”). Through this process, the residents learn to identify ways to avoid contextual errors in their patients’ care.
At the end of the month-long curriculum, all trainees are tested in the patient laboratory. “The simulated patients are trained to present with complex histories,” Dr. Weiner says. If residents don’t probe properly, the patients don’t reveal the context. Both groups—those who’ve had the intervention and those who have not—interview the patients, and the study is tracking which physicians get the cases ‘correct.’ ”
The Cost of Errors
For a next phase of research, the university has enrolled about 100 physicians from multiple centers in the Chicago/Milwaukee area to participate in visits by undercover actors simulating real patients. The cases require uncovering contextual information to avoid making errors when planning their care.
After each visit, the team downloads and scores the physician’s note, identifying both unnecessary tests and missed opportunities. Using Medicare reimbursement data, the team assigns a dollar amount to these errors that would have occurred had the patients been real. Dr. Weiner predicts publicizing the financial costs will bring more attention to the problem.
Access to Care Issues
Actually, physicians should talk to their patients about the cost of their care, says David O. Meltzer, MD, PhD, associate professor and chief of the Section of Hospital Medicine at the University of Chicago Medical Center. In research published in the Journal of the American Medical Association in 2003, Dr. Meltzer and colleagues found patient costs may be associated with medication nonadherence and considerable economic burden.3
“You have to ask a patient the type of questions that will be most revealing, including the broader questions, such as ‘Are there any challenges in your life to getting the care that we’ve discussed after you leave the hospital?’ ” Dr. Stinnette, of Kaiser, says.
In their study, Dr. Meltzer and colleagues also showed that although physicians and patients agree it is important to talk about money issues, it doesn’t commonly happen.3
“In a public hospital where there are greater numbers of uninsured patients, I expect it is much more a frequent topic of conversation,” Dr. Meltzer says. “My suspicion is that the people at greatest risk are uninsured patients who are hospitalized in settings where most patients are insured, and physicians are not attuned to bringing up this issue.”
Although a great deal of literature now deals with physician-patient communication, the techniques seem too scripted to Dr. Weiner. “When you engage with the patient simply as one person who is concerned about another,” he says, “you much more naturally find out what you could do that might help them.”
References
- Weiner SJ, Schwartz A, Yudkowsky R, et al. Evaluating physician performance at individualizing care: A pilot study tracking contextual errors in medical decision-making. Med Decis Making 2007;27(6):726-34.
- Weiner SJ. Contextualizing medical decisions to individualize care: Lessons from the qualitative sciences. J Gen Intern Med 2004;19(3):281-5.
- Alexander GC, Casalino LP, Meltzer DO. Patient-physician communication about out-of-pocket costs. JAMA 2003;290(7):953-958.