Summary
- Contextualizing care, the process of adapting care to the circumstances and behaviors of individual patients, has a powerful impact on health care outcomes. It’s a learnable skill, yet rarely systematically taught.
When Gloria Dawson (a pseudonym) arrived in the pre-operative testing clinic prior to bariatric surgery to treat her obesity, she met the clinical criteria — unsuccessful attempts to lose weight using more conservative measures, and complications including hypertension and diabetes. The resident provided an assessment to the attending that the patient was low risk for surgical complications. As they were heading to the exam room to see the patient together, the resident casually mentioned, “Oh, and she said she’s looking forward to taking better care of her son.” The attending asked, “What’s going on with her son?” The resident wasn’t sure, but assumed it meant the surgery would be helpful for her.
In the exam room, the attending addressed the question to Ms. Dawson and learned that she is the sole caregiver for a young adult son in his twenties who is dying of muscular dystrophy. She lifts him for daily bathing and to transfer him from bed to chair. She thought that losing weight would make these tasks easier. The attending immediately saw a problem: Ms. Dawson had a prior history of abdominal surgery with adhesions, so she would need an open procedure and would be unable to lift anything heavy for 40 days, or risk opening her wound. After discussing the situation, the patient and provider both agreed it was best to postpone the procedure. Ms. Dawson didn’t want anyone else caring for her son.
Had her doctors proceeded with the surgery, they would have put her in a high-risk situation where she could not safely recover while meeting her critical caregiver responsibilities. The term for a clinical decision that is appropriate from a strictly evidence-based or guideline perspective but inappropriate because it does not consider the patient’s specific circumstances and behaviors is a “contextual error.”
The Four-Step Approach to Contextualizing Care
The process of preventing contextual error is often called “contextualizing care.” As illustrated in the case of Ms. Dawson, it’s a four-step process. First, there was her statement about caring for her son, termed a “contextual red flag.” Second, the doctor asked her to elaborate, an iterative process known as “contextual probing.” Her response revealed caregiver responsibilities that were incompatible with the surgical plan, termed “contextual factors.” That information led to the final step of reconsidering the care plan, this time considering patient context. This resulted in a different approach, one that was now contextualized.
The contextualizing care process needn’t start with something a patient says. Contextual red flags include observed behaviors such as a patient missing appointments, not refilling medications, or losing control of their diabetes or hypertension. Each should prompt the clinician to probe for context.
A Foundational Competency in Patient Care
Contextualizing care is an acquired clinician competency. During busy clinical encounters, when physicians are so focused on numerous tasks, such as refilling medications, ordering screening tests, adjusting dosages to manage chronic conditions, and putting all of the information in the medical record, attention to patient context can fall by the wayside. Physicians sometimes say they don’t have time for it. Remarkably, however, studies using time stamps of audio recorded visits demonstrate that contextualizing care does not, in fact, add time to the length of a visit. Clinicians who contextualize care often save as much time as they expend by avoiding unnecessary or inappropriate care. Contextualizing care is a way of practicing medicine, not an additional task.
Significantly better health care outcomes and lower costs of care are associated with contextualizing care. In fact, the Number Needed to Treat (NNT — how many patients would need to receive the intervention to avoid one negative outcome) is just six, making it comparable to a highly effective drug, but without the side effects. Unfortunately, contextual factors go unaddressed about half the time, either because physicians fail to probe contextual red flags or neglect to incorporate contextual factors into their care plans. Contextual errors occur in about 15 percent of medical encounters, indicating ample opportunity to improve care.
The recently released Fundamental Competencies for Undergraduate Medical Education, produced by the Association of American Medical Colleges (AAMC), American Association of Colleges of Osteopathic Medicine (AACOM), and Accreditation Council for Graduate Medical Education (ACGME), include contextualizing care in their foundational competencies in patient care. Clinicians who learn to consistently contextualize care acquire a systematic approach, structured around the four steps, to ensure that each patient gets the care that is right for them.
Saul J. Weiner, MD, is the Deputy Director at the Center for Complex Chronic Healthcare at the Department of Veterans Affairs, and Professor of Medicine, Pediatrics, and Medical Education at the University of Illinois at Chicago.
Contextualizing Care for the Clinician is available on demand through IHI Open School — either as a standalone course purchase or included with individual and group subscriptions. Choose the option that works for you, with the ability to purchase the course with or without Continuing Education (CE) credits.
Photo by Cottonbro Studio on Pexels
You may also be interested in: