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Putting Context in Medical Care

Putting Context in Medical Care

Effective care requires diagnosing and treating clinical conditions using evidence-based practices and adapting care plans to individuals’ unique circumstances, or context. For instance, increasing the dosage of a medication to treat worsening disease may be appropriate, according to guidelines, but ineffective if the underlying problem is that the patient cannot afford the medication or is unable to take it as scheduled because of competing responsibilities. Failing to recognize and account for contextual factors that are essential to planning effective care has been termed “contextual error.” Conversely, the habitual practice of attending to patients’ life circumstances when planning care to avoid such errors has been termed “patient-centered decision making” or “contextualized care.” Contextualizing care is a three-step process: First, clinicians must recognize clues (eg, recent loss of disease control) that patients may have underlying unaddressed contextual issues. When these “contextual red flags” are recognized, they must ask patients about it, a process called “contextual probing.” If patients reveal an underlying “contextual factor,” physicians should attempt to address it in care plans. Does Contextualized Care Improve Outcomes? To investigate the effect of contextualizing care, my colleagues and I conducted a study—published in Annals of Internal Medicine—that aimed to determine if contextualized care improved healthcare outcomes. We evaluated patients who agreed to surreptitiously record their interactions with clinicians. Medical records and audio recordings of these encounters were then screened for contextual red flags and, when present, for contextual factors. Physicians were scored on the basis of whether they adapted care plans to the factor. The study involved 774 patients with common chronic conditions and 139 resident physicians. Among 548 red flags that...
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