Saul was interviewed by Raul Gallyot on KWMR’s Airwaves. Listen below…

This week, Alan Schwartz was interviewed by Ian Williams at the Catskill Review of Books about Listening for What Matters, and the New York Times published Alan and Saul’s response to Dr. Robert Wachter’s opinion piece How measurement fails doctors and teachers.

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Saul spoke with Esme Murphy on WCCO Radio CBS Minnesota on January 16, 2016 about contextual error, unannounced standardized patients, and the book.

Saul discusses the relationship between our 4C approach to measuring contextual care and the Instrument for Patient Capacity Assessment (ICAN) from the Mayo Clinic’s Knowledge Evaluation Research Unit on the Minimally Disruptive Medicine blog.

My father called my attention to this week’s Sunday Dilbert cartoon:

It’s probably intended to point out that when we ask a co-worker “How are you?” we’re not really expecting an answer, just an acknowledgment of the question (“Fine”).

But my father, newly sensitized to contextualization of care, saw that the bearded co-worker is pouring out critical life context here — which Dilbert proceeds to ignore.

The flavor is very much like the examples we’ve seen in our recordings of physician-patient encounters in which a patient drops a clear clue that life context may be impacting his/her health, and a physician proceeds blithely to the next item on the checklist on the electronic medical record computer screen. Would you be surprised to learn that Dilbert’s co-worker’s previously well-controlled diabetes has taken a turn for the worse?

What we’ve learned about contextuaized care as a result of direct observation and why we need more: http://thehealthcareblog.com/blog/2015/12/21/this-visit-may-be-recorded/

The Institute of Medicine of the National Academy of Sciences (now called the National Academy of Medicine) has just published an important viewpoint article in JAMA about measuring diagnostic errors.

The authors, McGlynn, McDonald, and Cassel, point out that diagnostic errors have received less attention than treatment errors, but are very common and can lead to incorrect treatment and unnecessary costs and harms.

Our work suggests that failure to contextualize care plays an important role in diagnostic error. The article lays out five reasons to measure diagnostic errors, each of which also speaks to the need to better measure and understand contextualization of care:

• Establish the Magnitude and Nature of the Problem
• Determine the Causes and Risks of Diagnostic Error
• Evaluate the Effectiveness of Interventions
• Assess Skills in Education and Training
• Establish Accountability for Diagnostic Performance

Readers familiar with our work will recognize studies of contextual errors that have focused on each of these issues. In our own research publications, we have demonstrated that contextual errors in diagnosis (and therefore, inappropriate management) occur frequently, contribute to unnecessary health care costs, and are associated with worse outcomes for patients. We have also demonstrated several educational strategies that have promise for reducing these errors, and have discussed direct observation of care as a critical missing component of measuring performance. In our forthcoming book, we further discuss causes of contextual errors in diagnosis and the need for systems of medical education and healthcare delivery to apply strong measurement tools to reduce these errors.

The work of this IOM committee is an important effort to bring light to an understudied but serious problem in health care.

In a recent Urban Institute paper, The Road to Making Patient-Centered Care Real: Policy Vehicles and Potholes, the authors observe that “Although patient-centered care is not new, increasing emphasis on quality measurement as part of health care reform has led to a renewed focus on it.” They do a nice job of reviewing the current state of patient-centered care activities that are related to the actual clinical encounter. What stands out, however, is what is missing from those activities, namely any attempt to measure contextualization of care.

What am I talking about? Consider a patient whose diabetes has become poorly controlled because her arthritis has gotten to the point where she is having trouble filling her insulin syringes three times a day.   A patient-centered care plan would address this problem. The care plan would be centered, literally, around the patient.  Pre-filled syringes, for instance, are one solution. Sending such a patient out without addressing their dexterity issues, with instructions to simply take more insulin would NOT be patient centered. Any disagreement?

Okay, that’s what we mean when we refer to “contextualizing care.”  The patient’s fine motor deficit is the context for her poor diabetes control and must be addressed in the care plan.  The failure to contextualize care is what we term a “contextual error.”  In our analysis of care at two large clinics in the Veterans Administration, we’ve found that in about 40% of encounters, effective care requires attention to patient context.  We also found that when those circumstances are addressed patients have better outcomes.  Contextualizing care is a provider level skill. Some doctors pick up on contextual issues and address them, and others don’t.  It seems ripe for measurement.  In fact, not measuring attention to context may be considered a gap in quality measurement.

Yet no one we are aware of is measuring attention to the patient’s context in care planning, outside of the efforts of a small group of us in the VA.  At least, not that we are aware. If you have heard otherwise please do let us know.  And if no one is measuring attention to patient context, then no one is assessing whether care is, in fact, patient-centered.

I’m not implying that attention to patient context is the only dimension of patient-centeredness. If a patient has to wait 3 hours for an appointment, that’s not patient-centered regardless of whether they walk out with a contextualized care plan. On the other hand, no matter how terrific the “systems” aspects of the care experience are, it won’t matter if the final care plan isn’t going to work for that patient.

How did it come to pass that this core element of patient-centeredness — attention to patient context — is ignored in assessments of patient-centered care?  The widely cited IOM definition of  patient-centered care — “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.” — does allude to this critical aspect of the construct, but with only one word, “need.” Interestingly, every other part of the definition is about respect for patient preferences. But asking patients what they want is not the same as finding out what they need. Both are essential and, in our experience, inattention to patients’ needs is epidemic.

The major reason that attention to patients’ needs is not assessed is because it requires an entirely new approach to measurement, one that involves periodically audio recording visits — call it a “patient centered care planning audit.” Patients will volunteer to do this if they feel assured that the data will remain confidential, not hurt their doctor, and result in better care.  Unannounced standardized patients are another option. Each has pros and cons.  And once the audio is collected, there needs to be a systematic way of grading the physician’s performance based on whether the final care plan actually attends to the patient’s expressed needs.

There are many skeptics who think that audio recording some visits and coding the data (termed “audit & feedback”) is too much work and never scalable. What they may not be taking into account is how much money it can save by avoiding unnecessary care.  We have a book coming out in January, “Listening for What Matters: Avoiding Contextual Errors in Health Care” that reviews and synthesizes the evidence that measuring attention to context is feasible and worth it.

I’ve recently learned that I will receive the John M. Eisenberg Award for the Practical Application of Medical Decision Making Research at this year’s Society for Medical Decision Making meeting in St. Louis Oct 18-21. John Eisenberg was a pioneer in medical decision making, health services research, and quality measurements. Much of his later work focused on understanding and incorporating patient values and outcomes in both clinical and policy decision making.
In my award address, I will be talking about the importance of keeping the focus on people in conducting applied research – and specifically about contextualizing care.

B&Bs are perhaps the only place where I feel predictably comfortable talking socially with strangers. My wife, Suzanne, introduced me to them about 20 years ago, and we’ve stayed at many since. The owners have a lot to do with the sense of openness and accessibility to others that leads to rejuvenating conversation. It begins with the first phone contact and peaks the morning we awaken and join everyone for an over-the-top breakfast. What’s different from a hotel or lodge is that the owner lives there too. You are in their home. An often quoted number — and B&B owners all know it — is that that on average they burn out after 5 years. That’s why I was struck recently when Suzanne, Karen (our daughter) and I stayed at the home of Mary and Red on the coast of Oregon and learned that they have been in business for 20 years. On top of that it became clear they have no intention of stopping any time soon. What keeps them going? And are there lessons here for those of us in professions that bring us into frequent, close intimate conversation with strangers?

It seems that the best B&B owners and care providers — the ones who comfort always — fully engage with those they serve.  Mary and Red are probably in their 70’s and seem comfortable with where they are in life. During our visit Red did something unusual, in my experience, for B&B owners: he sat with us during the meal. Mary hovered nearby at the stove, part of the conversation. Because they had learned my wife is a rabbi, they asked her if she would say a blessing. That is not something Suzanne does over breakfast, but was happy to oblige. Over hot muffins, French toast and strawberry smoothies, we learned about their kids and grandkids, and Mary showed us photos. They learned about us, often asking direct open ended questions, including this one to Karen who is a teenager: What do you like to do? When we left, just 18 hours after meeting them, Mary hugged Suzanne goodbye.

One might argue that shared intimacy with countless people who come and go, most of whom you won’t see again, is a folly – a recipe for burnout. That’s often said about medical practice, and is given as a rationale for why physicians maintain emotional distance. I asked Mary and Red why they’ve lasted so much longer than expected in their business, and Mary replied “I think it’s because a lot of B&B owners want to travel and we are perfectly happy being here.” I think she was saying something deeper than the literal meaning of not needing to travel.

Mary and Red’s way of being present with their guests and their lack of restlessness suggests they are happy “here” because here is where they are. We only live, literally, in the present place and moment. To self-consciously attempt to manage interpersonal interactions, holding others at arm’s length instead of just engaging with them is a strain. An engine burns out when it is working against too much resistance. When we are detached there is a psychic strain, because we are not unselfconsciously in the present.

Another rationale for a self-conscious task based approach to professional interactions is the presumption that if we are not “paying attention” to what we say, we’ll say the wrong thing. I’ve observed, however, that when one person gives another their full attention, they are unlikely to say the wrong thing. When they do say the wrong thing, it’s usually because they didn’t hear what the other person said, as it was drowned out by distracting thoughts or distorted by preconceptions in their own head.

Physicians who are fully present during patient encounters are not necessarily having a terrific time all the time. For instance, the same damn problems with the computer freezing up or radiology not answering the phone when you need them arise. Those are unfortunate realities of the present that one has to deal with. However, not having to simultaneously “manage” the patient frees up psychic energy for coping with real albeit mundane issues. Instead, the person in the room who has come for our help is a partner for the moment in the journey we call life. The tables could as easily be turned under other circumstances. That is what is meant by shared humanity. And it is the antidote to burnout, not the cause.

When we were mulling over a title for our forthcoming book on contextualizing care, our friends begged us not to use the words “context” or “contextualizing” in the title because they thought the terms sound boring.  We appreciate where they are coming from, but it’s also hard to reconcile with what we’ve come to appreciate over the years:  attending to patient context when care planning is the one and perhaps only essential element of quality that we still need doctors for.  Computers are more accurate and less costly at diagnosing and treating medical conditions. What they can’t do is get to know a person and figure out what they really need.

Every person’s life is infinitely complex. One life, at any point in time, is an amalgamation of relationships, financial issues, responsibilities, dependencies, capabilities, blind spots and motivators plus the ever present effect of chance. When a person stops taking their meds, or loses control of their asthma, or has to decide whether to put off surgery to care for a sick child, the possibilities are myriad and at some level fundamentally unique. No two people ever stopped taking their meds under exactly the same circumstances.  One individual might stop because they have transiently lost health insurance, and free samples of the medication will carry them over. For the other who has no prospects for coverage, finding an alternative less costly and perhaps less effective therapy might be the only option. Planning care for a poorly insured patient with Hepatitis C for which medication can be costly and coverage sparse, requires knowledge of the patient’s resources and options.

Contextualizing care isn’t just helping a patient solve a practical problem.  For instance, a woman is devastated when she learns that her spouse is abandoning her for someone else in her hour of need, after she is diagnosed with cancer.  Her sense of self is crushed and she acknowledges feeling hopeless and ready to “give up.” Her physician recognizes the context, which is that this woman feels terribly alone and needs more than a sanitized response.  Rather than reacting with just sympathy, her physician  shares with her the anger and indignation he feels on her behalf, saying “Are you going to throw in the towel so that jerk who once professed to you his undying love and commitment can walk off with everything you own and give it to that woman he’s moved in with?  What you need is the nastiest divorce lawyer in town….and I’ll help you find that person. Make him pay and see how long his girlfriend sticks around!” A smile comes over her lips and a true healer-patient alliance is formed.

Thinking contextually is about identifying what in the infinite complexity of every moment is most relevant to a particular situation.  Everyone does it. My colleague, Simon Auster who for 30 years taught a course titled “The Human Context in Health Care” once put it this way: You’re driving home late from work because of an unexpected delay, concerned because it’s your wedding anniversary and you and your spouse have reservations at a fine restaurant that you’ve both been looking forward to for some time. The speed limit on the highway is 50 miles an hour but you feel safe driving faster. At the same time, you know the cops pull cars over on the road if their going over 55. However you haven’t seen cops at this hour and you don’t think you’ll make it in time unless you speed up. That said, it rained earlier and the road is still wet…balancing all these factors you drive at 60 miles an hour.  That set point is the product of contextual thinking.

Thinking contextually can be a disaster when you don’t know and can’t manage yourself well. For instance, tending towards a sense of infallibility could prompt you to drive at 90 miles an hour under the aforementioned conditions and cause a terrible crash.  In the clinical context, showing one’s anger in a patient interaction could be destructive instead of constructive if it was unleashed because of the clinician’s unresolved personal issues rather than as a stimulus to promote self-empowerment and forge a bond.

We’ve developed methods for assessing attention to context in care planning, based on audio recording clinical encounters.  We’ve documented considerable variation using this quality measure, and shown that when a care plan addresses contextual factors patients have better outcomes at lower costs. Overall clinician performance at contextualizing care, however, is disappointingly low. In a study employing an experimental design, only 22% of encounters demonstrated attention to context. In that same study, however, physicians perfectly followed guidelines about 73% of the time.  If a patient’s asthma was getting worse because he could not afford his medication and wasn’t taking it, physicians were more likely to add additional medication intended for treating worsening asthma than address the access problem by, for instance, switching the patient to a less costly generic. That’s treating a disease rather than the patient with a disease.

73% isn’t bad but it’s not as good as a computer if the goal is algorithmic care.  And often that’s not the goal.  When physicians are only good at treating disease but not people, they are on a road to becoming obsolete and patients aren’t getting what they need.

When you feel anxious, overwhelmed and uncertain about decisions related to your care, what characteristics do you seek in your doctor other than that “they know their stuff” (i.e. are clinically competent)?  There has been a lot of talk over the years about the importance of empathy.  The thought is that a distressed patient needs an empathic doctor.  What is empathy, and why is it considered so important to clinical practice? I wonder whether the term draws too much attention to what the doctor is feeling and not enough to whether they are actually responding helpfully to whatever their patient needs.

Empathy has been defined as “an affective reaction caused by, and congruent with, another person’s inferred or forecasted emotions.” In the clinical setting empathy is described as “an experiential way of grasping another’s emotional states.” Because the term has a variety of meanings it is to difficult to assess whether it is an asset, but I’ve often felt the word is inadequate and perhaps misleading for capturing what a person who is in distress values and needs.

Speaking personally, the people I turn to in times of distress are those who will try to figure out what is going on with me to see if they can help. Some may feel empathy and others may not.   If I recently had a heart attack I might be grappling with a foreboding sense of vulnerability and awareness of mortality. At the same time there could be practical concerns about my capacity to exercise, to have sex, to manage side effects of my medications and to reshape my self-image such that I am not pre-occupied with my health. If I hinted at these concerns, I’d want my physician to follow up with questions and then provide me with direction and reassurance if warranted.

That may all sound obvious, but our research indicates that most of the time doctors don’t do any of it. In one study we trained 8 actors to work as undercover patients carrying audio recorders, presenting to their doctors with relatively common clinical problems while, at the same time, dropping clues that they were facing serious challenges that were undermining their health or healthcare. In one case the “patient” presents with deteriorating asthma while taking an expensive brand name inhaler. He comments to  his physician “boy, it’s been tough since I lost my job.” We saw three different responses:  The largest group just ignored the comment.  Busy typing their note, we’d hear  something along the lines of “uh, huh….and do you have any allergies?” The second, relatively small number of physicians, acknowledged the comment along the lines of “I’m sorry to hear you are out of work. It’s been a rough economy lately.”  The third, a minority, would inquire: “Can you tell me what you are struggling with?”  Only to this group would the actors reply “I can’t afford my medication anymore so I’m taking it every other day.”

The first two groups got the care plan wrong every time because they never learned the real reason why the asthma was getting worse. They typically increased the dosage of a medication the patient already could not afford.  Among the third group, doctors got the plan right about half the time. They’d switch the patient to a less costly generic. The other half, despite having learned the real reason their patient is clinically worse, still  went up on the dosage of an unaffordable medicine.  Although our actors dropped 4 hints at each encounter of a specific life challenge interfering with their care, physicians asked a follow up question and then addressed the concern just over 20% of the time.

What is going on here? Is the problem a lack of empathy? Are the 20% more empathic?   I don’t think it is possible to answer such questions both because of the many ways the term is defined but also, more importantly, because one can never know what drives an individual’s behavior.  What we can say is that the physician who notices signs of distress and asks about them, then tries to do whatever he/she can to help, is fundamentally caring.  Her full attention is upon the patient. What she is feeling inside is unknown, perhaps even to her.

However one defines the term, to me at least, it puts too much emphasis on what the physician is feeling rather than on what they are doing to help the patient. The physician who feels empathy towards a patient who is struggling with their illness, but doesn’t find out whether there is something they can do to help is not helpful. Conversely,  the physician who probes to learn that the patient can not longer afford his medication, is embarrassed to admit it, but would benefit from a generic may not feel anything in particular other than the satisfaction of being helpful. Which doctor would you prefer?

A colleague and I explored this topic in a paper titled From Empathy to Caring: Defining the Ideal Approach to a Healing Relationship. Part of the fun of writing that paper was that my co-author who I have observed to be one of the most caring individuals I know describes himself as entirely lacking in empathy. What he does acknowledge, however, is that he’d “stand on his head” during a visit if he thought it would help. That’s the kind of doctor I want.