Contextualizing Care

We spent the morning of February 2 live on the air with Geoffrey Riley and Emily Cureton on The Jefferson Exchange on Jefferson Public Radio in Oregon, discussing the book, contextualizing care, and unannounced standardized patients.

You can listen at http://cpa.ds.npr.org/ksor/audio/2016/02/The_Jefferson_Exchange_02_03_2016_Hr2_0.mp3 or use the embedded player here:

There wasn’t time for us to address one of the points brought up by listener Connie, about doctors “locking in” to diagnoses. In the decision making world, we call that “premature closure”, and it’s a reflection of the general human propensity that it’s easy to come to a (first) conclusion than to change your mind. As we discuss in the book, doctors are taught to develop a “differential diagnosis” – a list of additional possible medical explanations for the symptoms – as a way to keep them from focusing solely on what they first believe is most likely; we have written about the additional value of developing a “contextual differential diagnosis” – a list of possible contextual factors that could also be contributing to the patient’s problem.

John Aeillo has reviewed Listening for What Matters for the Electric Review blog. Read the review here:

http://electricrev.net/2016/01/26/listening-for-what-matters/

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.