Contextual Errors and Failures in Individualizing Patient Care: A Multicenter Study


Uploaded by UICmedicine on 14.05.2010

Transcript:
Contextual Errors and Failures in Individualizing Patient Care: A Multicenter Study.
Standardized Patients and Scenarios.
Hi. I'm Dr. Saul Weiner.
And I'm Dr. Alan Schwartz.
We're the first two authors in the study Identifying Contextual Error: Unannounced Standardized
Patients Expose Failure to Individualized Care.
Part of the study utilized unnanounced standardized patients -- or S.P.'s.
We thought it would be helpful if we showed how we used the S.P.'s in a video.
In this recreation, we show how a participating physician was visited by an announced S.P.
in their clinic. The S.P. is an actor, trained to portray a patient case the same way each
time. This was scheduled as a first visit with a new patient.
- Hey, Mr. James. - Hi.
- I'm Dr. Murray. And you're new to the clinic? - Yes, this is my first time here.
- Well, welcome! Uh, did you have something specific that you wanted to talk to me about
today? - I wanted to talk about my asthma.
S.P.'s were trained to present a common ambulatory complaint accompanied by a specific set of
verbal clues or red flags for each and every appointment. Then, depending on the visit,
they were to present answers to probes for those red flags from one of four variations.
- OK, tell me about your asthma, and how long have you had it?
- Well I've had asthma since I was a kid. I kind of outgrew it until about five years
ago when it started getting worse. It kept getting worse and it got to the point where
I was having episodes about twice a week. Now a couple of months ago, I saw a doctor
and he put me on Pulmicort, and it helps, but I'm still having episodes at least once
a week, sometimes more.
- Do you have any specific triggers for your asthma?
- Well that's kind of difficult to say. Sometimes cold weather outside, sometimes exercise,
sometimes I wake up coughing and wheezing.
The statement "Sometimes I wake up wheezing and coughing," is a red flag that indicates
there may be an atypical biomedical reason for the patient's complaint, specifically
gastroesophogeal reflux or GERD, often referred to by patients as heartburn. This biomedical
red flag is intended to see if the physician will probe further.
- Well it's difficult to say. Sometimes cold weather outside, sometimes exercise, sometimes
I wake up coughing and wheezing. - Do you have any pets at home?
- No. - And where do you work?
- I actually just lost my job and things have been tough.
The statement "I just lost my job and things have been tough," is a red flag that indicates
there may be a contextual issue affecting this patient's health care. This contextual
red flag is intended to see if the physician will probe further. These two red flags, biomedical
and contextual, were included in every variant the S.P. portrayed. The answer the S.P. gave
to a probe however depended on which of the four variants he or she was portraying. In
the baseline variant, there is no atypical biomedical or contextual issue, so a physician's
probe will not elicit any additional evidence of GERD or financial hardship affecting health
care.
- When you wake up coughing, do you feel like you have a burning in your chest -- what many
people would call heartburn? - No, no heartburn. Just the wheezing and
coughing. - Where do you work?
- Actually, I just lost my job and things have been tough.
- When you say "tough," what do you mean? - Well, you know, it's a drag being unemployed.
- Do you still have health insurance? - Yes. Luckily I'm covered by my wife's insurance.
- So you can afford your meds? - Yeah, my meds are covered.
The example you just saw was the baseline variant, and the response to the questions
about GERD and about health insurance problems raised no additional concerns for care. In
the following biomedical variant that you are about to see however, there is a positive
finding to a probe following the biomedical red flag, but not the contextual red flag.
- When you wake up coughing, do you feel like there's a burning in your chest -- what many
people would call heartburn? - Yeah, now that you mention it, I do feel
like I have heartburn when that happens.
In the contextual variant, there is no atypical biomedical issue, but there is a positive
finding to a probe of a contextual red flag.
- When you say "tough," what do you mean? - Well we're having a tough time getting by.
Uh, I just lost my health insurance. - Can you afford your meds?
- No. And actually, I've been kind of stretching them out.
- What do you mean? - Well I'm supposed to take the Pulmicort
twice a day, but instead, if I'm feeling alright, I'll take it once a day or not at all.
In the biocontextual variant, there is both the atypical biomedical issue and the atypical
contextual issue and the patient responds to both probes. In this study, a physician
received credit for asking biomedical and contextual probe questions regardless of the
variant. For instance, if the physician probed for financial difficulties for any variant,
they received credit. If they asked an open ended question that would yield the same information,
they were also coded as having probed.
- Actually I just lost my job and things have been tough.
- How have things been tough for you? - I lost my insurance and I can't afford my
meds. In fact I've kind of been stretching them out, maybe taking them half the time.
If the physician did not pick up on the contextual red flag, they were not scored as having probed
for the contextual clue.
- And where do you work? - Actually, I just lost my job and things
have been tough. - Oh, I'm sorry about that. Where did you
work? - At the YMCA.
- And were you exposed to checmicals at the Y?
- No, I worked in registration.
The same scoring procedure was applied to the biomedical red flag. All encounters were
recorded using a concealed tape recorder. The audio recordings were scored by a trained
coder. Inter-rater reliability checks were performed for samples of all ratings. Physicians
may have probed one or both red flags, but failed to recognize the importance of the
information when planning treatment. We also obtained the visit note written by the physician
for each visit and scored the notes for whether the physician's treatment plan would be appropriate
for the patient, given the variant. After each visit, the S.P. also completed a communication
skills checklist. The S.P.'s presented their scenarios reliably over the course of the
study. An S.P. portrayal quality assessment was completed for each visit to ensure that
the unannounced S.P.'s performances remained consistent with the scenarios.
That completes the demonstration. For more information, feel free to contact me at sweiner@uic.edu.