Hospitals, insurers, and regulators today direct unparalleled time and resources toward battling medical errors. According to research from Saul Weiner, MD, a teacher and hospitalist at the University of Illinois, Chicago, one type of error is being ignored.
“I found that contextual errors are as least as common and probably even more serious in inpatient care,” Dr. Weiner says. Contextual errors occur when physicians neglect to recognize the crucial role a patient’s life plays in care planning, he says. “I would argue that there are contextual issues in virtually every admission,” he adds.
Dr. Weiner and his team are trying to prove the importance of systematizing how physicians learn to contextualize care. For their research, published in the September 2007 issue of Medical Decision Making, the doctors trained actors to present scenarios in which contextual information was essential to planning appropriate care. They then tested 54 internal medicine residents to see how many would provide contextually appropriate care. More than half made serious errors.1
From the time Dr. Weiner started precepting residents in 1997, he noticed many were quick to fit patients into categories where they could apply evidence-based approaches to care. “But I sometimes sensed that there was something not so straightforward about a particular patient’s situation, some unexplained issue for why the patient wasn’t taking his asthma meds properly, or was coming in today of all days,” he says. When he and the residents would re-question such patients, “key factors often arose that made everything change about the way we wanted to manage them.”
For him, the seminal case occurred in 2002 when a patient who came to the preoperative testing clinic for bariatric surgery. She qualified for surgery, although because of history of adhesions, the surgery was going to be open rather than laparoscopic. When she said she was looking forward to getting the surgery so she could better care for her son, a red flag went up for Dr. Weiner.
“Patients don’t typically offer such reflections,” he says. Further probing revealed that she had a son in his 20s with a fatal disease, she was the sole caregiver, and her husband was an alcoholic. “She really hadn’t processed the fact that she would not be able to do anything for 40 days,” Dr. Weiner says. “Suddenly, when she got that, she wound up canceling surgery.”
The importance of learning a patietn’s contextual factors depends on the setting and the availability of resources, such as case managers, social workers, and outpatient chronic disease teams. Even with those resources, the onus still is on the hospitalist to determine an effective plan of care using context, he says.