Monday, August 23, 2010

Contextual and biomedical errors in medicine

A fascinating Annals study examined the premise that contextual errors conspire with biomedical errors to cause poor decisions in clinical practice. The authors explain what contextual errors are:

A contextual error occurs when a physician overlooks elements of a patient's environment or behavior that are essential to planning appropriate care. In contrast to biomedical errors, which are not patient-specific, contextual errors represent a failure to individualize care.

The investigators used standardized (fake) patients to present scenarios containing biomedical red flags, contextual (psycho-social) red flags, both or neither and found:

Physicians probed fewer contextual red flags (51%) than biomedical red flags (63%). Probing for contextual or biomedical information in response to red flags was usually necessary but not sufficient for an error-free plan of care. Physicians provided error-free care in 73% of the uncomplicated encounters, 38% of the biomedically complicated encounters, 22% of the contextually complicated encounters, and 9% of the combined biomedically and contextually complicated encounters.

Although we didn't use the same terms, my Roundtable colleagues and I talked about this a couple of years ago. In that article I related this story:

I'm reminded of some experiences from my own practice. A patient (not a real one but a composite of several I've observed) with "resistant hypertension" was treated with sequential dosage increases and additions of several antihypertensive medications. When the patient entered the hospital with an unrelated illness, the nursing staff dutifully "reconciled" the patient's hospital medications (the Joint Commission would have been proud!) with his primary physician's list, which had been kept up to date during all the titrations. When progressive hypotension and renal insufficiency developed over the next several days, the hospital physicians were perplexed until a little detective work revealed that for months, the patient had been taking only a fraction of what his medication list reflected. The ever changing and increasingly complex medication instructions had proved overwhelming to the patient, who had limited cognitive function. At last, the complete version of the history explained not only the patient's hypotension and renal insufficiency, but also the resistant hypertension. Examples such as this teach us that although getting to know the patient takes time, the investment is cost effective.

A related Huffington Post piece makes the case that we need a shift in focus of traini
ng toward contextual medicine.

But this is not something new. As I began my third year Internal Medicine rotation in 1973 one of our faculty mentors, the late Thomas E. Brittingham, taught us the importance of context.

My father, an old fashioned GP, knew about contextual medicine although there was no formal training in his day. He didn't have the biomedical resources we have now. He had to rely on his context based instincts and knew that they were an extensions of basic clinical skills

So it's not that this is a new area of training. The problem we face today, as pointed out in the Huffington Post piece, is that the perfunctory “metrics” we are overwhelmed with are distractions to real quality.

If this video is any indication, though, the authors of the Annals piece take the wrong approach by making the art of context based medicine just another checklist that we can be measured against. Watch as the physician, going down the checklist and asking all the “right” questions, fails to encourage the patient to tell his uninterrupted story, hammering away on the keyboard the whole time as he follows the EMR template.

DB comments here.

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