Medicine is as much about Science as it is about Art.
This is no better illustrated than an educational intervention study about "contextualizing" patient care, published in JAMA.
What is contextualization?
It is the "process of identifying individual patient circumstances (their context) and, if necessary, modifying the plan of care to accommodate those circumstances". In other words, this is care beyond the evidence-based guidelines, beyond standardized quality measures, and beyond the checklists.
- What if the patient hasn't been able to afford the more expensive blood pressure medications they've been prescribed by their primary care physician?
- What if your patient is marginally housed with poor access to food?
- What if your patient gets confused easily when reading pill bottles?
- What if your patient has no access to care?
These are real concerns in the Emergency Department setting. In contrast, contextualized patient care really isn't taught in any formal fashion in medical school or residency. It's learned on the job.
Study question
Can a 4-hour educational course on contextualizing patient care improve a 4th year medical student's ability to detect and act on contextual "red flags" in standardized patient exams?
Study methodology
Students at 2 sites were quasi-randomized into the control (no educational course) versus study group (received educational course). Students from both groups participated in an end-of-rotation session where they each assessed 4 standardized patients.
There were 4 patient cases:
- 43 y/o man with recent persistent asthma symptoms despite being prescribed a low dose of a high-cost, brand-name, inhaled glucocorticoid
- 47 y/o woman presenting for preop assessment of hip replacement reports mild hypertension and being overweight
- 59 y/o man with diabetes presents with 2 presyncopal episodes after previous physician increased insulin dosage
- 72 y/o man with unexplained weight loss
Each case had 4 variants:
- Baseline case
- Had a contextual red flag
- Had a biomedical red flag
- Had both a contextual and biomedical red flag
For instance, in the case of the 59 y/o diabetic man with presyncopal symptoms:
- Contextual red flag: Confuses dosages and says "It's hard for me to keep numbers straight".
- Biomedical red flag: "I felt some pounding in my chest when it happened."
- Baseline error: No adjustment of insulin dosing or discussion of dietary change to prevent hypoglycmemia
- Contextual error: No discussion of obstacles to self-care in patient with cognitive disabilities which impair his ability to administer his own insulin. He had recently left a community where he had assistance.
- Biomedical error: No EKG, Holter monitor, or stress test ordered in patient with symptoms of arrhythmia.
Results
Students in the intervention group (90%) were more likely to probe for contextual issues in the standardized patient encounters than the control group students (62%). The intervention students were also more likely to develop appropriately revised treatment plans for patients with contextual issues (69%) compared to the control group students (22%). As expected there was no difference between the two groups in the rate of probing and treatment plan development for patients with biomedial issues.
Limitation
As with many prospective educational studies, there was a large attrition rate. Of the 189 of who consented to participate, only 124 remained to participate in the standardized patient encounters at the end of the 4 weeks. The authors appropriately conducted a sensitivity analysis to determine the worst-case scenario, which assumed that the students in the intervention group did NOT benefit from the educational intervention. Even with this scenario, recalculations still demonstrated statistically significant benefit from the intervention:
- Probing contextual red flag: Control (60%), Intervention (82%)
- Planning contextually-appropriate treatment: Control (22%), Intervention (55%)
Conclusion
This study demonstrates that teaching contextualized patient care is possible and that a 4-hour course is effective in changing student behavior.
