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BACKGROUND/RATIONALE:
Overlooking critical information about a patient's life and unique circumstances - their "context" -- can have predictable and avoidable adverse effects as significant as those anticipated from an incorrectly diagnosed but treatable condition. When such oversights result in "the failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim" they represent instances of medical error, as defined by the Institute of Medicine. Such "contextual errors," however, are usually missed using current methods to identify or predict medical error.
OBJECTIVE(S):
Using a factorial design, this study will test hypotheses and explore mechanisms of how physicians under-prioritize contextual, relative to biomedical, information during the processes both of history taking and of planning patient care. It also will attempt to identify the cognitive processes associated with avoidance of contextual error, and the characteristics of physicians and the medical encounter that influence the likelihood of contextually appropriate care.
METHODS:
The experiment involves using unannounced standardized patients and four scripted cases, each with four variations, three of which are embedded with biomedical and/or contextual information that is essential to care. At the start of the study, 112 fully trained internists at four VA hospitals and their university-affiliated medical centers, will provide data on their education, practice experience, and sociodemographic background. They will then be randomized to receive one of four variations from each of the four cases, appearing as new patients in their practice some time over a study period of 18 months. Eight actors, four African American and four Caucasian, will be paired in groups of two with each pair assigned to one case and its variants. The first variant, known as the baseline, consists of a patient presenting with a straightforward clinical problem, typical of what a primary care physician might encounter routinely in the office setting. In the second, appropriate questioning will uncover atypical features pointing to an unexpected biomedical condition requiring alternative management. In the third, appropriate questioning will uncover atypical features pointing to an unexpected psychosocial, or contextual, situation requiring alternative management. In the fourth, appropriate questioning will uncover both the biomedical and contextual "qualifiers," requiring a multifactorial approach to management. The encounters will be audiotaped and analyzed using checklists and interaction analysis. Outcome variables are whether the physician attempts to elicit the embedded information in the atypical cases and, if they do, whether their treatment recommendations incorporate that information. Analysis across the groups and cases will allow comparisons of subjects' priorities and interpretive abilities for managing biomedical and contextual complexities in patient care. Factor analysis of data from the interaction analysis will be used to develop a latent factor score of contextual reasoning for each case of each subject. A path analysis will test a predictive model of contextual reasoning skills, physician characteristics, and encounter conditions that influence the outcome variables.
FINDINGS/RESULTS:
At this time, there are no results.
IMPACT:
This study will elucidate the mechanisms of medical errors caused by failures to gather or use information about patients' life context. It will also attempt to identify the characteristics of clinicians (particularly their cognitive skills) and the encounter conditions that predict contextual error-making. Finally, by introducing a methodology for identifying contextual errors it will enable future study of interventions to reduce their frequency.
PUBLICATIONS:
None at this time.
DRA:
Health Services and Systems
DRE:
Technology Development and Assessment, Quality of Care, Communication and Decision Making
Keywords:
Adverse events, Decision support, Safety
MeSH Terms:
none
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