Contextual Care (2016)

16-14 Contextual Care

Nancy Benson: We all want to feel listened to, especially when it comes to talking with our doctor. But new research shows that more than half of all physicians in the United States don’t listen carefully enough to their patients. And the result? Care plans that don’t work and higher health care costs.

Dr. Saul Jeremy Weiner: The kind of thing that we saw a lot was that a patient would say something that really needed to be explored, like a patient might say, “Doc, it’s been really tough since I’ve lost my job and my asthma is out of control,” and when that kind of comment is made, what you’d like the doctor to say is, “Well gosh, tell me about that. Are you having trouble paying for your medicine?” or whatever. And sometimes they heard that, but more often the physician was more focused on entering data into the computer and would say, “Well, you know, I’m sorry to hear that, do you have any allergies?” and just kind of miss these important comments that patients would make that were often critical to getting the care plan right.

Benson: That’s Dr. Saul Jeremy Weiner, Professor of Medicine, Pediatrics and Medical Education at the University of Illinois, Staff Physician at Jessie Brown V.A. Medical Center, and co-author of the new book, Listening for What Matters – Avoiding contextual errors in health care.

Weiner: The problem with that is that patients will often walk out with a care plan that is just not likely to be effective for them. At its worst, what it suggests is that physicians kind of have a very narrow focus, they’re focusing on the narrow biomedical things that they do for a patient but not looking at the larger picture, which is as a person what does this person need? What can I do that’s really going to help them?

Benson: Weiner has been teaching medical students for over 15 years, and he’s noticed that while young doctors are very good at the science of medicine, they often miss the larger picture–the context of care. For example, one of Weiner’s residents who had interviewed a patient preparing for bariatric surgery: the resident reported to Weiner that “she’s good to go.”

Weiner: She’s got all of the indications to have surgery, she’s tried other ways of losing weight, you know, she’s looking forward to taking better care of her son once her weight’s down and so forth. I said, “Well, what’s wrong with her son?” and the doctor said, “Well I don’t know, the son’s not the patient.”

Benson: So Weiner himself went in and talked with the patient.

Weiner: I asked this woman you know, “Gosh, I understand you have an ill son, what’s going on?” and what she told me was that her son is dying of muscular dystrophy, he was in his 20s, she was responsible for taking care of him and had to lift him and bathe him and she felt that if she could get off some weight she could be in better shape to do that. But what she didn’t realize was that for over a month after the surgery, she wouldn’t be able to do anything because she’d have a big abdominal wound and if she actually tried to lift her son, she’d tear open that wound. And when we talked about that, she realized that the surgery was absolutely the wrong thing for her at this time. What I realized from that particular case, and it was one of many, is that it can sound perfect, it can sound like you’re giving the person the right care, but once you delve into what’s going on in that person’s life, it all of a sudden may look like absolutely the wrong care.

Benson: Weiner’s co-author is Dr. Alan Schwartz, Michael Reese-Endowed Professor of Medical Education at the University of Illinois, Chicago. The pair’s research focuses on what happens when doctors don’t take patient circumstances into consideration.

Dr. Alan Schwartz: I think some of the implications of our research are alarming even to us. I say, you know, the medical care in the United States is very good and, on average, patients get a lot of very good care. The problem comes when you try to distinguish the average care from this patient and their particular life and their particular needs. Is that physician taking those things into account and providing care that will actually work for this patient? Because unless you ask about these things and discover that this patient’s life circumstances require something particular and personalized, you assume that they’re like most patients. You go on and do what you would do for most patients and you walk away feeling like you’ve done a great job, your chart looks right, and the patient doesn’t get any better.

Weiner: What we’ve shown in our research is we’ve followed patients for up to nine months after audio-recording visits and we’ve shown that when the doctor addresses these life issues, the patient actually has a better outcome. We’ve also shown that when these issues are missed and the care plan is just sort of biomedically correct but not right for that patient, health care costs are higher because the doctor tends to order a lot of unnecessary tests when he or she isn’t really sure what’s going on. So, you know, if your patient’s asthma is getting worse and you don’t know that it’s because they can’t afford their medicine, you are probably going to add on more medicines, you’re probably going to order pulmonary function tests and all sorts of other tests and we’ve seen that. We’ve seen it many times and we’ve recorded that and studied it. So I think that this is an issue not just of quality but also of health care costs.

Benson: Weiner says that unlike medical errors, such as prescribing the wrong drug or dosage, contextual errors are detected by tracking what’s said during a patient’s doctor visits. For their study, Weiner and Schwartz recruited undercover actors to pose as patients, and then recorded each visit. They found that more than half of the physicians they recorded missed the contextual red flags the actors were trained to drop into the conversation. Those doctors just plowed on, sitting at their computers taking biomedical details. Weiner says this failure to pick up contextual cues is a quality issue. And the way to address it, he says, is really no different than what the retail world employs to uncover quality issues in customer care.

Weiner: There are two approaches. One is you have a mystery shop program in health care. Right now, mystery shoppers go into department stores and hotels and restaurants to assess the performance of staff and that’s used to provide feedback. In health care, you could also send in what we do, unannounced standardized patients, who will collect data on the performance of physicians and then that’s used never in a punitive what, that’s used as a form of quality improvement so you provide data back to physicians. By the way, you can collect data on lots of things when you send in unannounced standardized patients. That’s just a fancy term for mystery shopper, mystery patients in health care. But the reason we call them unannounced standardized is because they’re more trained, they do the same thing at every visit, they collect data, they know how to assess what’s going on in the health care visit. That’s a very powerful way of identifying problems in health care that you can only know about if you’re actually observing the doctor during the visit.

Benson: Schwartz says this “mystery shopper” kind of approach to addressing quality is very new to healthcare, and that so far, the doctors participating in the program are grateful for it.

Schwartz: In our research and quality improvement project, the response by the physicians who have been involved and most of the other clinical personnel has been very positive. People do get into medicine because they want to take care of people. It is a healing profession. Giving them feedback on how they are or aren’t doing a great job and taking care of their patients is something that many physicians really greatly value. We think that we’re on to something because we’ve done the best job we can of rigorously studying this problem using a variety of methods and a variety of angles and they all seem to be pointing to the same answer.

Weiner: Once we train people to listen in to audio recordings, there’s 95% agreement about whether the care was contextualized or not, regardless of who listens to the audio recording, so it’s very measurable. And so what I would say is we’ve simply taken a key part of patient-centered care and turned it into something that everyone can agree on that’s very measurable and also that actually predicts how the patient will do.

Benson: However, in order to implement these changes and incorporate them into standard practice, Weiner and Schwartz say the entire health care community, including patients, need to talk about the importance and implications of contextual care. Can it really improve patient outcomes and lower health care costs? Schwartz says the only way to find out is to give it a try.

You can learn more about our guests, Dr. Saul Jeremy Weiner and Dr. Alan Schwartz, and their book, Listening for What Matters by visiting our web site at radiohealthjournal.net.

Our writer/producer this week is Polly Hansen.

I’m Nancy Benson.