Patients' life circumstances an important factor in care

Treatment plans need to incorporate patients' social and economic circumstances, including access to medical care or health insurance, rather than just follow standard guidelines for care, a new study says.

Inattention to such factors could lead to errors in providing patient care, according to Saul J. Weiner, MD, lead author of the study in the July 20 Annals of Internal Medicine.

For the study, standardized patients made 399 unannounced visits to 111 internists between April 2007 and April 2009 at practices in Chicago and Milwaukee. Actors portrayed patients and followed scripts that contained hints of clinically significant biomedical issues, such as an asthma patient wheezing at night.

The scripts also featured contextual issues, including unemployment. The interactions were recorded on audiotape. Dr. Weiner defined contextual issues as elements of a patient's environment or behavior that are essential to providing care.

Researchers analyzed the recordings and doctors' notes to calculate how often physicians identified red flags that signaled possible complications and whether they adjusted their plan of care. Failure to do both was considered an error.

Doctors noticed more biomedical red flags (63%) than contextual ones (51%), according to the study (link).

Dr. Weiner said the findings suggest that doctors are taught to notice medical issues or complications and tend to disregard patients' contextual concerns. He recommends that medical school curriculum be revised to offer students and residents more training in identifying socioeconomic issues that could affect patients' health.

"Overlooking contextual aspects of patients' life circumstances is just as important as overlooking biomedical situations and [both] can lead to inappropriate care," said Dr. Weiner, associate professor of medicine and pediatrics at the University of Illinois at Chicago.

Listening to patients

John Prescott, MD, chief academic officer of the Assn. of American Medical Colleges, said the study highlights a problem with physicians who don't carefully listen to patients. But he does not consider the study's findings a call to radically change medical school curriculum.

He said schools already are addressing the issue, in part, with a clinical skills component of the U.S. Medical Licensing Examination. The component tests medical students and graduates on ability to gather information from patients, perform physical examinations and communicate their findings to patients and colleagues.

"It's not only testing whether students can do a procedure. It's about understanding and appreciating how to communicate" with patients, Dr. Prescott said.

Dr. Weiner said the key to appropriate care is paying attention to the information that a patient brings up during an office visit and then asking the right follow-up questions.

For example, if a patient says, "It's been tough since I lost my job," the physician should ask, "How has it been tough?" Instead, physicians often respond with empathy and say, "I'm so sorry to hear that," Dr. Weiner said.

Dr. Weiner said physicians should be aware of patients' economic situations, social support, access to transportation, cognitive abilities and competing responsibilities, such as a job or caretaker role.