Doctors often miss nonmedical clues in patient visits

Patients might be missing appointments or medication refills because of job losses. Such “red flags” should prompt physicians to probe further, a new study says.

By — Posted May 8, 2013

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Physicians frequently overlook factors that are not strictly biomedical and yet can contribute to poor outcomes, according to a study based on covert audio recordings of hundreds of visits to internal medicine clinics. (See correction)

So-called red flags such as missed appointments, drug noncompliance, missed screenings and sudden spikes in previously controlled diabetes and hypertension went unexplored in more than 60% of patient visits to physicians, said the study, published April 16 in Annals of Internal Medicine (link).


Saul Weiner, MD

These red flags often indicate that factors such as job loss, change in insurance status and trouble with transportation are impeding care, said Saul Weiner, MD, professor of medicine at the University of Illinois College of Medicine in Chicago. (See correction)

“There are algorithms for how to manage certain chronic conditions, but that is not going to help you when in fact the underlying problem is that the physician missed a cue about something else that is happening with the patient,” Dr. Weiner said.

When physicians ask patients about nonmedical impediments to their care, they may be able to address problems by prescribing generic alternatives or referring patients for other help, he added. This is especially true in the context of the study, which involved 774 patients at two Veterans Health Administration clinics in Chicago who recorded conversations with their physicians. For example, doctors can refer patients for transportation services available through the VA.

In the 38% of cases when studied physicians did probe about red flags, they often were able to develop patient-centered care plans — such as prescribing a less-expensive treatment. Fifty-nine percent of the time those plans led to improved outcomes such as fewer missed appointments and better-controlled chronic conditions. (See correction)

The covert recording used in the study allowed researchers to uncover what physicians may have missed in their visits with patients, Dr. Weiner said. The physicians involved consented to being recorded for the study, and part of the study's design was that the doctors did not know which particular patients would be taping them.

“If we want to look at the issue of whether physicians are picking up on patients' life context, you have to audio-record the encounter,” he said. “We're not going to get that information from the medical record. No physician is going to document something that they've missed.”

Secret recordings used to spot gaps

The Chicago VA clinics now use secret audio recordings by patients on a regular basis as a quality improvement tool. Physicians get individual feedback about how often they missed red flags and specific examples of when they could have probed more deeply to uncover patients' social or economic impediments. The concept is being spread to other VA locations as a quality improvement project, meaning the recordings are protected from legal discovery or use in medical liability cases.

Medical schools and residency programs should do more to train future physicians on how to spot nonmedical factors and how to improve health systems to address them, Dr. Weiner said.

“Physicians have a biomedical bias,” he said. “We're trained to think about things from a biomedical standpoint, and we tend to put a higher priority on information like a lab value, a new pain here or a lump there. We put lower value on information about a patient's context. I'd argue that a patient's insurance information is just as important a piece of knowledge as the type of bacteria the patient has. They are both critical to ensuring that the patient ends up with the right care.”

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8 signs that patients need extra help

Certain “red flags” should prompt physicians to probe what social, economic or other factors may be affecting patients and explore individualized care plans to address them, experts say. Actions that signal possible problems are when patients:

  1. Miss two or more appointments in the last four months or at least four in 12 months.
  2. Miss one or more prescription refills in the last four months or at least four in 12 months.
  3. Have uncontrolled diabetes, with a hemoglobin A1c level of 8% or higher.
  4. Have uncontrolled hypertension, with systolic blood pressure greater than 140 mm Hg or diastolic BP higher than 90 mm Hg.
  5. Miss one or more tests or scheduled imaging studies in the last four months or at least four in 12 months.
  6. Make two or more visits to an urgent care center within 12 months.
  7. Make two or more emergency department visits within a year.
  8. Decline or miss recommended screenings or vaccines such as colonoscopy or the flu shot.

Source: “Patient-Centered Decision Making and Health Care Outcomes: An Observational Study,” Annals of Internal Medicine, April 16 (link)

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An earlier version of this story misstated the faculty title for Saul Weiner, MD, professor of medicine at the University of Illinois College of Medicine in Chicago, and mischaracterized the kind of outcomes examined in the study. American Medical News regrets the error.

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