Patients’ Circumstances Count in Care Planning

The Hospitalist. 2008 October;2008(10):

October 1, 2008|The Hospitalist

Hospitals, insurers, and regulators today direct unparalleled time and resources toward battling medical errors. According to research from Saul Weiner, MD, a teacher and hospitalist at the University of Illinois, Chicago, one type of error is being ignored.

“I found that contextual errors are as least as common and probably even more serious in inpatient care,” Dr. Weiner says. Contextual errors occur when physicians neglect to recognize the crucial role a patient’s life plays in care planning, he says. “I would argue that there are contextual issues in virtually every admission,” he adds.

Dr. Weiner and his team are trying to prove the importance of systematizing how physicians learn to contextualize care. For their research, published in the September 2007 issue of Medical Decision Making, the doctors trained actors to present scenarios in which contextual information was essential to planning appropriate care. They then tested 54 internal medicine residents to see how many would provide contextually appropriate care. More than half made serious errors.1

Why Now?

From the time Dr. Weiner started precepting residents in 1997, he noticed many were quick to fit patients into categories where they could apply evidence-based approaches to care. “But I sometimes sensed that there was something not so straightforward about a particular patient’s situation, some unexplained issue for why the patient wasn’t taking his asthma meds properly, or was coming in today of all days,” he says. When he and the residents would re-question such patients, “key factors often arose that made everything change about the way we wanted to manage them.”

For him, the seminal case occurred in 2002 when a patient who came to the preoperative testing clinic for bariatric surgery. She qualified for surgery, although because of history of adhesions, the surgery was going to be open rather than laparoscopic. When she said she was looking forward to getting the surgery so she could better care for her son, a red flag went up for Dr. Weiner.

“Patients don’t typically offer such reflections,” he says. Further probing revealed that she had a son in his 20s with a fatal disease, she was the sole caregiver, and her husband was an alcoholic. “She really hadn’t processed the fact that she would not be able to do anything for 40 days,” Dr. Weiner says. “Suddenly, when she got that, she wound up canceling surgery.”

The importance of learning a patietn’s contextual factors depends on the setting and the availability of resources, such as case managers, social workers, and outpatient chronic disease teams. Even with those resources, the onus still is on the hospitalist to determine an effective plan of care using context, he says.

Cases of Context

Re-questioning of these inpatients and their families revealed contextual factors that significantly affected the plan of care.

Case 1: A 46-year-old Spanish-speaking woman with diabetes mellitus, end-stage renal disease on hemodialysis (HD) came to the emergency room with fluid overload secondary to missed HD and with hyperglycemia. She had several similar prior ER visits.

Red Flag: She missed HD several times, with frequent admissions for a preventable problem. No one asked why.

Contextual Narrative 1: Patient’s son is s/p renal transplant and receives nearly weekly care at the same hospital. The patient receives HD at a center in the opposite direction from her home. Frequently, she must choose between her son’s care and her own. He is her priority.

Solution: Transfer her HD to the same hospital where her son receives care.

Contextual Narrative 2: Questions about her worsening diabetes control reveals she cannot read her medications clearly due to worsening eyesight. An argument with an ophthalmologist she’d seen a year before led her to go without care.

Solution: Find a new ophthalmologist.

Contextual factors: Access to care (transportation) and attitudes toward the healthcare provider and healthcare system.

Case 2: A 57-year-old diabetic man is admitted with two pre-syncopal episodes, with palpitations. Both times he drinks some juice and feels better.

Red Flag: When the physician is taking history, the patient keeps mixing up his medications and dosages.

Contextual Narrative: He has poor health literacy, probably a combination of a limited education and an undiagnosed learning disability. He had help with his meds at his former home, but since moving to care for his aging mother, he is now on his own.

Solution: Recognize the literacy issues and work to find a solution (pre-filled syringes, diabetic education, etc.).

Contextual factors: Cognitive abilities.

Case 3: A middle-aged patient has newly worsening asthma.

Red Flag: He mentions during the intake exam that it’s been hard since he lost his job.

Contextual Narrative: Through his wife’s employer, he’s on an insurance plan that provides him only with major medical coverage, not medications. He’s been using an expensive brand name inhaler incorrectly (every couple of days instead of daily) when less costly generics are available.

Solution: Get him a prescription for an affordable generic medication.

Contextual factors: Economic situation.

Case 4: A 52-year-old woman with a CVA neurogenic bladder had recent multiple admission for UTIs. She had previously done well.

Red Flag: On the third admission the resident was puzzled as to how the patient catheterized herself given that she had little use of her arms.

Contextual Narrative: On questioning, the woman explained that her husband assists in catheterizing her, but his worsening alcoholism no longer made him reliable.

Solution: The primary care physician was notified, and met with the patient and her adult daughter to develop another caretaker plan.

Contextual factors: Caretaker responsibilities.