Patients’ Circumstances Count in Care Planning
How Well Do Hospitalists Spot Red Flags?
Tuning up the radar to prevent these errors comes down to providers asking one question and listening to one answer: What is the best thing I can do for this patient at this time? Watch for red flags, statements patients make or actions they take that may signal something lying beneath the surface that could make a huge difference in outcomes, Dr. Weiner says.
Spotting red flags isn’t always easy for hospitalists, who don’t see the same patients on a regular basis, says William Stinnette, MD, hospitalist with Kaiser Permanente in San Rafael, Calif. “Unless patients are a part of that ‘revolving door,’ with frequent visits to the hospital, we have to work up most of our patients with limited background knowledge,” he says.
Dr. Stinnette, who has worked in hospital medicine groups in both small and large facilities, believes the ability to ferret out contextual factors depends on the setting and teh availability of resources, such as case managers, social workers, and outpatient chornic disease teams. Even with those resources, the onus is still on the hospitalist to determine an effective plan of care using context, he says.
Dr. Weiner agrees. “Clinical decision-making,” he writes in the Medical Decision Making article, “requires two distinct skills: the ability to classify patients’ conditions into diagnostic and management categories that permit the application of research evidence, and the ability to individualize (contextualize) care for patients whose circumstances and needs require variation from a standardized approach.”1
Though most hospitalists recognize the importance of doing this, according to Dr. Weiner, they lack a systematic and coherent way to do so.2
Standardized Training
Physicians are well trained in assessing biomedical information, but not in listening for contextual red flags. “When you need to know what’s unique about a particular patient that might be relevant to the case, you don’t really know what you’re searching for,” Dr. Weiner says. “You just need clarity, and that is theory-building or inductive reasoning, a very different skill.”
Since July, with support from the National Board of Medical Examiners, the University of Illinois, Chicago, team has been testing a contextual-care curriculum for fourth-year medical students to complete during their inpatient medical sub-internships. In the randomized controlled trial, half of the trainees receive the intervention, half do not. Those getting trained learn that when they intuitively feel there is more to a patient’s story, they should return to the patient to find out why.
