We are proud to announce our esteemed plenary speakers:
Professor of Medicine, Paediatrics and Medical Education at the University of Illinois, Chicago
Contextualising medical decisions to individualise care
Evidence based care plans can fail when they do not take into account relevant patient life circumstances, termed contextual factors, such as a loss of social support, new competing responsibilities, or financial hardship. For instance, increasing the dosage of insulin in a patient who has lost control of their diabetes may be appropriate when the underlying problem is that they have become physiologically resistant to the dosage they have been taking. However, when the underlying problem is that they have poor eye sight and depend on a family member to help them fill their insulin syringe – and that individual is no longer available — increasing the dosage is not beneficial and may even be dangerous. Overlooking contextual factors when doing so results in an inappropriate plan of care is called a “contextual error.” Contextual errors represent a failure of communication due to a clinician’s inattention to their patient’s life situation. Dr. Weiner will provide an overview of research on contextual errors including: how they are identified, data on their frequency, causal factors, their impact on health care outcomes, and several studies testing methods to prevent them.
Saul Weiner MD is a practicing internist and pediatrician who has led numerous federally studies on contextualizing care. His research team analyzes over 1000 audio recordings of physician-patient, nurse-patient, and pharmacy-patient encounters a year utilizing a methodology called “Content Coding for Contextualization of Care” or “4C.” In addition to his academic position, he is co-founder and president of the Institute for Practice and Provider Performance Improvement, also called “I3PI,” which applies methods for directly observing care to health plans and individual practices seeking to enhance value based care. Dr. Weiner is a graduate of Harvard College and Dartmouth Medical School, and compled his residency training at the University of Chicago. His 2016 book, Listening for What Matters: Avoiding Contextual Errors in Health Care, published by Oxford University Press, received the American Publishers Award for Professional & Scholarly Excellence in the Life Sciences from the American Association of Publishers. His most recent book, On Becoming a Healer: The Journey from Patient Care to Caring About Your Patients, was recently published by Johns Hopkins University Press (April 2020).
Professor of Primary Care at the University of Marburg,
A deconstruction of clinical care, but ending on a positive note.
The starting point of my reflection are population studies of medical imaging (knee, hip, spine) which show negligible or no association of pathological findings with symptoms reported. In other words: the prevalence of objective findings in symptom-free individuals is almost as high as in those complaining of pain or functional limitations.
In practice, neither clinicians nor patients obtain this kind of complete feedback as provided by population based studies. Diagnostic effectiveness thus seems to be vastly overestimated. Findings usually understood and accepted by doctors and patients as the explanation of symptoms and functional impairment, must be regarded as spurious. The contribution of technologies regarded as ‘modern’ and highly effective, seems to be much smaller than generally assumed.
Emphasizing technical procedures over the patient’s history has some obvious advantages: reducing clinical complexity, providing a hermetic system essential for archetypical healing functions, and giving clinicians power over their intimidated patients. Moreover, this emphasis fits in with current discourses of innovation and progress. It creates the illusion of immediately touching on the pathological process.
The kind of analysis I will present, closely related to what is called ‘reversal’ in the literature, must not lead to medical nihilism. I will try to outline an alternative clinical approach in which all findings are seen as signs of a pathological process, which is not accessible as such. If any sign had a preferred status, this would be history given by the patient: symptoms, functional and temporal associations, and explanations suggested by the patient. The physical examination, which also has a strong communicative component, would come second. To what degree this kind of clinical reasoning is justified against a background of rapidly evolving new diagnostic technologies will be an interesting point for discussion.
Norbert Donner-Banzhoff, MD, MHSc is a practicing family physician who also has an appointment as professor of Primary Care at the University of Marburg/ Germany. He is co-developer of arribaTM, the most widely used decision aid in Germany. He has conducted several studies evaluating this decision aid and/or its components (e.g. Ann Fam Med. 2008;6:218-27). Diagnosis in primary care has been another research topic resulting in the development and evaluation of the Marburg Heart Score for diagnosing coronary heart disease in primary care (CMAJ 2010;182:1295-300). Based on video-recordings of physician-patient consultations and reflective interviews with physicians, he coined the term ‘inductive foraging’ as an essential component of a patient-centred diagnostic assessment (Med Decis Making 2017;37:27-34 – Ann Fam Med 2018;16:353-358). Diagnostic error and patients’ preferences regarding the deprescribing of chronic medication are currently investigated by his team. He is author and co-author of books on continuing medical education, interventional health services research and evidence-based medicine (in German). He was a longstanding Member of the board of the DEGAM, the National Association for General Practice/Family Medicine, the German EBM network and Section Editor for BMC Family Practice.