Understanding the patient’s context

How Well Do You Know Your Patient? – By Jennifer P. Schneider, MD, PhD and Bennet Davis, MD – Mar 2017

Can you describe a day in your patient’s life?

As treating chronic pain with opioids comes under greater and greater scrutiny, one of the lessons that has become more evident to prescribers is that initial assessment and follow-up are no longer a matter of just gathering facts about the characteristics of the pain and its level.

We cannot provide safe and effective care unless we understand the patient’s context.  

This subject was addressed in a recent book that we highly recommend. In Listening for What Matters: Avoiding Contextual Errors in Health Care, authors Saul Weiner and Alan Schwartz write that contextually appropriate care requires obtaining a wider breadth of information about many aspects of the patient’s life, including his or her financial situation, social support, competing responsibilities, and cognitive abilities.

It also means paying attention to information offered by the patient and probing further, an approach that can result in making better treatment decisions.

For example, if the patient hasn’t followed through with physical therapy (PT) appointments or making an appointment with a consultant, before immediately concluding that the patient is “noncompliant,” do you ask why?

It is also very relevant to ask about the patient’s support system. Does she have a family? Children at home? And does the patient have any activities that he enjoys doing?

And, on the flip side, stress, anxiety, and depression are well known to exacerbate pain, and treating them can be an important component of improving pain and function. You won’t know about this if you don’t ask!

In a study involving “mystery patients” wearing recorders, Weiner and Schwartz found that physicians planned appropriate care in 73% of the visits when the case did not include a complicating medical or contextual factor, 38% when the complication was only medical, and only 22% of the time when the case included both complicating contextual and medical factors.

When it comes to patients who have chronic pain, it is at least as important to learn about the patient’s functioning as about his pain level.

A good starting point is, “What is a day in your life like?”

If the patient says, “I’m better—I can now walk my dog again,” ask for details: “How far? How many minutes? What size dog do you have? How many hours a day are you now spending in bed?”

You need to gather enough information to create a picture of the patient’s daily life, not just that his function has improved to a 5 out of 10 or by 30%. Numbers and percentages tell you very little about the patient.

Documenting information about his specific activities, both before and after initiation of treatment, is also the best way of keeping track of, and supporting, any benefit the patient may receive from the treatment plan he has been given.

When opioids are being considered as a treatment option, risk assessment is an essential component in the prescriber’s decision making. This involves asking questions that you might not generally feel comfortable asking.

The bottom line is, as described by Weiner and Schwartz, that paying attention to the patient’s context is an essential element of good health care.

References:

  • Weiner SJ, Schwartz A. Listening for What Matters: Avoiding Contextual Errors in Health Care. Oxford, UK: Oxford University Press; 2016.
  • Weiner SJ, Schwartz A, Weaver F, et al. Contextual errors and failures in individualizing patient care: a multicenter study. Ann Intern Med. 2010;153(2):69-75.
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2 thoughts on “Understanding the patient’s context

  1. Kathy C

    These Articles are just silly. Perhaps for some of the idle rich or those with really good insurance they might apply. Physicians do nto have the time or the inclination to communicate with their Patients. This is especially true of people with Medicare or Medicaid, and even the VA. It appears they are timed or under serious time constraints and other pressures. They have also been Indoctrinated if they work for an HMO. They are made aware constantly that any superfluous Information in the Record could possibly be used to create a Liability Issue, even though it is unlikely the HMOs prefer to operate that way. They have created an us against them climate in Healthcare.
    the HMOs found it was more profitable to avoid documenting anything. This also helped with deniability, which they deemed more important for their bottom line. This Physician is writing about Pain, which is very subjective and invisible, therefore deniable. They found it inconvenient for the Industry to put the reason the patient even visited the Physician in the first place. time and time again i have heard the same story, about a Patient, with an unusual pain who went to a physician. They mentioned the pain because it was unusual,not because they wanted drugs. Only when patient was in a certain category, rich, and with good Insurance did the Physician take the concern of the patient seriously.
    In some of theses cases the “pain” was an indicator of cancer, which the Physician ignored initially, and on several subsequent visits. one case the senior man was made to feel stupid by the physician for mentioning the trivial pain. Being a nice person he didn’t mention it again. A couple of years later his doctor found cancer in his blood-work. the Pain was from a tumor, which had already metastasized by the time the physician found it. The same thing with a 70 year old woman with kidney cancer, the initial “Back Pain” was ignore and attributed with “Complaining that old women are subject to. The Medical Industry found that keeping track of theses instances wasly inconvenient for them. They also made sure that no record they keep would reflect any of this kind of Postponement or missed opportunities to catch these things early.
    The Industries that profit from his regularly Lobby Congress and have their insiders on various regulatory boards, so they have been very good at determining what kind of Information even Medicare, the largest insurer can collect. They knew for some time that in order to keep their Profitability, they had to obfuscate the data that is collected. They loosened reporting requirements and even changed the questions or data that has to be collected at a doctors visit. Even the reason for the visit is now not collected. Only data that shows they were actually present. This has created a Groundhog day scenario at Physicians Offices and Clinics. each time the Patient goes back it is like groundhog day.
    This has little to do with Pain,but Pain is easier to deny. Pain also forces the patient to return, unlike other issues. In a lot of cases the Patient is relieved, the Physician did not find anything wrong. Health Conditions that the patient is in denial about, like Hearing Loss, Dementia and other conditions people would rather not have, are ignored. The Patient is actually relieved, happy to think there is nothing wrong. Hearing Loss might interfere with communication with the Physician, and lead to Cognitive issues and isolation. Physicians are either unaware of this or have disincentive to diagnose or provide a referral. Things that are easily observable, are deliberate ignored by Physicians, In Some healthcare situations, it is a way they get more reimbursement since the Patient has to return on multiple occasions.
    Since the Industries that profit from all of this are now writing Healthcare Policy, and protecting profits for the Industry, this will only get worse. the so called Non Profits and the VA have adopted these models too. They are more concerned with the numbers, so seeing the same Patient several time for the same issue keeps the numbers up, and keeps the money coming in. there is no incentive to actually figure out why the Patient is there. They describe this too for the gullible Physicians, they just want attention, they are not there for their health. Even when the patient requests a Referral they will talk over them or ignore them, they certainly would never put that in the record. it is a new Era people, one where faith and Imagination are more important than sensible healthcare. These Physicians talk about Communication, when even if it does exist the Physician is to busy.
    What this Physician is doing id PR for the Industry, by talking about it the media it gives the appearance they are concerned about Communication. It is just like “Innovation” another meaningless word. there has not been much innovation, we are except for a few rare instances worse off than we were 20 years ago. The only Innovation we have seen in healthcare, has been in the area of extracting more Profits. To do this they have to give the appearance of communication. They also have to continue to mislead the public, with the help of their partners in the Corporate Media. They have been very innovative in undermining any attempt to collect the data they don’t like or that hey find unprofitable. We are all being duped, the new “Wellness” “Communication” and even”Innovation” instead of healthcare is one more way they are exploiting all of us. this is why we have the most expensive and least effective healthcare System in the developed world, and it is why our Mortality, and Suicide rates are climbing. They have written people off, given them a Death Sentence.

    Liked by 1 person

    Reply
    1. Zyp Czyk Post author

      This is the problem when social needs are manipulated or ignored in capitalism’s single-minded pursuit of profit.

      Somehow, financial interests need to be aligned with social needs, but even then, we cannot agree on what those needs are. Pain and other states of health cannot be measured and I believe that’s why our purely financially and metric-driven healthcare system isn’t working.

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