Most physicians probably recognize the importance of assessing patient context in making clinical recommendations, but may not approach the task in a systematic and coherent way that considers the full breadth of the patient's life circumstances. While physicians are trained to assess a patient's clinical state (from the history of present illness, physical exam, laboratory, and other tests), their preferences (values), and the research evidence (through a critical appraisal of the literature), integrating patient context into health care decisions remains an element of what the evidence-based medicine literature calls “clinical expertise.”1
Although a recently published prescriptive model of evidence-based decision making mentions patient “circumstances” (see ), the term is narrowly qualified as “physical” and “clinical circumstances.”2
There has been little methodological consideration of how one identifies, from the complexity of each patient's life, that which is pertinent to their care.
FIGURE 1 A current model of clinical decision making. Adapted from Haynes et al.1
The cognitive challenge of individualizing clinical decisions at a discrete moment and place with limitations of resources and possibilities is the point of departure for this paper. While a number of models of the medical interview outline the overarching goals and objectives of the physician-patient encounter, few conceptualize the reasoning applied in answering the ever-present question: “Under the circumstances, what is the best next thing for this
patient at this
time?” In his seminal writing on the biopsychosocial model, George Engel introduces general systems theory as a framework for broadening conceptions of illness beyond the biomedical model to include social, psychological, and behavioral dimensions, noting that “Systems theory holds that all levels of organizations are linked to each other in a hierarchical relationship so that change in one affects change in the others.”3
In a subsequent essay, “The clinical application of the biopsychosocial model,” he illustrates how perturbations in biomedical and psychosocial systems affect one another.4
What he does not offer, however, is a methodology for tracking those perturbations amid the infinite complexity of a patient's life, given the constraints of time and resources during a medical encounter.
Engel's model has stimulated many projects to define and describe the medical interview in a manner that incorporates psychosocial and biomedical elements into patient care.5–10
Stewart et al. have developed “patient-centered communication,”12
aptly described as a “cluster of physician behaviors” that promote “knowing the patient as a person, in addition to accurately diagnosing their disease.”11
Greater emphasis has been placed on the functions of the medical interview (collecting information, responding to the patient's emotions, influencing behavior)13
rather than on just its structure (e.g., greeting, followed by chief complaint, then history of present illness, etc.). This “three-function” model, introduced by Bird and Cohen-Cole, has been elaborated by Lazare, Putnam, and Lipkin as: determining and monitoring the patient's problem; developing, maintaining, and concluding the therapeutic relationship; and carrying out patient education and implementation of treatment plans. For each function, there are tasks such as “acquiring the knowledge base of psychosocial issues” and “eliciting data for the biomedical, psychological, and conceptual domain,” for determining and monitoring a patient's problem, for instance.14
Functional analysis thus describes what successful clinicians do but not how they think. We shift here from a focus on the objectives for the clinician providing patient-centered, individualized care, to consideration of the cognitive processes for accomplishing those objectives.
This essay draws on the literature on qualitative methods theory to describe an approach to individualizing clinical decisions, which is called “contextualization.” Contextualization involves identifying what is relevant to the immediate clinical problem from across the spectrum of a patient's life, including their cognitive abilities, emotional state, cultural background, spiritual beliefs, economic situation, access to care, social support, caretaker responsibilities, attitude to their illness, and relationship with health care providers (). In the following case, consider how the failure to contextualize caretaker responsibilities results, initially, in a failure to determine what is the best next thing for this patient at this time:
Contextual Categories to Consider for Each Patient (with examples)
Ms. Gloria Dawson (a pseudonym) presented in the preoperative testing clinic for evaluation for gastric bypass surgery to treat morbid obesity. She was 44 years old, 5′ 6″ tall, and weighed 270 lbs. She had been referred to a surgeon experienced in the procedure from the weight loss clinic after unsuccessful nonsurgical attempts to lose weight. He scheduled her for an open rather than laparoscopic procedure because of concerns about adhesions from a prior cholecystectomy. The internist who examined Ms. Dawson noted well-controlled diabetes and hypertension. Despite her weight she could walk up two flights of stairs, and her exam was unremarkable. Ms. Dawson commented that she looked forward to losing weight so that she could get around more easily and better assist her son who is disabled.
Concerned about the passing reference to her caretaking responsibilities, the physician asked her about her disabled son. He was aware that abdominal surgery for obesity can be fraught with complications, including wound dehiscence and a prolonged course. Average recovery time for the procedure recommended to Ms. Dawson is 46 days.15
In the discussion that followed, the patient described how she was the sole functioning adult member of her household at a critical time. Her son was dying of end-stage muscular dystrophy and her husband, who was an alcoholic, was abusive and unhelpful. She also had an 8-year-old daughter. She had not “thrown out” her husband, she said, because she needed money that came from his disability income and social security to support the family.
As they discussed her home situation and her plans for surgery, Ms. Dawson expressed dismay at the thought of being unable to care for her children for weeks or months. “They need me now more than ever,” she said. The physician also pointed out that assisting her son with toileting and bathing, which required heavy lifting, could complicate her recovery. She noted that she had been informed about the possibility of a lengthy postoperative course, but had been focused on the positive aspects of surgery, particularly greater mobility. She concluded, and the physician concurred, that this was the wrong time for the procedure.
Although Ms. Dawson met the criteria for bariatric surgery, sending her to the operating room at that time would have been an error for several reasons: first, it would have been inconsistent with her immediate priority to care for her children, and protect them from her husband's abuse; second, her need to assist her son might have led to unwise physical activities during recovery; and, finally, any serious complications may have wreaked havoc on her family's fragile homeostasis. How were these issues initially missed? After all, her doctor had discussed the surgery with her and she had indicated her preferences. The problem was that nobody had identified the incongruity between her personal situation (her context) and the proposed plan of care. One might call this a “contextual error.”
How can clinicians prevent contextual errors? Need they just do a better job at eliciting patients’ preferences, as in a utility analysis, so that patients can independently determine what is best for them?16,17
Or should they exhaustively explore with each individual how every aspect of their life situation relates to potential outcomes? While the former approach does not take into account the wide spectrum of patient comprehension of the implications of context, the latter is impractical. In Ms. Dawson's case, it is the physician who has the greater potential to recognize that premature weight bearing, precipitated by the need to care for a disabled child, might compromise her recovery. Patients need physicians not only for their knowledge and procedural skills, but for their skills as contextual thinkers.
As with the other components of clinical decision making, contextualization requires a systematic approach that prevents physicians from succumbing to personal biases and preconceptions, or relying exclusively on clinical experience. The following section introduces such an approach using three concepts from the qualitative sciences to integrate patient context into clinical decision making: The first is explanatory theory building
the second is reflexivity
and the third is triangulation