July 20--The elderly man was emaciated, so hospital physicians were running a series of tests for cancer, a common cause of weight loss in older patients.
Dr. Saul Weiner suspected something else might be going on.
"Where are you living?" he remembers inquiring. "I move around a lot," the haggard man responded. Weiner then asked if his patient was eating regularly. Sometimes, but not every day, the man admitted.
A diagnosis snapped into focus: The disheveled patient was homeless and starving. Weiner canceled the medical tests and called in a social worker.
The experience at a Chicago hospital several years ago inspired Weiner to study what he calls "contextual errors," or the failure by doctors to consider an individual's social or economic circumstances when diagnosing illness or prescribing treatment.
Weiner arranged to send actors playing patients into physicians' offices and discovered that errors occurred in 78 percent of cases when socioeconomic concerns were a significant factor, according to a paper published Monday in the Annals of Internal Medicine.
That's worrisome because care delivered without regard to someone's personal situation can fail to achieve its intended effect, said Weiner, an associate professor at the University of Illinois Medical Center in Chicago and staff physician at the Jesse Brown Veterans Administration Medical Center.
What's needed, Weiner says, is a systematic way to uncover the issues patients are confronting, such as the loss of a job or health insurance or the inability to understand verbal or written medical instructions. Such a "contextual history" could be taken from patients along with their physical history, he suggests, though the idea may be controversial among time-pressed physicians.
"A lot of doctors are going to say, 'God almighty, it's not enough to be a brilliant clinician? You're telling me I've got to be a financial counselor or social worker on top of that or I'm doing something wrong? Give me a break!'" said John Banja, a medical errors expert at Emory University.
The new study, led by researchers at six Chicago-area medical centers, is the largest on record to use "mystery patients" to investigate how physicians operate in practice. One hundred eleven doctors participated between 2007 and 2009, including 87 from Chicago. The physicians knew only that they were part of a study about medical decision-making.
Actors playing patients each presented a well-rehearsed case and made an audiotape of their interactions with physicians. In one case, the patient presented as a middle-age man complaining of uncontrolled asthma. In another, a woman came in for a blood-pressure check before surgery. In a third, a diabetic man reported almost fainting twice after taking a higher dose of insulin. A fourth involved a patient similar to the older man described above.
For each case, there were four carefully scripted variations that introduced a so-called contextual complication involving the patient's personal circumstances, a biomedical complication involving the patient's physical condition, simultaneous contextual and biomedical complications or no complications.
Researchers used the audio recordings and medical records to calculate how often physicians picked up on red flags signifying possible complications and consequently adjusted their plan of care. The failure to do both counted as an error. In contextually complicated encounters, error-free care was provided only 22 percent of the time; in biomedically complicated encounters, the error-free rate was 38 percent.
During nearly 50 visits to doctors, only a few followed up on the hint that Amy Binns-Calvey dropped as a mystery patient. She pretended to be a woman scheduled for hip-replacement surgery and mentioned during the appointment that she hoped the procedure would help her care for her son.
Most doctors said nothing or "that's nice." A few asked how old the son was. (He was 23, according to the script, and very ill with muscular dystrophy.) Only a couple asked if something was wrong and suggested that surgery be postponed upon learning that Binns-Calvey was her son's primary caregiver, a job that involved considerable heavy lifting and wouldn't be possible during her recovery.
"I was shocked," Binns-Calvey said.
Asked about doctors' behavior, Dr. Daniel Rosenthal, of Chicago, a participant in the study, said most physicians are under "incredible time pressure and don't want to go there because it could open up a whole can of worms."
Also, "sometimes we don't have a lot to offer people, and that's an uncomfortable feeling," said Dr. Timothy Hofer, an expert on medical errors at the University of Michigan Medical School.
Hofer pointed out a limitation of Weiner's study: It examines first-time appointments, not care delivered over time. Some doctors may feel more comfortable asking about patients' lives after they've developed a relationship, Hofer said.
For Weiner, the critical issue is how physicians are trained. While doctors learn in medical school how to thoroughly investigate patients' biomedical concerns, no similar training exists for contextual issues, he said.
The U. of I. medical school is developing a training module on the topic and plans to test it on a pilot basis.
Weiner said doctors can take simple, practical steps to personalize patients' care, including speaking in simple language, listening carefully to concerns that patients mention and keeping a list of resources and agencies that help supply essential social services.
"I see this as an opportunity," said Dr. Eric Christoff, a Chicago internist in the study. "All of us have a lot to learn about how we can do our jobs better."
jegraham@tribune.com
-----
To see more of the Chicago Tribune, or to subscribe to the newspaper, go to http://www.chicagotribune.com.
Copyright (c) 2010, Chicago Tribune
Distributed by McClatchy-Tribune Information Services.
For more information about the content services offered by McClatchy-Tribune Information Services (MCT), visit www.mctinfoservices.com, e-mail services@mctinfoservices.com, or call 866-280-5210 (outside the United States, call +1 312-222-4544).