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Evaluating Physician Performance at Individualizing Care: A Pilot Study Tracking Contextual Errors in Medical Decision Making

Department of Medicine University of Illinois at Chicago, Department of Pediatrics University of Illinois at Chicago, Veterans Affairs Center for Management of Complex Chronic Care, Chicago, Illinois, sweiner{at}uic.edu

Alan Schwartz, PhD

Department of Pediatrics University of Illinois at Chicago, Department of Medical Education University of Illinois at Chicago

Rachel Yudkowsky, MD, MHPE

Department of Medical Education University of Illinois at Chicago

Gordon D. Schiff, MD

John H. Stroger Jr. Hospital of Cook County and Rush University, Chicago, Illinois

Frances M. Weaver, PhD

Northwestern University Feinberg School of Medicine, Chicago, Illinois, Center for Management of Complex Chronic Care, Hines VA Hospital, Hines, Illinois

Julie Goldberg, PhD

Department of Medical Education University of Illinois at Chicago

Kevin B. Weiss, MD

Northwestern University Feinberg School of Medicine, Chicago, Illinois, Center for Management of Complex Chronic Care, Hines VA Hospital, Hines, Illinois

Objectives. Clinical decision making requires 2 distinct cognitive skills: the ability to classify patients' conditions into diagnostic and management categories that permit the application of research evidence and the ability to individualize or—more specifically—to contextualize care for patients whose circumstances and needs require variation from the standard approach to care. The purpose of this study was to develop and test a methodology for measuring physicians' performance at contextualizing care and compare it to their performance at planning biomedically appropriate care. Methods. First, the authors drafted 3 cases, each with 4 variations, 3 of which are embedded with biomedical and/or contextual information that is essential to planning care. Once the cases were validated as instruments for assessing physician performance, 54 internal medicine residents were then presented with opportunities to make these preidentified biomedical or contextual errors, and data were collected on information elicitation and error making. Results. The case validation process was successful in that, in the final iteration, the physicians who received the contextual variant of cases proposed an alternate plan of care to those who received the baseline variant 100% of the time. The subsequent piloting of these validated cases unmasked previously unmeasured differences in physician performance at contextualizing care. The findings, which reflect the performance characteristics of the study population, are presented. Conclusions. This pilot study demonstrates a methodology for measuring physician performance at contextualizing care and illustrates the contribution of such information to an overall assessment of physician practice.

Key Words: medical error • patient-centered care • communication • quality of care.

This version was published on December 1, 2007

Medical Decision Making, Vol. 27, No. 6, 726-734 (2007)
DOI: 10.1177/0272989X07306113


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