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"Undercover" Patients Study Reveals Errors

Anyone who has spent very much time in the doctor’s office, is familiar with the long wait time and short face-to-face time with the doctor.  Scheduling for patients is most often in 15 minute increments allowing doctors to see about 32 patients per day for a normal 8:00am – 5:00 pm work day, with an hour for lunch. 

Add the patients that are “worked in” (don’t have an appointment, but need medical attention), the time it takes for doctor’s to dictate patient notes, go to the bathroom, receive a phone call, sign transcribed notes from previous days’ patients, etc., and the actual time a doctor actually talks to patients can be cut to about 5 minutes.

So, are doctors considering all of the necessary patient information to make an accurate diagnosis?  If not, why not?

That is the question in a study published July 19 in the Annals of Internal Medicine led by Saul J. Weiner, MD, Internist and Pediatrician University of Illinois Medical Center Chicago (UIMCC),  Associate Professor UIMCC, Staff Physician, Jesse Brown Veterans Administration Medical Center.

Dr. Weiner has a primary research interest in exploring and identifying ways to improve how physicians individualize treatment decisions.  Developing the concept of “contextual errors” to describe medical errors resulting from failures to identify or see as relevant circumstances in patients’ lives relevant to their care.

Using actors as ‘undercover 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.

Each patient presented 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 studied the audio recordings and medical records to calculate how often physicians picked up on red flags signifying possible complications and adjusting their plan of care. The failure to do both counted as an error. In contextually complicated encounters, error-free care was provided for just 22% of patients; in biomedically complicated encounters, the error-free rate was 38%.
“Good medical practice clearly involves another step, it involves knowing when you have to individualize care," said Weiner. "That is not the same as following the guidelines. It often means not following the guidelines and that we are not measuring."

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."

However, this study's results did not seem to be about doctors being rushed. "We found that those who did well didn't spend any more time with patients than those who did poorly," said Weiner.
 Weiner believes there needs to be a systematic way to uncover the issues patients are confronting, such as grief, unemployment, bankruptcy, no health insurance or the inability to understand verbal or written medical instructions. A standardized "contextual history" could be taken from patients along with their physical history, he suggests, though the idea may be controversial among time-pressed physicians.


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.”

Taking simple, practical steps to personalize patients' care: speaking in simple language; listening carefully to patient concerns; keeping a list of essential social services agencies and resources would facilitate more precise diagnosis and treatment.

WebMD suggests preparation for every doctor visit to receive the best care and make the most of each visit.

1.)    Be ready to say what your main symptoms are, when they started, and what you have done to treat them so far. It may help to write these things down before your doctor visit.
2.)    Write down the three questions that you most want to have answered. If the doctor does not bring them up, don't be afraid to ask.
3.)    Bring a list of all the medicines, vitamins, and herbal supplements that you are taking.
4.)    Bring copies of recent test results if the tests were done by a different doctor.
5.)    Pay attention. Ask questions if you don't understand something.
And, inform your doctor of changes regarding employment, environment, housing, insurance and family that may be essential to your diagnosis and treatment.

Laura Lamp King