Doctors found better at standardized than individualized patient care

 

[caption id="attachment_9474" align="alignleft" width="211" caption="Doctor and patient"][/caption]

Carol Forsloff - New research finds doctors do better at hypothetical medical treatments following a standardized approach to care than individualized care based upon actually seeing patients.

This is important information given the fact doctors ask patients to keep appointments and follow certain schedules for treatment.

But what doesn't happen is a doctor individualizing care from what they see or are told during the patient visit.

This comes from research by the University of Illinois at Chicago and the VA Center for Management of Complex Chronic care and is the largest research on this topic, presently published in the Annals of Internal Medicine.

"Physicians did quite well at following guidelines or standard approaches to care, but not so well at figuring out when those approaches were inappropriate because of a particular patient's situation or life context," said Dr. Saul Weiner, associate professor of medicine and pediatrics at UIC and staff physician at the Jesse Brown VA Medical Center, who was lead author of the study.

As a consequence, Weiner said physicians need to determine the reasons why a patient is failing rather than just following the standard treatment approach or increasing the dose of drugs prescribed.  

 Specific issues, such as the lack of health insurance, the need for less costly treatment, or difficulty understanding or following instructions, are contextual pieces of information that must be recognized also in patient care, according to this research in order to avoid errors in making decisions.

The study used actors trained to simulate real patients in 400 visits to a wide range of physician practices in Chicago and Milwaukee, including several VA sites.  In each situation the identities also had medical records and insurance information provided.  The doctors involved did not know which "patients" were actors.

These "actor patients" were then compared with the results of real patients, in this case four case scenarios were developed with each case having four variants.

The actors followed scripts that had "red flags" of significant issues which, if confirmed, would need to be addressed to avoid error. The actors always started with the same two red flags, but were randomly assigned to respond differently based on the variant.

For example, in a case involving a 42-year-old man concerned about worsening asthma, the actor mentioned both a biomedical red flag (coughing at night) and a contextual red flag (losing his job) that suggested acid reflux and loss of health insurance, respectively, as a key part of the problem.

The study looked at whether the physician picked up on the red flags and implemented an appropriate care plan for each of the case variants.

At visits where no modification of customary practice was required, 73 percent of physicians provided error-free care.

But at visits where individualizing care required an alternative to the customary treatment, only 22 percent of physicians provided error-free care during a contextually complicated encounter, 28 percent during a biomedically complicated encounter, and 9 percent during a combined contextually and biomedically complicated encounter.

"To date, measures of doctors' performance have focused on situations where knowledge of the individual patient is ignored," said Weiner. "Under those conditions, physicians did fairly well. But as soon as care required more than following an algorithm -- finding out what's really going on with a patient and acting on that information -- only a minority of physicians got cases right."

The researchers also looked at the demographics of physicians, that included training and experience as well as races of people assigned to the doctors in the study.

"We expected that if physicians had more time with patients, they would be more likely to individualize care," Weiner said. "But what we found was that among those visits where physicians did a great job identifying contextual issues and addressing them, they did not on average spend any more time with patients than the physicians who didn't recognize contextual issues. That was surprising."

The study found that physicians were more likely to respond to the biomedical rather than contextual red flags even when both were equally important to planning appropriate care. "We believe that reflects the way in which physicians are educated," said Weiner. "The lesson here is that there has to be a dramatic change in the way we train physicians."