Contextualizing patient care — making sure that prescribed treatments, medications and other instructions for care are relevant and reasonable in the context of the patient’s real-life circumstances — should be routine, not revolutionary.
But physicians often prescribe care without knowing whether patients will be able to follow the instructions. The diagnosis and care may medically be spot on but disconnected from the patient’s reality. Physicians may not check to ensure that patients fully understand instructions and even more rarely ask if patients can afford medications, take time off from work, access transportation, etc. When it’s clear that treatment has failed and the patient’s health has deteriorated because they haven’t followed the care plan, providers may assume patients have willfully or lazily fallen into “non-compliance.”
Patients who have the gumption or confidence to say they don’t have sufficient resources to follow through on care and need help or an alternative treatment plan are atypical. And even when patients drop subtle hints —“Gee, it’s been tough since I lost my job” — they may need to be encouraged to engage in frank discussion about real-life factors that can affect health just as much than the treatment itself. These “social determinants of health” are more often discussed in academic settings than exam rooms.
Saul Weiner, M.D., has been leading efforts to change that, to contextualize care by encouraging physicians to listen and engage with patients to learn how and if they will be able to manage their care. Weiner is a professor of pediatrics and medical education at the University of Illinois at Chicago and deputy director of the Center of Innovation for Complex Chronic Health Care at the Veterans Health Administration. His work to connect physicians, especially those in primary care, with patients has a dual focus; 1) to improve adherence and outcomes by tailoring the demands of care to patient circumstances (and get patients help when needed) and 2) to improve the experience of practicing medicine for physicians who are also poorly served by delivering impersonal care in a highly pressured, disjointed healthcare system.
At the VA, Dr. Weiner has been involved in a large pilot program that measures contextual disconnects in care and gives physicians feedback designed to be illustrative and helpful, not accusatory. In addition to better care, experience and outcomes, adjusting care to the context of the patient’s life offers a way to reduce cost. Prescribing a care plan that patients cannot use is ineffective and inefficient and may eventually lead to the need for more acute care. The pilot program, which involved more than 4,400 clinical visits and 666 clinicians from May 2017 through May 2019, showed a decrease in hospitalization rates for an estimated savings of $25.2 million. Surprisingly, it did not reduce rates of emergency care. The program is described in an article published in July 2020 in JAMA Network Open.
In addition to the JAMA article, Dr. Weiner’s work is the subject of other publications and discussions available online:
The promise and pitfalls of adjusting care to context – A conversation with Kedar Mate, M.D., president and CEO of the Institute for Healthcare Improvement. August 23, 2021, episode of the Coffee & Science podcast.
Advancing health equity by avoiding judgmentalism and contextualizing care – Case and Commentary article by Saul Weiner, M.D., in AMA Journal of Ethics, February 2021
Listening between the lines – September 20, 2019, video interview with Monica Eng, reporter for WBEZ Chicago. Part of The Human Touch: The Future of Medicine, September 2019, an event sponsored by Chicago Ideas.