An educational intervention for contextualizing patient care and medical students' abilities to probe for contextual issues in simulated patients

Context: A contextual error occurs when a physician fails to identify elements of a patient’s environment or behavior, such as access to care, that must be addressed in order to appropriately plan care. Research has demonstrated that contextual errors can be identified using standardized patients. Objective: To evaluate an educational intervention designed to increase physicians' skills in incorporating the patient's context in assessment and management of care and to thereby decrease the rate of contextual errors. Design, Setting, and Participants: Quasi-randomized controlled trial, with assessments by blinded observers. Fourth-year medical students (n=124) in internal medicine subinternships at the University of Illinois at Chicago or Jesse Brown VA Medical Center from July 2008 – April 2009 and August 2009 – April 2010 participated and were assessed. Intervention: A 4-hour course on contextualization. Main outcome measures: Probing for contextual issues in an encounter, probing for medical issues in an encounter, and developing an appropriate treatment plan. Outcomes were assessed using 4 previously validated standardized patient encounters performed by each participant, and were adjusted for subinternship site, academic year, time of year, and case scenario. Results: Students who participated in the contextualization workshops were significantly more likely to probe for contextual issues in the standardized patient encounters than students who did not (90% [95% confidence interval {CI}, 87-94% ] vs 62% [95% CI, 54-69%]), and significantly more likely to develop appropriate treatment plans for standardized patients with contextual issues (69% [95% CI, 57-81%] vs 22% [95% CI, 12-32%]. There was no difference between the groups in the rate of probing for medical issues (80% [95% CI, 75-85%] vs 81% [95% CI, 76-86%]) or developing appropriate treatment plans for standardized patient with medical issues (54% [95% CI, 42-67%] vs 66% [95% CI, 53-79%]). Conclusion: Medical students who underwent an education intervention were more likely to contextualize care for individual standardized patients.