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Weiner SJ, Schwartz A. Author's Reply Re: The need for biomedically and contextually sound care plans in complex patients: thoughts on creating a better practice environment. Annals of internal medicine. 2010 Sep 15.
IN RESPONSE: One of the findings of our study (1) that surprised us was that while physicians who spent more time with patients were more likely to probe for biomedical or contextual red flags, they were not more likely to provide contextually appropriate care. In the case of a patient whose health literacy problems accounted for an inability to dose his diabetes medications correctly, for instance, physicians more often identified the literacy issue during longer visits, but were not more likely to appropriately intervene. Those who intervened, however, did not on average have longer visits. Physicians who avoid contextual errors seem to think differently, considering context not as an afterthought, but as a part of the clinical reasoning process. We have recently studied an educational intervention that suggests such reasoning processes can be effectively taught (2). Drs. Kathol and Kathol propose that if physicians had more time and specialized support personnel, such as case managers and mid-level providers they would be more likely to provide contextually appropriate care. While we did not find that additional time alone helped, it may well be that the combination of additional time and a medical home environment, would substantially improve care. Physicians who, during longer visits, unmasked health literacy problems as the root cause of a patient's poor diabetes control may simply have concluded that there was nothing they could do about it, not having for instance, a diabetes educator who could assist. We share the Kathols' concern that the major challenge for those in system-level care delivery enhancement, is designing financially sustainable practice environments that support physicians who have developed the cognitive skills to individualize care, with the resources and tools needed to do so.
