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BACKGROUND: A contextual error occurs when a physician overlooks elements of a patient's environment or behavior that are essential to planning appropriate care. In contrast to biomedical errors, which are not patient-specific, contextual errors represent a failure to individualize care. OBJECTIVE: To explore the frequency and circumstances under which physicians probe contextual and biomedical red flags and avoid treatment error by incorporating what they learn from these probes. DESIGN: An incomplete randomized block design in which unannounced, standardized patients visited 111 internal medicine attending physicians between April 2007 and April 2009 and presented variants of 4 scenarios. In all scenarios, patients presented both a contextual and a biomedical red flag. Responses to probing about flags varied in whether they revealed an underlying complicating biomedical or contextual factor (or both) that would lead to errors in management if overlooked. SETTING: 14 practices, including 2 academic clinics, 2 community-based primary care networks with multiple sites, a core safety net provider, and 3 U.S. Department of Veterans Affairs facilities. MEASUREMENTS: Primary outcomes were the proportion of visits in which physicians probed for contextual and biomedical factors in response to hints or red flags and the proportion of visits that resulted in error-free treatment plans. RESULTS: Physicians probed fewer contextual red flags (51%) than biomedical red flags (63%). Probing for contextual or biomedical information in response to red flags was usually necessary but not sufficient for an error-free plan of care. Physicians provided error-free care in 73% of the uncomplicated encounters, 38% of the biomedically complicated encounters, 22% of the contextually complicated encounters, and 9% of the combined biomedically and contextually complicated encounters. Limitations: Only 4 case scenarios were used. The study assessed physicians' propensity to make errors when every encounter provided an opportunity to do so and did not measure actual error rates that occur in primary care settings because of inattention to context. CONCLUSION: Inattention to contextual information, such as a patient's transportation needs, economic situation, or caretaker responsibilities, can lead to contextual error, which is not currently measured in assessments of physician performance. PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs Health Services Research and Development Service [ABSTRACT FROM AUTHOR]

PROBLEM. Nurse-physician communication affects patient safety. Such communication has been well studied using a variety of survey and observational methods; however, missing from the literature is an investigation of what constitutes effective and ineffective interprofessional communication from the perspective of the professionals involved. The purpose of this study was to explore nurse and physician perceptions of effective and ineffective communication between the two professions. METHODS. Using focus group methodology, we asked nurses and physicians with at least 5 years' acute care hospital experience to reflect on effective and ineffective interprofessional communication and to provide examples. Three focus groups were held with 6 participants each (total sample 18). Sessions were audio recorded and transcribed verbatim. Transcripts were coded into categories of effective and ineffective communication. FINDINGS. The following themes were found. For effective communication: clarity and precision of message that relies on verification, collaborative problem solving, calm and supportive demeanor under stress, maintenance of mutual respect, and authentic understanding of the unique role. For ineffective communication: making someone less than, dependence on electronic systems, and linguistic and cultural barriers. CONCLUSION. These themes may be useful in designing learning activities to promote effective interprofessional communication. [ABSTRACT FROM AUTHOR]

BACKGROUND: Despite the highly acclaimed psychometric features of a 360-degree assessment in the fields of economics, military, and education, there has been increased interest in developing 360-degree instruments to assess competencies in graduate medical education only in the past recent years. Most of the effort to date, however, has focused on developing instruments and testing their reliability and feasibility. Insufficient attention has gone into issues of construct validity and particularly understanding the underlying constructs on which the instruments are based as well as the phenomena that affect ratings. PURPOSE: In preparation for developing a 360-degree assessment instrument, we explored variations in evaluators' opinion type of a competent resident and offer observation about evaluator's professional background and opinions. METHOD: Evaluators from two residency programs ranked 36 opinion statements, using a relative-ranking model, based on their opinion of a competent resident. By-person factor analysis was used to structure opinion types. RESULTS: Factor analysis of 156 responses identified four factors interpreted as four different opinion types of a competent resident: (a) altruistic, compassionate healer (n = 42 evaluators), (b) scientifically grounded clinician (n = 30), (c) holistic, humanistic clinician (n = 62), and (d) patient-focused, health manager (n = 31). Although 72% of nurses/respiratory therapist evaluators expressed type C, 28% expressed other types just as often. Only 14% of evaluator physicians expressed type D, and the remainders were evenly split among the other types. CONCLUSIONS: Our evaluators in 360-degree system expressed four opinion types of a competent resident. The individual opinion and not professional background influences the characteristics an evaluator values in a competent resident. We propose that these values will have an impact on competency assessment and should be taken into account in a 360-degree assessment. [ABSTRACT FROM AUTHOR]

Background: The whole-test Ebel and Yes/No Angoff methods offer the possibility of faster and easier standard-setting exercises for local, medium-stakes performance exams. Purpose: We sought to establish if these less demanding methods might be substituted for the traditional but complex case-level Ebel. Methods: Six faculty judges each used all three methods to set standards for six standardized-patient checklists used for 178 fourth-year medical students. We compared the cut scores, passing rates, reliability, ease of use, and credibility of the three methods. Results: The three methods produced roughly equivalent cut scores. Generalizability of judgments was .94 and .96 for the case-level and whole-test Ebel, and .76 for the Yes/No Angoff. Judges found the simplified methods more credible than the case-level Ebel. The Yes/No Angoff method was preferred by five of six judges. Conclusions: The whole-test Ebel and the Yes/No Angoff may be simple and realistic options for setting standards for local performance exams. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Clinical decision making requires 2 distinct cognitive skills: the ability to classify patients' conditions into diagnostic and management categories that permit the application of research evidence and the ability to individualize or-more specifically-to contextualize care for patients whose circumstances and needs require variation from the standard approach to care. The purpose of this study was to develop and test a methodology for measuring physicians' performance at contextualizing care and compare it to their performance at planning biomedically appropriate care. METHODS: First, the authors drafted 3 cases, each with 4 variations, 3 of which are embedded with biomedical and/or contextual information that is essential to planning care. Once the cases were validated as instruments for assessing physician performance, 54 internal medicine residents were then presented with opportunities to make these preidentified biomedical or contextual errors, and data were collected on information elicitation and error making. RESULTS: The case validation process was successful in that, in the final iteration, the physicians who received the contextual variant of cases proposed an alternate plan of care to those who received the baseline variant 100% of the time. The subsequent piloting of these validated cases unmasked previously unmeasured differences in physician performance at contextualizing care. The findings, which reflect the performance characteristics of the study population, are presented. CONCLUSIONS: This pilot study demonstrates a methodology for measuring physician performance at contextualizing care and illustrates the contribution of such information to an overall assessment of physician practice. [ABSTRACT FROM AUTHOR]

Describes a workshop in curriculum development for international medical fellows designed and implemented at the Department of Medical Education of the University of Illinois at Chicago. Definition of curriculum; Basic principles involved in the course; Educational strategies.