Contextual knowledge can be defined as everything a physician knows from his/her patient apart from the signs and symptoms. Contextual knowledge seems to be a major determinant of gut feelings in a GPâ€™s diagnostic reasoning process.(1;2) In the illness script model contextual factors are described as those illness features that are associated with the acquisition of the illness, so-called â€˜enabling conditionsâ€™ like sex and age, or risk factors originating from work, behavior and hereditary taint.(3) Continuity of care results in an accumulated knowledge of GPs about the patientâ€™s history and background which is a vital part of the decision-making process.(4-7) Weiner et al describe the patient context as â€˜those elements of a patientâ€™s environment or behavior that are relevant to their care, including their economic situation, access to care, social support, and skills and abilitiesâ€™.(8) The authors refer to decision-making errors that occur because of inattention to patient context as contextual errors which represent a failure to individualize care. Weiner describes clinical decision making as answering one question: â€˜what is the best next thing for this patient at this time?â€™ and refer to individualizing clinical decisions as contextualization.(9) â€˜Contextualization involves identifying what is relevant to the immediate clinical problem from across the spectrum of a patientâ€™s life, including their cognitive abilities, emotional state, cultural background, spiritual beliefs, economic situation, access to care, social support, caretaker responsibilities, attitude to their illness, and relationship with health care providersâ€™.(9)
Medical decision-making in evidence-based medicine (EBM) is the integration of current best evidence, the physicianâ€™s clinical expertise and the preferences of the patient.(10;11) Research into how physicians have to integrate all these different sources of knowledge in EBM is very scarcely available. Contextual knowledge is probably a part of the physicianâ€™s clinical expertise. According to Weiner EBM-literature lacks an operational definition of this individualizing aspect of decision making just like a methodology to interpret the clinically relevant patient-specific variables.(9) Freeman and Sweeney concluded from their study why GPs do not implement evidence that â€˜doctors are shaping the square peg of the evidence to fit the round hole of the patientâ€™s lifeâ€™.(12) The psychosocial context of general practice can make evidence irrelevant.(13)
(1) Â Â Stolper CF, Van Bokhoven MA, Houben PHH, Van Royen P, Van de Wiel M, Van der Weijden T, et al. The diagnostic role of gut feelings in general practice. A focus group study of the concept and its determinants. BMC Fam Pract 2009 Feb 18;10(17).
(2) Â Â Stolper CF, Van de Wiel M, Van Royen P, Van Bokhoven MA, Van der Weijden T, Dinant GJ. Gut feelings as a third track in general practitioners’ diagnostic reasoning. J Gen Intern Med 2011;26(2):197-203.
(3) Â Â Hobus PP, Schmidt HG, Boshuizen HP, Patel VL. Contextual factors in the activation of first diagnostic hypotheses: expert-novice differences. Med Educ 1987 Nov;21(6):471-6.
(4) Â Â McWhinney I. Problem solving and decision making in primary medical practice. Can Fam Physician 1972;18:109-14.
(5) Â Â Hjortdahl P. The influence of general practitioners’ knowledge about their patients on the clinical decision-making process. Scand J Prim Health Care 1992 Dec;10(4):290-4.
(6) Â Â Hjortdahl P. Continuity of care. In: Jones R, Britten N, Culpepper L, Gass DA, Grol R, Mant D, et al., editors. Oxford Textbook of Primary Medical Care. Volume 1 Principles and Concepts.Oxford: Oxford University Press; 2004. p. 249-52.
(7) Â Â Jones I, Morrell D. General practitioners’ background knowledge of their patients. Fam Pract 1995 Mar;12(1):49-53.
(8) Â Â Weiner SJ, Schwartz A, Weaver F, Goldberg J, Yudkowsky R, Sharma G, et al. Contextual errors and failures in individualizing patient care: a multicenter study. Ann Intern Med 2010 Jul 20;153(2):69-75.
(9) Â Â Weiner SJ. Contextualizing medical decisions to individualize care. Lessons from the qualitative sciences. J Gen Intern Med 2004 Mar;19(3):281-5.
(10) Â Â Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ 1996 Jan 13;312(7023):71-2.
(11) Â Â Haynes RB, Devereaux PJ, Guyatt GH. Physicians’ and patients’ choices in evidence based practice. BMJ 2002 Jun 8;324(7350):1350.
(12) Â Â Freeman AC, Sweeney K. Why general practitioners do not implement evidence: qualitative study. BMJ 2001 Nov 10;323(7321):1100-2.
(13) Â Â Zwolsman S, te PE, Hooft L, Wieringa-de WM, van DN. Barriers to GPs’ use of evidence-based medicine: a systematic review. Br J Gen Pract 2012 Jul;62(600):e511-e521.