Contextual knowledge

Monday, November 25th, 2013

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 GP’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 ‘enabling conditions’ 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 patient’s history and background which is a vital part of the decision-making process.(4-7) Weiner et al describe the patient context as ‘those elements of a patient’s environment or behavior that are relevant to their care, including their economic situation, access to care, social support, and skills and abilities’.(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: ‘what is the best next thing for this patient at this time?’ and refer to individualizing clinical decisions as contextualization.(9) ‘Contextualization involves identifying what is relevant to the immediate clinical problem from across the spectrum of a patient’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 providers’.(9)

Medical decision-making in evidence-based medicine (EBM) is the integration of current best evidence, the physician’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 physician’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 ‘doctors are shaping the square peg of the evidence to fit the round hole of the patient’s life’.(12) The psychosocial context of general practice can make evidence irrelevant.(13)

(1)    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)    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)    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)    McWhinney I. Problem solving and decision making in primary medical practice. Can Fam Physician 1972;18:109-14.

(5)    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)    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)    Jones I, Morrell D. General practitioners’ background knowledge of their patients. Fam Pract 1995 Mar;12(1):49-53.

(8)    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)    Weiner SJ. Contextualizing medical decisions to individualize care. Lessons from the qualitative sciences. J Gen Intern Med 2004 Mar;19(3):281-5.

(10)    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)    Haynes RB, Devereaux PJ, Guyatt GH. Physicians’ and patients’ choices in evidence based practice. BMJ 2002 Jun 8;324(7350):1350.

(12)    Freeman AC, Sweeney K. Why general practitioners do not implement evidence: qualitative study. BMJ 2001 Nov 10;323(7321):1100-2.

(13)    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.