Intervening to Prevent Contextual Errors in Medical Decision Making

US Department of Veterans Affairs (VA) logo

US Department of Veterans Affairs (VA)




Psychosocial Circumstances


Behavioral: Seminar and Practicum

Study type


Funder types

Other U.S. Federal agency


EDU 08-430

Details and patient eligibility


This study assessed whether a medical education intervention improves the quality of medical decision making in the care of patients with complex psychosocial -- or contextual -- needs that are essential to address when planning their care. A group of internal medicine residents were randomly assigned to participate in the seminar and practicum and then they, along with a control group that had not participated, were assessed for the quality of their clinical decision making and its impact on patient care. The study also assessed whether contextualization of care is associated with better patient health care outcomes

Full description

We enrolled 139 internal medicine residents at 2 VA hospitals, Jesse Brown and Hines, in a randomized controlled design. Half participated in a 4 hour seminar series integrated into their ambulatory curriculum. Each month a total of 8 residents participated. Following the intervention there were 3 levels of assessment: (1) All participants, intervention and control, participated in a brief exercise interviewing 4 standardized patients (SPs). Note that we separately enlisted the assistance of 8 attending physicians to assist with case development for these SPs. (2) The research team subsequently enrolled 3 real patients from each physician's practice with "red flags" such as poor adherence, or missed visits, suggestive of contextual issues that need to be addressed. Physicians were scored on their performance at identifying the underlying contextual factors that account for these red flags and on formulating an appropriate plan of care. (3) The coders prospectively defined successful vs. unsuccessful outcomes for each case. At the follow up visit data was collected on whether the desired outcome was achieved. The analysis compared the skills, performance and outcomes of the intervention compared with the control group to determine the efficacy of training residents to individualize care.


138 patients




No Healthy Volunteers

Inclusion criteria

  • Internal Medicine Residency with continuity of care clinics at either Jesse Brown or Hines VA Medical Centers

Exclusion criteria

  • All resident physicians who do not meet inclusion criteria

Trial design

Primary purpose

Health Services Research



Interventional model

Parallel Assignment


Single Blind

138 participants in 2 patient groups

Seminar and Practicum
Experimental group
Seminar and practicum that occurs over 4 week period for internal medicine residents, designed to provide a systematic approach to identifying and addressing contextual factors essential to planning patient care.
Behavioral: Seminar and Practicum
No intervention
No Intervention group
No educational intervention.

Trial contacts and locations



Data sourced from

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