Intervening to Prevent Contextual Errors in Medical Decision Making

We plan to enroll 144 internal medicine residents at 2 VA hospitals, Jesse Brown and Hines,
in a randomized controlled design. Half will participate in a 4 hour seminar series that is
integrated into their ambulatory curriculum. Each month a total of 8 residents will
participate. Following the intervention there will be 3 levels of assessment: (1) All
participants, intervention and control, will participate in a brief exercise interviewing 4
standardized patients (SPs). Note that we will separately be enlisting the assistance of 8
attending physicians to assist with case development for these SPs. (2) The research team
will subsequently enroll 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 will be 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 will prospectively define successful vs. unsuccessful outcomes for
each case. At the follow up visit data will be collected on whether the desired outcome was
achieved. The analysis will compare the skills, performance and outcomes of the intervention
compared with the control group to determine the efficacy of training residents to
individualize care.

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