Note that this is distinct from previous usage of the concept of a patient clue “as a direct or indirect comment that provides information about any aspect of a patient’s life circumstances or feelings” for the purpose of “… creating an opportunity for empathy and personal connection.” 4 Rather, clues here indicate there is a broader context the clinician needs to know about to provide appropriate care. In the example above, a clue is the unexpected loss of control of diabetes.

Practically, it is not realistic to conduct an exhaustive search for contextual factors during each clinical encounter therefore, clinicians must instead watch for clues of their presence. Respectively, they are: Access to care, Competing responsibility, Social support, Financial situation, Environment, and Resources and Skills/abilities/knowledge, Emotional state, Cultural perspective/spiritual beliefs, Attitude towards illness, Attitude towards health care provider and system, and Health behavior. For instance, an inability to afford a needed medication is a “financial situation.” If the loss of control of diabetes were due, instead, to the departure of a friend or family member who helped with cooking, the contextual factor represents a loss of “social support.” Previously, we have described a typology in which all contextual factors sort into 12 such broad “domains of patient context.” 3 Six pertain to a change in life circumstance (ie, are external to the patient), and 6 pertain to intrinsic drivers of behavior (ie, are internal to the patient). While there are many possible contextual factors that can complicate a patient’s care, they sort into a relatively small number of categories. Simply prescribing more insulin, for instance, without addressing the cost issue would not logically lead to better diabetes control. Such an inability to afford a needed treatment, due to a change in life circumstances, has been termed a “contextual factor.” 2 Contextual factors must be taken into account when planning patient care. 1 For instance, a diabetic patient who has lost their job and can no longer afford their insulin may “stretch out” the medication, resulting in a loss of control of their chronic condition.

For clinical decision-making to be effective, a patient’s life circumstances, or context, should be considered along with their clinical state, the applicable research evidence, and preference for treatment options.

Red flags base game