Developers: Saul Weiner, Naomi Ashley, Amy Binns-Calvey, Brendan Kelly, Gunjan Sharma, Alan Schwartz

Year of publication: 2012

Date of last revision: 24 May 2021

Setting in which the tool was originally developed/validated: Internal medicine; veterans administration (VA) population

Restriction to setting(s): Not specified

Target group: Physicians (in training)

Language(s): English

Tool topics:

Patient perspective–considering, eliciting
Shared decision making

Specific constructs/behaviours:

Contextualization of care / Patient-centered decision making: incorporating clinically relevant, patient-specific circumstances and behaviors, that is, the patient's context, into formulating a contextually appropriate plan of care

Classification of encounters aimed at identifying contextual red flags (B-D) and contextual errors (B & C):
A. The patient did not present any information suggesting contextual issues in care.
B. The patient presented a contextual red flag, but the health care provider did not probe it.
C. The patient presented a contextual red flag, and the health care provider probed it but did not
incorporate the context into the plan of care.
D. The patient presented a contextual red flag, and the health care provider probed it and
incorporated the context into the plan of care.
Red flags can be at one of 4 different levels

Types of data required to use the tool: Video recordings, Audio recordings

Intended application: Education, Research

Reference(s) to development/validation paper(s):

1. Weiner SJ, Ashley N, Binns-Calvey A, Kelly B, Sharma G, Schwartz A.
Content Coding for Contextualization of Care (с4Cо) Training & Coding Manual.
Dataverse Network Project

2. Weiner, S.J., Kelly, B., Ashley, N., Binns-Calvey, A., Sharma, G., Schwartz, A. and Weaver, F.M., 2014. Content coding for contextualization of care: evaluating physician performance at patient-centered decision making. Medical Decision Making, 34(1), pp.97-106.

3. Weiner, S.J., Schwartz, A., Sharma, G., Binns-Calvey, A., Ashley, N., Kelly, B., Dayal, A., Patel, S., Weaver, F.M. and Harris, I., 2013. Patient-centered decision making and health care outcomes: an observational study. Annals of internal medicine, 158(8), pp.573-579.

Tool/manual available: Yes. (Video on contextualization of care. Training manual. Website with a range of resources. )

Tool description by the author:

Through review of the patientНs chart and content coding the interaction between physician and patient, the 4C Instrument aims to determine if the physician adequately elicited patient contextual cues and subsequently used this information in creating an appropriate care plan. The 4C Instrument requires between two and five coders to administer. Coders must be given access to the patient medical record as well as to the recorded audio of the physician-patient encounter. Contextual red flags are identified along the following domains: Cognitive Abilities, Emotional State, Cultural Beliefs, Spiritual Beliefs, Access to Care, Social Support, Caretaker Responsibilities (of patient), Attitude to Illness, Relationship with Health Care Providers, and Economic Situation. Physician-patient interactions are coded for whether a red flag was probed, revealed, identified, and taken into consideration when planning care.

Using an elaborate process, coders need to answer 4 questions:
1. Question 1: Are There Contextual Red Flags?
2. Question 2: Did the Clinician Explore the Red Flags?
3. Question 3: Are There Contextual Factors (Elicited or Revealed)?
4. Question 4: Was the Contextual Factor Addressed in the Care Plan?

Access: Public