Context Matters, But Let's Not Go Too Far

The commentary offered by Regehr1 serves a useful purpose in reminding medical educators and medical education researchers that we often tend to overestimate the power of stable individual factors to predict behavior, whether that be the clinical behavior of physicians or that of people in general. In drawing attention to issues such as case specificity in problem solving, he reminds us that we cannot blithely assume that physicians act consistently from one situation to another, and he comes to a most reasonable conclusion in stating that “context matters.” However, Regehr does a disservice when he goes a step further to pit the 2 factors, situation and personality, against one another. When Regehr states that “situation trumps personality” he sets up an unproductive dichotomy that parallels the debate as to whether nature or nurture is more important. In citing the literature in social psychology, Regehr omits what is perhaps its single most basic principle. As stated by Kurt Lewin,2 the first great thinker in that field, (1) behavior is a function of the person and the environment. As backed by nearly a century of empirical research, this suggests that we understand and account for behavior best when we consider the interaction of personal predispositions (e.g., attitudes, personality) with the power of the situation. Rather than focus on which of these 2 factors is more powerful, it is far better to consider the domains in which each may play a powerful role, and to harness the influence of person and situation for the betterment of patient care. An arena in which we ought not completely dismiss personal consistency is that of communication and physician-patient interaction. Although physicians (and patients) definitely vary their behavior according to the needs of the situation, a large body of research exists demonstrating that physicians are predisposed to enact certain communication styles. For instance, using a complex scoring system of 2,500 audiotaped patient visits, Byrne and Long3 found that physicians enacted a consistent interpersonal style with a wide variety of patients who presented a wide variety of symptoms. Roter et al.4 characterized physicians' communication patterns into 1 of 5 clusters, and found that half of the physicians studied used only 1 pattern for the majority of the visits studied. Noting that physicians often did adapt their behavior to the demands of patients, Street5 nonetheless found evidence for overall stylistic differences among physicians in areas such as relationship building, information provision, and positive socio-emotional behavior; and Shields et al.6 have reported that “emotional communication style” tends to be consistent from one patient to another. In other research specifically focused on measuring various skills across patients, using practicing physicians with actual and standardized patients7 and using students with standardized patients,8 generalizability coefficients were found to be higher for interpersonal/communication skills than for other skills measured. The purpose of citing this literature is not to draw us back to arguing for person over situation. Both are important, to the extent that the very principle of relationship-centered care implies that physicians should be sensitive to their own stylistic predispositions and adapt these to the needs of the patient and situation. I would assert instead that we should look for the influence of both: for personal factors that can predispose the behavior of physicians and sometimes reveal themselves in “stylistic” differences; and for a host of situational factors (medical condition, practice setting, bureaucratic demands, patient preferences, etc.) that will powerfully interact with these. Until we develop a more sophisticated understanding of how person and context contribute to behavior, let us not over- or underestimate the role of either.