Original Publication
Open Access

Critical Synthesis Package: Content Coding for Contextualization of Care (4C)

Published: August 5, 2015 | 10.15766/mep_2374-8265.10178

Included in this publication:

  • Critical Analysis of the Content Coding for Contextualization of Care.pdf
  • Content Coding for Contextualization of Care Instrument.xlsx
  • 4C Training and Coding Manual.pdf
  • 4C Master List of Coded Encounters Form.xlsx

To view all publication components, extract (i.e., unzip) them from the downloaded .zip file.

Editor's Note: This publication predates our implementation of the Educational Summary Report in 2016 and thus displays a different format than newer publications. It is also part of a discontinued collection that focused on the presentation of health sciences education assessment tools and their reported validity data. The coding manual for the Content Coding for Contextualization of Care (4C) is occasionally updated.


This Critical Synthesis Package contains: (1) a Critical Analysis of the psychometric properties and application to health science education of the Content Coding for Contextualization of Care (4C) Instrument, and (2) a copy of the 4C Instrument, 4C Training and Coding Manual, and 4C Master List of Coded Encounters Form developed by Saul J. Weiner, MD.

The 4C Instrument was developed in response to a growing body of literature demonstrating improved patient outcomes when care plans take context into account. Through review of the patient’s 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. The 4C can be used for formative or summative assessment at the graduate medical education or continuing medical education levels. Additionally, the 4C Instrument can be used as a research instrument for investigating physician-patient communication and patient outcomes. To date, the 4C Instrument has only been validated in the context of internal medicine residents and requires further evidence of validity and reliability across other contexts and populations before it can be widely used as a research tool. Specifically, addressing issues of reliability and validity in student learners and practicing physicians as well as learners in other medical disciplines (e.g., pediatrics) might allow this tool to be used across the spectrum of medical education. It would also be useful to develop this instrument for use in other healthcare professions in which contextualization of care is important (e.g., physician assistants, midwives, etc.).

Educational Objectives

  1. To describe the purpose and basic properties of the Content Coding for Contextualization of Care (4C) Instrument, including number of items and scales, and psychometric properties;
  2. To describe the application of the 4C Instrument to the field of health sciences education;
  3. To evaluate the relative strengths and weaknesses of the 4C Instrument; and
  4. To provide the 4C Instrument and supplemental materials to aid in its administration.

Author Information

  • Veronica Michaelsen, MD, PhD: George Washington University School of Medicine and Health Sciences
  • Michelle Yoon, PhD: University of Virginia School of Medicine

None to report.

None to report.


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Michaelsen V, Yoon M. Critical Synthesis Package: Content Coding for Contexualization of Care (4C). MedEdPORTAL. 2015;11:10178. http://doi.org/10.15766/mep_2374-8265.10178