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Discussion in 'Medical Students - MD' started by hope12, Jun 12, 2008.
Good thing these fake patients aren't taking the spots that actual patients need, thus delaying their eventual treatment.
My initial reaction was disgust. I've thought about it some more and can see where they are coming from and the merits of such a practice... but no. Just no. There has to be better ways to evaluate physician performance and quality control than this.
I was under the impression that M&M meetings served this purpose.
The hospitals are the ones promoting this practice and I think it's unethical. Some of these Sham patients could be taking the place of someone who really needs care. As an organization, it's fine that hospital strive for quality improvement, but there is a proper way of doing this.
This makes me wonder about the future rights of Hospitalists. Since these physicians are hired/payed by a Hospital organization, their practices will be ruled more and more by the big fat board of directors.
Hospitals might end up taking the supreme role of MCO's.
This is probably one example of when litigation-happy lawyers will eventually HELP physicians.
lawyer - "So doctor, you were attending to Mrs. Jones whom you believed was having a heart attack"
doc - "yes"
lawyer - "and you spent 30 minutes with her?"
doc - "yes"
lawyer - "and during that time my client was in the next room suffering"
doc - "yes"
lawyer - "and did you later learn that Mrs. Jones was faking her ailments, and had been hired by the hospital"
doc - "yes"
lawyer - "and is it true that had my client been seen 30 minutes earlier, his appendix may not have ruptured"
doc - "that may be true"
lawyer - "I rest my case"
I think the concept is fine. Usually EM docs and nurses do a great job managing which patients need priority and I haven't seen or heard of many cases where where caring for one patient meant that another did not get the care s/he needed (excluding natural disasters and a handful of obvious screw-ups). A undercover patient who isn't sick is probably going to wind up waiting 8 hours before being served.
I had to chuckle a little bit though ... let's hope the quality of the physicians these "undercover" patients are testing isn't too low because those needles and scalpels are "loaded."
I have to strongly disagree. A 60 year old "fake" patient who comes in after splashing a little water all over themselves complaining of chest pain is going to take a good bit of time away from all of the other people waiting to be seen. If my Mom is one of those other people waiting, you better believe I would be very pissed if she were left to suffer in pain because some administrator somewhere decided to "test" the ED attending by sending in some fake patient.
It's all fun and games until somebody ends up with a chest tube.
This is by far the dumbest thing a hospital could do. Not only do you waste valuable time and resources that could be used on real patients (and resident time is more of a commodity in light of the 80 hour limitations), but you also create doctors who are going to be more skeptical of their patients ailments. In a day when doctors are criticized for not having as strong a patient relationship as in prior generations, you create a generation of physicians who are going to start thinking patients are fakers trying to trap them. Very foolish indeed.
There was a great article a few years back (JAMA maybe?) about how standardized patients encouraged medical students to form a "fake" persona to deal with them. I think the idea has some merit.
This practice discussed in the article is hugely unethical. When people talk about the consecrated doctor-patient relationship the onus is usually on the physician. I've got news for you, patients are just as capable of soiling the relationship.
The other issue here (which is also a problem with SPs for med students) is that there is very little room for bringing your personality into your bedside manner. We've all gone into an SPs room realizing that we have try to make key comments to show our compassion ("oh that must be so difficult for you, tell me more about that"). It's disrespectful of the reality that med students/docs have different personalities and while the one SP in front of them might not respond to it, alot of others might.
Yet another example of how the AMA just constantly ends up screwing over physicians instead of helping them.
So your mom is going to wait 6.3 hrs instead of 6 hrs? They will do an ECG on the 60 yo fake patient and figure out that s/he is O.K. in about 10 mins. Keep in mind that the goal here is to improve quality of the physicians. This isn't just for everyone's entertainment. What this means is that if this system works correctly, that your mother will get better care than she would have otherwise. It might actually identify improvement that would mean that your mother would be seen sooner. I know it's a stunning assertion, but I'll assert that the quality of medical care leaves room for improvement and improving medical care doesn't just involve training physicians longer. There are systemic problems with medical care quality that are not trivial to document and improve.
I see where you are coming from. However, I hate to say it, but some patients are fakers or just super sensitive. Not every 60 male obese smoker who comes into the ER staggering, confused, and sweating with chest pain has a treatable condition (at least not more treatable than it already is being treated). I think if physicians understand that there are going to be some "standardized" patients coming through they won't be as upset as if they are not told. It should be disclosed and perhaps even identified as to when they might expect this individual. We have fire alarms and we don't "mistrust" firealarms all of a sudden. If done correctly, I think the idea has merit and value. This patient might have some kind of yellow card to indicate that they are are standardized patient if things get out of control, I suppose.
I agree that quality control measures are important, but this is NOT the way to go about it. Truly sick patients must never wait while physicians are deceived by their administration into providing care to those who don't need it. The attending physician deserves the courtesy and respect of being able to decide if they have the time to prioritize an assessment of their skills by means of a fake patient, or if the patient load at that moment is simply too great.
Your presumption that a "quick 10 minute EKG" will magically free up the bed this fake patient is sitting in is either simply naive, ignorant, or deluded. An elderly chest pain patient would be more likely to sit in the ED waiting for a series of cardiac enzymes to come back. This would take many more hours, and could prevent that bed from being used to rotate truly ill patients through.
I know which way I would decide if I were on a jury and a patient sat in a waiting room having a bad outcome while a fake patient sat in an ED bed.
If you want to improve quality processes, how about starting by interviewing staff about opportunities for improvement? They will be able to identify far more areas needing improvements than some outsider faking being a patient.
I'm not a medical student but a chief resident who is about to graduate in a psychiatry residency.
I hate saying this but I agree that the methods being debated should be used.
I've just seen too many doctors get away with bad practice.
I may sound patronizing or condescending, but I think medstudents hold doctors in a higher place than most doctors actually deserve. There are several bad doctors out there---something that medstudents may not realize is going on as much as they thought because medstudents work so hard to achieve the honor of being a doctor. However once graduation from residency, & after obtaining a license, a doc need not take any more exams & I've seen several practice substandard care.
Further, other methods to keep doctors "in check" such as malpractice suits are not merit based per studies. Patients often sue in malpractice cases simply based on how much they liked the doctor on a personal level & not based on the standard of care treatment given by the doctor. This is understandable given that patients do not know what the standard of care is. A mechanic as an analogy could say several things are wrong with your car and if you don't have car mechanical knowledge, you don't know what is true & what isn't.
And in the field of psychiatry--actors coming into a psychiatry unit & faking symptoms, while reporting to a state agency if the psyche unit is actually following standard of care has revealed several institutions violating standard of care & patients' rights. Had these methods not been done, those institutions would not have been exposed.
In several cases, its only due to these actors that these problems could have been exposed. A psychotic patient for example making accusations of being mistreated is probably going to get nowhere with his complaints. A doctor claiming a patient has an illness usually does so based on behavioral observations--which are not video taped & thus can be grossly exaggerated or even fallaciously reported.
In the words of a nurse manager I have worked with & come to respect, "we shouldn't be scared of the state putting in an actor into our unit to see if we're doing anything wrong because we aren't doing anything wrong, so we have nothing to fear."
She was right. If you're doing the right thing, you got nothing to fear in this regard.
Whopper, I agree that there is a time and a place for quality checks using fake patients - but I still feel strongly that the emergency department is NOT an appropriate place for a QA check like this.
When will people realize that medicine is STILL an art? Its not like we are helping people file their taxes. When we see a patient we are dealing with alot more than their ailment; their are so many other aspects to think about like their emotions, our emotions, Sometimes we may get distracted or we have a bad day, which happens to lawyers, teachers, pilots, etc. I resent the fact that if I'm evaluated on a not so good day, I am graded as a bad physician.
I think we have moved too close to the business-consumer model. Patient satisfaction has been decreasing over the years and its because we have moved further from the doctor-patient relationship to the business-consumer model. Unless you are a plastic surgeon, dermotologist, or an ophthalmologist, you are not selling a product. We aren't customer service reps who need to be evaluated like this. It is things that like that make me think more and more of not practicing in the U.S. Its B.S.
Sure, but the more fakers you add to the mix, the more likely you create the attitude with young physicians that they are ALL fakers. It's a matter of degree. Someone who sees mostly legit ailments will have a better regard for the patients and his role. And you simply don't know whether this standardized person is going to be the straw that tilts the balance from regarding patients positively or negatively. Every little bit hurts. There are so many ways to evaluate and improve physicians without abrogating the physician patient relationship (ranging from periodic shadowing, requiring better documentation, getting patient feedback, sim lab training), it's kind of offensive that this is what was picked, both because of the increasing waiting room time aspect for other patients, and the likelihood that fake patients will make doctors more jaded for when they actually are seeing real patients. There is no way this is the best approach.
The above is perhaps how you test non-professionals. You call up your receptionist to see how she answers the phone. But you don't test professionals this way. You treat them as professionals and they need to respond in kind. This isn't a run of the mill employee. It is someone who you have let into your profession -- an exclusive club -- because they have the aptitude and attitude and character you find acceptable. If that's not the case, you address this by changing the requirements to get into the club. Make them have to get references from patients, or pass a character interview (as folks in law often do). But you don't let them in and then try to trap them.
Agreed--when people are debating this nonsense, just apply the same scenario to a different, yet no less high-stakes field. I'm willing to bet that people would be outraged if fire depts. were called out to fake calls without knowing it until they reached the scene or the same thing with fake calls of distress for police assistance.
I can just imagine that one:
Radio: Shots fired--Officer down at gas station on corner of Center St. and 37th
Police: Roger, moving to location (siren, siren)
Dude at 7-eleven: Ha-ha, but seriously great work guys in getting here quickly--false alarm. Hopefully you didn't injure any one getting here at 90 miles/hour or really had your guns drawn with the intent to fire. Just glad know that in a real emergency you'll do just as well.
Uh, folks, twenty percent of my patients are fakers or at least exxagerating their symptoms for some kind of secondary gain. What's a few more?
Fake patients are not a problem in the NICU.. We're pretty sure that most of our premature infants are not faking their RDS and we've not had too many pretend gastroschisis patients.
In general, however, I think that this isn't the most effective way of evaluating the health delivery system. Focused chart reviews and patient satisfaction surveys (that all of our NICU parents fill out) are effective measures when used properly.
This should go on a t-shirt
But really, when did hospitals take over the business model of McDonald's? Things like "customer satisfaction" are really overrated. It is, of course, necessary for a doctor to attempt to act in a professional and caring matter, but in the end, it is their job to provide the proper medical intervention to prevent you from dying, becoming more sick, or becoming permanently debilitated.
And of course doing this in psychiatry is different than in another area of the hospital where immediate care such as the ER.
3rd party observations in several areas of medicine are effective in weeding out certain bad apples.
Perhaps in situations like an ER, a better approach would be to video record the health care practitioner's work on the patient, & should the patient give permission--it could be evaluated by a 3rd party---> kinda like an M&M but you don't necessarily have to have a bad outcome.
Again, IMHO you guys are overrating attendings. I have actually told my friends & relatives that if they should receive medical care they will have me review their chart. Why? Since I've been a resident (4 years), I've had about 10 situations where the doc of friend or relative was not practicing standard of care. In 3 of those cases--it truly was malpractice. I've also noticed that when a patient is a doctor or a lawyer--everyone on the medical floor actually triple checks themselves when they should be doing that with everybody because they're scared their mistakes could be better easily detected.
I hate saying this but you will see plenty of bad doctors when you guys become residents--doctors that need to be put on a leash, and several of the methods to weed out bad docs aren't effective or lead to slaps on the wrist. I think in medschool, the perception of the quality of docs is positively skewed--because in academic institutions, the quality of doctors are very high & there are more organized efforts to make sure people are practicing standard of care.
However in community hospitals & with doctors who have private practice--its a lot easier for a doctor to get away with substandard care--& trust me it happens, more often than we'd like it to happen.
You've raised some excellent points and as a chief resident your perspective is probably better than the rest of ours.
HOWEVER, I think this system of trying to check everyone is wasteful and flawed. The onus needs to shift to clinical supervisors to identify and expeditiously deal with the problem docs/med students.
Just to use med school as an example (since I'm more familiar with it): instead of our having to talk to 50 standardized patients and having to fufil 243 "professionalism competancies" our clinical attendings should step up and start trying to identify the students who need extra help or behavior modification.
LIESSSSSSS. Everyone is honest ALL the time.
Hell, why don't we just have little comment cards on the wall like fast food joints. Nobody but old, disgruntled people fill those things out anyway.
In private practice there are no clinical supervisors. Even when there are clinical supervisors--politics can mess things up. In university centers where this type of problem occurs less than in community hospitals, for several reasons--more whistle blower 3rd party organizations come in such as ACGME to evaluate a program, there's more people going in & out who shake up the political structure forcing people to act in the right manner.
And even in university centers, where the problem is much less, you get patients who only come to you after a duration of bad service from a doctor, and when you check the old records you're shocked to see what the doc did. Then you tell the patient what's going on and they mention they had no idea that the doc was doing the wrong thing.
Bottom line--a system that is unchecked leads to problems.
Of course I do not want someone over analyzing every move I make, but the solution is to have methods that do not hurt patient care or slow care down. I agree that fake patients in a setting such as an ER where things can get acute can cause problems. However, the solution is not to simply entrust a doctor to never do the wrong thing, because trust me--several will the second eyes are not watching.
Anyways, I think another factor affecting perception is medstudents are IMHO over analyzed in this type of area. You guys get so many tests & people knocking you down. Medschool is hard and I'm glad I'm past that point.
I wish the best of luck to all of you. I also need to apologize for inserting myself into this medschool section. You medstudents deserve a place where you can discuss issues among yourselves.
I would refuse to work at and quit a hospital that videotaped patient encounters, the key point being that they would need my permission as well and I wouldn't give it. Are you crazy? That's all we need is some more date to give to the lawyers to say, "Well, why didn't you say this or that."
And I'm not a health care practitioner, I'm a physician.
Medicine realized a few decades back that it is a service providing field, and like other service providing fields, its quality is largely based on customer satisfaction. Medicine does not want to be measured based on treatment successes because honestly when your patient base is ever increasingly going to be aging hypertensive diabetic obese people, you are fighting a losing battle. So you can at least provide service with a smile. This is the basis upon which medical students now need to be more well rounded, rather than just bio majors (as they all were in the 70s). Your job as a physician is in very real terms measured by how well your patients like you. In repeat business specialties you are rewarded for this by them coming back to you and in one time business, you are sued when you screw up more often if your patient doesn't like you. So no, I don't think the customer satisfaction aspect is overrated -- it is the real core of the profession. But I think testing professionals with fake patients at the detriment to anyone in the waiting room is appalling and there are many many less offensive and intrusive ways to measure quality.
Why is the AMA endorsing this? The AMA is such a pathetic excuse for an organization. Have they done anything recently that is actually in the interest of physicians?
So far some of the key objections I'm hearing could be summed up with "we're special" and deserve a pass because we are "so special." Just because a quality improvement method is effective for lower life-forms like secretaries as well as pharmacists (many physicians don't respect them) who get tested with "fake" patients, it doesn't mean it's beneath us. I'm not convinced that because something is a good approach for a pawn, like a secretary or grocery clerk, doesn't mean it's good enough for royalty, like physicians. If anything, such arrogance is a barrier to quality improvement and helps sustain ineffective and in some cases dangerous practices. For those of you that plan to practice medicine as a charitable service, where patients do not have to pay, I agree, business models don't apply. For the rest of you, you will be part of a business with a business model, unpleasant as that reality may be.
Yes, there is an art to medicine, but that doesn't suggest we have no logical way to evaluate quality of medical care. Perhaps we should meditate and hold hands in a circle or just respect Dr's more to improve quality. Well ok then, if interviewing staff for improvements, etc. really works, let's do some quality improvement studies and see what actually does improve quality -- per standard of care compliance, health outcomes, cost, reliability, and, yes, even patient comfort and satisfaction (shudder). I'm sure there will be a variety of tools that could be effective and just as one drug isn't appropriate for every patient's ailment, we might need to use a different mix quality improvement tools for different hospitals or clinics depending on what we suspect the barriers to improving quality might be.
If chart reviews are the most effective approaches to improving quality, scientific studies should prove that out. If standardized ("fake") patients are effective or not effective or dangerous, the numbers should prove it once again. If standardized patients are so horrible, then that arm of the study could be abandoned early -- as is often the case in certain clinical trials, based on the numbers and defined objective criteria. I do think that physicians and staff should be told about what is being done, why, and what the measurable objectives are. The staff should have input on how to conduct these test safely and effectively. However consideration of input sometimes involves with dealing with comments such as "it's more work and I'm already tired." Well, if we had a better process, maybe we would be spinning our wheels less and you would be less burned out.
Rather than deciding the best approach based on emotion or nostalgia when MD's were above being questioned, I would suggest we should base our decisions in large part on facts that might involve testing. Not all physicians provide the same quality of care. Even a physician might vary in the quality of care provided depending on the situation in an ER or hospital. We don't test drugs by evaluating if the medication looks nice, tastes sweet, or has a soothing texture. That might be important for certain pediatric meds, but these aren't the primary factors for evaluation in most pharmaceuticals. We inject things and administer these substances to patients in studies in a carefully planned and controlled process and eventually must to prove that they are safe and effective with real tests that might hurt people. It's a tradeoff we accept as reasonable and unavoidable. If we never did anything that would have the potential of harming someone, the practice of medicine would be limited to prescribing small quantities of water and administering massage therapy with hypoallergenic oils.
As far as the safety aspect is concerned, as a country, we have tested nuclear weapons safely in the past. It wasn't always done safety. Above ground testing was the norm until we figure out that it killed people and contaminated the environment. However, in all, testing nuclear weapons helped ensure their safety (testing for accidental detonation, safe handling, for example). More down to earth, physicans have some necessary, life-saving procedures that involve cutting patients open, removing much of their abdominal contents and then putting most of it back --- safely. Other procedures look much more benign but turn out to be more risky when you look at the mortalities. This is done every day. If we can figure out how to manage extremely dangerous procedures like this safely and effectively, I'm sure we can figure out how to conduct quality tests and checks safely also, even with the dreaded "fake" patients, if that proves to be a good approach that isn't beneath us.
Police departments and fire departments frequently do drills and test their procedures to help ensure safety. Every school has a fire drill at least every semester. Emergency responders practice how to do their jobs in natural disasters with, gasp, fake patients. Houses aren't burning down and people aren't getting killed left and right because our emergency responders and being tested on their ability to respond to certain situations. There are processes in place to ensure that this is done safely. These fake patients could also be implemented safely. No one is suggesting that this should not be done in a careful, safe, and effective way.
Taking it one step further, I would suggest that medicine as it is practiced today in the U.S. is difficult to sustain (financially, labor wise, etc.) and quality is inconsistent. I'm sad to say that thousands of patients die or are injured because of physician and medical staff screw-ups. It's a big problem and it's not anything to be proud of. Most rational people would agree that the status quo in medical care has plenty of room for improvement in quality. There are some hospitals and clinics where I would rather no be treated for anything because the word that describes care there is "incompetent" or perhaps "dangerous." Bizarre complications occur. Medications are not administered or administered twice. A standardized patient isn't going to be able to test this easily, but such an approach might be part of an effective program. Even within a clinic or hospital the care might be inconsistent, e.g., worse nights or weekends. Even if care at a facility is "marginal" (but passing) perhaps we could aim for "good" or "excellent" instead.
I agree that we should start with chart reviews before we moved to standardized patients. However, we are taught not to blindly trust what is written in a chart as extremity pulse measurements on amputated limbs and vitals on deceased patients unfortunately attest. Some charts are also mysteriously lost. I was speaking with a patient the other day and a major hospital has no chart for the CABG that was done there ... the procedure was done late in the day, maybe the physician lost it or forgot to prepare it. Stuff happens.
It could get worse before it gets better. Because we have failed to manage our profession effectively (costs escalating out of control, access to care decreasing, thousands of patients injured or killed due to errors), we are no longer in the drivers seat in many areas when it comes to various quality improvements. In some cases, physicians who intervened to save the life of a patient have been reprimanded because they embarrassed a more senior physician or the hospital. Quality improvements will be done to us because lack of quality has the attention of people who are able to tell us what to do. Whether anything will really change or whether quality will improve remains to be seen. What is clear is that there will be various experiments and changes headed our way. Hopefully they will help more than they hurt. I suppose we could be part of the conversation of how quality will improve; I recommend this. I hate to say it, but improving the quality of medicine might require some bitter medicine and painful procedures on the way we practice.
How exactly are fake patients going to evaluate quality of care? My guess is that, like standardized patients, they will be making their evaluations based on whether they like the physician or not. Since there is nothing wrong with them, how exactly is the physician going to be evaluated in any other way other than subjective personality traits? Medicine ISN'T like being a secretary, or an accountant, or a sales rep. Evaluating doctors based on some "Secret shopper" corporate gimick is a farce, which is likely driven more by the desire of hospitals to make more money than to actually improve patient care.
I think there are three arguments here, all of them strong. (1) By sending in fake patients, you eat up time that could be used for real patients. (2) You create jaded physicians and poor patient care when they believe that some percentage of their patients are sent there to trap them. and (3) physicians are members of a profession, and yes, they are "special".
The way "profession" has been historically defined, they are, in fact "special". It's already a higher level of expectation, more duties, oaths and obligations, and in return different treatment, collegiality, etc.. A profession is self policing, and self selecting, and has obligations to its patients that extend beyond mere customers. As a result it is quite different than all those jobs you just apply to with no formal training. Or at least should be. If not, then what is the point of a profession, beyond just a job? So yes, doctors do need to evaluate each other with a slightly different approach than you might evaluate your receptionist or secretary. These are your brethren in an organization that folks have already jumped through a ton of hoops to get into, and passed various licensing tests, and continue to be obligated to take relicensing obligations. The checkpoints are already there. When you need to use deceit and not give professional behavior the benefit of the doubt, you undermine the idea of professional. This needs to be addressed within the profession, not via external traps.
Perhaps when I actually begin to practice medicine in the real world I will share your perspective.
I think you are correct in saying that med student tend to hold doctors in a higher place than most doctors actually deserve its part of the socialization process that we undergo. However, I doubt this is a contributing reason why students would disagree with using sham patients for quality improvement. Some of the objections raised here include:
1. Sham patients taking the place of a real patient,
2. Waste of resources, (e.g. time),
3. Increasing skepticism by young physicians towards patients,
4. Erosion of the doctor-patient relationship,
5. TPTB becomes the Hospital; more decrease in doctor autonomy.
My main opposition is that the practice is unethical. Yes, there are physicians out there who are rendering subpar care. They should be indentified and held responsible. For example, my Father was placed into hospice shortly after being diagnosed with NPC (squamous cell), the PCP failed to refer him to a specialist on time (after 4 months of the same signs and symptoms). The guy no longer works in the clinic. Suffice to say, Dad had Medicaid, and thats another issue. Ive written about it in my blog if you care. But the point is that a system wide approach of using sham patients to improve quality of care seems unethical because of points 1-5.
One possible way of addressing the ethical issue is doing like OncoCap suggested TPTB should disclose the week or month when the sham patients will be coming into the hospital. But still, the prospect of treating sham patients hired by a hospital irks me.
It probably depends on the situation. My guess is that it would be a technique that might be useful for identifying certain gross omissions such as ignoring the signs of a subarachnoid hemorrhage and advising the patient to take some ibuprofen and come back if they feel worse or someone at an ER with signs of severe appendicitis with leaking bowel contents being prescribed an antibiotic for a (misdiagnosed) urinary tract infection (both of these are actual cases that I'm aware of). Some of these incompetencies would not necessarily be obvious from a chart review, especially if the patient winds up at a different hospital when they have a seizure and die or go to a different ER for another evaluation. If it saves patient lives and morbidity it's worth the "wasted time" in my book. Heck, read panda's blog (defunct as it now is). More than 90% of the time and resources in the ER and in many hospitals is completely wasted ... less than useless ... down the drain. An occasional fake patient, particularly during slower times would make no measurable difference in workload. I would suggest reviewing actual facts about the effectiveness of a method before dismissing it with an emotional knee-jerk reaction.
Also, to your comment about the AMA being useless to helping physicians ... you might want to take another look. It seems like they have done a few things to help physicians keep their practices open, especially here in Texas (fighting certain legal and insurance practices). Any organization could always improve and perhaps you could provide some of your ideas to that organization.
Oh, and about the erosion of the doctor-patient relationship: like panda said, "fake" patients are common in real life. Cynical physicians are common in real life. A handful of fake patients cause no measurable change as far as I can tell (can you tell the difference between 200 -- the ones that come regularly and 205 (200+5 "shoppers")? -- I wouldn't be able to you but maybe for some those 5 would be the straw that broke the camels' back). If it really did have such a negative impact on actual practicing physicians, perhaps this argument is valid. As it stands we are all just speculating about the impact because we simply don't have any data.
Well, we don't have data, but it stands to reason. Every fake patient a doctor is exposed to makes him a little more jaded. Sure doctors already see lots of folks motivated by secondary gain. But saying "things are already bad so it's okay to make it worse" is simply never a valid argument.
It's a trade-off to be sure. When we give a medicine, the patient might feel worse but in the end have a better outcome. Some medicines might only help a fraction of patients (giving acyclovir to patients with encephalitis because HSE is the only one we can treat). Quality is similar. Sometimes quality improvement and dealing with denial about quality problems is unpleasant. What I'm suggesting is that we don't look at this solely on the basis of "wasted time" or "jaded physicians." Those are negatives that need to be weighed against the potential positive outcome. If this approach saved 10 patient lives or prevented a similar number of adverse outcomes per year at a particular clinic (that sees say, 10000 patients per year), would that change your mind? Quality tools should be viewed in context, weighing the positive against the negative.
In your opinion, fake patients cannot have sufficient value to offset the negatives. I'm not so sure and suggest that we get some actual data before we dismiss something on the basis of opinion, especially because the approach has been used quite successfully (even though we might look down on other professions). Perhaps identifying the patient as a quality tester might provide adequate results and not require "fake" patients. Somehow I don't think that it would be as effective.
There was a time when going to a physician actually decreased chances of patient survival (days of bleeding and other unscientific but, based on the knowledge of the time, well-reasoned treatments). In some places and with some physicians, this is unfortunately still the case. With the advent of science we learned that despite what we might reason, where appropriate, we should test things in falsifiable experiments that can prove us wrong. Fake patients certainly should not be a first-line approach to quality improvement in my opinion. It would be more of a tertiary approach. Lots of people have opinions about what would improve quality but not everyone has double-blind data to back it up (almost no one does). I certainly don't see fake patients as an alternative to say, chart reviews. However, I could see it being one part (perhaps even a small part) of a larger quality program if it can be proven to be effective.
I'm saying there are a lot of alternatives they should try first before one that is so detrimental to the physician patient relationship. So yeah, at this juncture this tactic isn't justified. If you can ultimately show that this is the ONLY or least disruptive way to address the problem, then I can be persuaded. But you don't get to jump to the most intrusive approach first. It's sort of like jumping to surgery without trying conservative or medical management of a patient. (Which if we did on some of these fake patients, might quickly put an end to this issue).
1. I know that there isn't a ton of supervision in private practice, but I'm not at all sure that these patients would be a great solution to that problem. My grand plan would be that many "problem" people could probably be identified early (med school/residency) and dealt with then.
2. The nastiest part of this whole discussion is one where we have to identify our final goal. I mean, are we looking to completely eliminate medical error and pillory any physician who makes a mistake? I just think it gets pretty dicey. We do have to accept some level of error in the system, I personally do not think that the surveillance of physicians in this manner is appropriate for reasons others have stated better than I could. If that means that a few more medical errors are made then, I hate to say it, so be it.
3. Say that the fake patient wanders into clinic on a day when Dr. Smith just got into a huge fight with his wife. Maybe this is one of Dr. Smith's top 5 worst days of his life and despite providing adequate care the fakie decides that Smith was brusque with her and feels very offended. What are the ramifcations for the good doctor? Is he labeled as "possibly problematic" on some sort of grand list kept by bureaucrats and insurance companies? Is there an appeals process?
Bingo. Nowhere is the call for physicians to be caring, empathetic, and invested personally in their patients sounded louder than on SDN. It is inconsistent to glorify the sanctity of the Dr-pt relationship while suggesting that injecting this falsehood into it is somehow beneficial.
I try my hardest to be all of those things to everyone I see. If I spent time with someone, talking about their problems, explaining treatment, answering questions, trying to assuage fears etc etc only to find out their were some hack actor hired by Phyisican Evaluation Corporation I would feel utterly disgusted.
All good responses.
What are the methods where we doctors are kept in "check"?
1)Malpractice: this is a poor method. Studies have already proven that the #1 factor on a lawsuit is simply based on how much the patient liked the doctor, not if the care given followed the standard of practice. Lawyers & some patients (not all) wanting to get maximum $ also screws this up as a fair & balanced method to keep bad doctors in check. (tangential story: I know a doc that completely screwed up on a patient--ended up destryoing that patient's kidneys, but since the patient liked the doc, she never sued him. Honestly. It was a completely avoidable error that the doc committed. She'll be on dialysis for the rest of her life but because that doc gives her a hug everytime he sees her, well she's alright with him.)
2) State boards: This highly depends on the state. Some boards hardly do anything in terms of regulating doctors that have showed questionable ethics & practice. I only have the experience of the board of the state I'm in and the word here is its very difficult to get your license, but once you get it, you're pretty much set--even if you do bad practice.
3)Institutional oversight (including some of the methods above such as chart reviews): IMHO one of the better ways to deal with the situation. There still are problems with this. Politics for example....a doc could be good friends with the doc in charge, so that doc will overlook poor performance from their friend. Still, better than the above, not perfect. As I mentioned above--private practice--there is little if any oversight.
4) patient evals: Not good IMHO unless the only thing you're looking to gauge is the doc's skill in patient interviewing because patients don't know what the standard of care is. Same analogy applies as I mentioned above-if a car mechanic told you your car had x number of problems & you don't know anything about a car other than driving it, you don't know if you can trust this mechanic. Patients often times can only gauge how "Friendly" the doc was. While empathic & caring treatment is an integral part of good treatment, its still only a part of the treatment.
5) M&Ms: probably the best method I can think of--however it only catches problems after the bad outcome has already happened. There are several episodes of "accidents waiting to happen" but only get caught after a patient has a bad outcome. M&Ms also are not occurring in several hospitals. University & teaching hospitals have M&Ms. Some however do not do this. Private practice if ever hardly does it.
6) actors: the method we're currently debating.
IMHO excluding the actor method, of the above, only 2 are good methods to evaluate doctor performance, and of those 2--one doesn't touch private practice, the other doesn't either.
Completely getting rid of medical error is impossible.
However I'd rather have an actor than several of the above methods. E.g. Malpractice is a piss poor method of nabbing bad doctors. Personally, I wouldn't care if I got an actor or not. If I follow standard of care practice, than I got nothing to fear. Whether or not is a supervisor or an actor evaluating me, doesn't make a difference to me.
I do though agree that use of actors can cause problems such as in acute care settings.
Is anyone else disturbed that one of these fake patients thought that excellent care was based on the fact that she received gourmet coffee and a neck pillow massage??? WTF are you kidding me with this right now.
Exactly. It seems like a very, very narrow range of poor practice that this would pick up. Somehow it would have to be things that are a) easily fakeable, b) have a clearly defined standard of care with c) no room for clinical decisionmaking. I bet it's a whole lot more likely that people will be judged based on meaningless things like coffee and wait times.
Just like the stupid insurance chart reviews are all about whether you documented what the insurance company wants to see documented, not whether you actually take good care of your patients.
I'm curious, are they required to notify doctors they do this as part of the hospital contract? If they don't, wouldn't it be kind of fradulent for them to hire someone to obtain information under false pretenses which could be used against the doctor?
Thanks for the considered response. And now for my riposte.
The point is that you may very well have something to fear. What Noel raised is that this particular lady was giving bonus points for each way that her physician's office sought to emulate a day spa. You may follow the standard of care to a tee, but what happens if this actor decides for whatever reason that they don't like you? What if she dings you for serving Folgers instead of Peets? Are there ramifications?
Plus it is VITAL to keep in mind that medical error =/= bad physicians. Good doctors make mistakes, ALL doctors make mistakes. Patients are getting sicker and sicker, people that would have died even a few decades ago are hanging on for a long time with horrible illnesses. Pile on the usual host of comorbitities (DM, HTN, CHF, CRI) and you have a patient who literally may require hundreds of interventions a day to keep them going. Even when these people are not septic and in the ICU they are often walking monuments to pharmaceutical science.
A good point and this SAME problem occurs with patient evaluations being used to rate doctors.
The fake patient, and I really should apologize because my idea of the fake patient does not include her mentioned example--should be someone who knows what the standard of care is. For example another doctor, or a nurse coming in & posing as a patient. This allows the evaluator to know what the standard is but to also not rate the performance of the doctor on more superficial aspects such as free coffee.
A fake patient who is for all intents & purposes a layman is no better than simply just having a patient fill out an evaluation & wastes money & time. That fake patient knows nothing more than a real patient on what to look for.
Anyways, here's an example of someone who faked an identity & entered a hospital system who did a lot of good. Former NJ Governor Richard Codey.
Malboro which was abusing its patients among a slew of other problems would not have been exposed. Doctors there were covering for the mistakes of staff, staff were covering for mistakes by doctors--in a cesspool of problems that only outside intervention was able to uncover to the point where it made a positive difference.
Want to read the full report?
Codey was educated on what to look for & thus was someone who when inside the system, was able to detect a number of problems that no on within the institution was addressing.
Its because of Codey that I'm convinced that outside evaluation is not a bad thing, but again, and I should've pointed this out, I'm not talking about a layman playing the fake patient but someone who understands the field & understands what type of care the doctor needs to be giving.
And for clarification-Codey did not pose as a fake patient but a fake employee. However the point IMHO is the same. Want to get anal & say that invalidates my argument?
Well how about someone who did fake being a patient.
Ok--occurred almost 100 years ago, so want a more recent example of a similar thing occurring? (I'll end my post here since its already way long).
I brought up a lot of psychiatric examples--because that's my field, & I happened to have studied it much more intensely however the same problems occur in every field, and the same abuses could've been exposed by 3rd party outside intervention. That's the entire point of the field of journalism--to have someone investigate what's going on from a 3rd person perspective.
Oh and the argument that "we're special"?
The presidency is a heck of a higher honor than the one we got--and that office is chock full of abuses. Anyone want to say that doctors are above corruption among other problems (e.g. laziness) because we're special doesn't understand human nature.
Um, malpractice is not meant to nab bad doctors. It is meant to reallocate financial responsibility from the victim to the negligent party. Meaning someone gets injured by a deviation of standard of care, he gets made whole by the person who caused the harm (or their insurance carrier). Malpractice exists in many fields besides medicine. It's about professional negligence, not about oversight. So I would omit this from your list of methods to keep doctors in check. It is a "poor method" of nabbing bad doctors because that simply isn't its purpose. It is a longstanding method for compensating victims of mistakes, accidents, deviations of the standard of care, and nothing more.
True, but it does act as a counter to some docs commiting bad practice & has also been a force to encourage responsibility in the field.
Unfortunately it also encourages some docs to practice "defensive medicine" in the bad sense of the word.