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 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 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."
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.
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.
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. 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.
There has to be better ways to evaluate physician performance and quality control than this.
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).
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.
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.
but I still feel strongly that the emergency department is NOT an appropriate place for a QA check like this.
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.
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?
clinical supervisors to identify and expeditiously deal with the problem docs/med students.
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...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...
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.
.....
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 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.
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.
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.
In your opinion, fake patients cannot have sufficient value to offset the negatives.
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.
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.
I mean, are we looking to completely eliminate medical error and pillory any physician who makes a mistake?
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.
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.
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.
State senators are not known for undertaking one-man undercover investigations. But that is what New Jersey Senate President and former Governor Richard Codey did at the former Marlboro State Psychiatric Hospital 20 years ago.
His actions uncovered widespread patient abuses, led to the firing of 35 employees, and contributed to a record that earned him APA's 2007 Jacob K. Javits Award.
she talked her way into the offices of Joseph Pulitzer's newspaper, the New York World, and took an undercover assignment for which she agreed to feign insanity to investigate reports of brutality and neglect at the Women's Lunatic Asylum on Blackwell's Island.
Committed to the asylum, Bly experienced its conditions firsthand. The food — gruel broth, spoiled meat, bread that was little more than dried dough — she found inedible. The inmates were made to sit for much of each day on hard benches with scant protection from the cold. The bathwater was frigid, and buckets of it were poured over their heads. The nurses were rude and abusive, telling the patients to shut up and beating them if they did not. Speaking with her fellow residents, Bly was convinced that some were as sane as she was.
All good responses.
What are the methods where we doctors are kept in "check"?
1)Malpractice: this is a poor method. ...
E.g. Malpractice is a piss poor method of nabbing bad doctors
malpractice is not meant to nab bad doctors