Monday, June 16, 2008

I'm Not a Real Patient, But I Play One on TV

What do you call a patient who fakes their history, symptoms and physical exam to gain medical care? For many of us, this sounds like a classic case of Munchausen syndrome.

So what would you call it when a hospital administration hires such people to covertly evaluate the quality of care in their facility? Users and purveyors of this service use a variety of terms, including "mystery shoppers", "secret shoppers", "ghost shoppers", "undercover patients" and "sham patients".

This concept of Munchausen management is currently being pushed, ironically enough, by the ethics council of the American Medical Association. During their current 5 day meeting (which began on June 14) the AMA ethics council is pressing the rest of the AMA to endorse the use of undercover patients to evaluate the quality of care at medical facilities and physician offices.

The AMA's Virtual Mentor site has a point-counterpoint style discussion of this topic, with commentaries on both sides of the issue. Of the opinions posted there, I think that University of Illinois professor Richard C. Frederick, M.D. gets it right:
This practice highlights the crisis of medical professionalism—failure to view the physician as a professional. Finally there is the huge question about the consequences of using deceit in a field where truthfulness is a core virtue.

A Priori Assumption of Guilt

When police set up a sting operation in a pawn shop, a downtown hooker hangout, or a congressional office, they are not out to improve quality control. They are not doing it to prove that someone is innocent. They do it because they are pretty darned sure that something is wrong and they want out to nail someone for it. When there is sufficient evidence of malfeasance, I'll grant that a sting is a fine technique.

However, foisting the same tactic on physicians for "routine quality control" is a completely different kettle of fish. The message it sends is not: "We want to help you improve your care." To a health care practitioner, it clearly says: "We don't trust you." To patients, it is equally clear: "We don't trust your doctors."

Surrogate Endpoints

I am all for improving patient care. I want all of the patients in our medical center to feel welcome and well-taken care of. However, let me emphasize the word "patient" here. I want to get as much feedback as possible from actual patients on how we are doing and how we can do it better. Contrast this with data collected from a sham patient -- no matter how well these folks are trained, their data is going to be, at best, a surrogate of what an actual patient feels, needs and experiences. Since these medical mystery shoppers don't have actual medical needs of their own, they will pretty much be checking off items on someone else's arbitrary feature checklist. As Dr. Frederick puts it:
One wonders how effective the secret shopper can be in assessing physicians' most important roles. If these people are not sick, frightened, tired, and vulnerable like real patients, how helpful is their appraisal to the physician whose patients are frightened and vulnerable?
Doré's caricature of Baron Münchhausen

Is Anyone Actually Harmed by Sham Patients?

How ethical is it to put a sham patient through medical tests and procedures for which there is no medical necessity? If the only people concerned were the sham patients themselves, this might not be an issue -- after all, they volunteered for it, and are often paid to do this sort of thing.

However, sham patients are not the only ones put at risk by this practice. Consider the patient with real chest pain who has to wait in the ER a little longer while a sham patient with no disease at all is seen first. But wait, there's more. Dr. Frederick again nails it:
Consider the scenario where a nurse or lab tech gets a needle stick while treating this "planted" patient and develops hepatitis or HIV.
It's only too easy to extend this concept to the radiology department. Any time I perform a shoulder arthrogram on a patient, I and my radiology technologist are exposed not only to needle sticks, but also to a certain extra dose of ionizing radiation. I am quite willing to take a few extra rays if it will help an actual patient. However, the thought of doing so on a sham patient for no medically indicated reason makes me a bit livid.

The Problem of False Positives

Some apologists for medical mystery shopping rationalize the practice by pointing out the rare cases where unexpected findings turn up in these sham patients. A big problem with this is that the predictive value of a positive test is tightly coupled to the underlying disease prevalence. In a sham patient, that prevalence is usually going to approach zero. This means that a false positive result is far more likely than a true positive result.

What if a false positive result leads to a more invasive procedures, such as a biopsy or surgery? The results of this, alas, can occasionally be dire, and I'll offer one extreme example from a good friend. Two of his medical school classmates, upon reaching a certain age, gifted each other with a full-body CT exam. One of them underwent a needle biopsy after the CT showed a questionable lung lesion. This biopsy was complicated by a tension pneumothorax and death. This is about as dire as it gets.

Reaping What One Has Sown

If this management fad becomes commonplace in medicine, I can only hope that its proponents are quickly hoist on their own petard. For example, why should a hospital be the only one who can set medical spies on their staff? There's really nothing to stop a competing practice or hospital from doing the same thing. A disgruntled patient or former staff member could do the same thing, and spray the results all over the media and the web.

On a personal note, I would find it extremely hard to ever trust a hospital or departmental administration who inflicted a program like this on me. I'll let Dr. Frederick have the last word on this:
Finally, we teach our residents and medical students that when we are not truthful with our patients, we violate their trust. We also put into question the next physician's truthfulness. We have all heard a patient say, "Those doctors at that institution lied to me, so I trust none of them." In reality maybe only one physician lied, but all are tarred with the same brush. Trust is fragile, and, once violated, it is hard to restore. But trust goes both ways. Are we physicians not human too? Once we are fooled by these "good actors," will there be an element of doubt about the legitimacy of the next patient with a similar complaint? I work in an emergency room and have been lied to frequently, but not by my administration or the executive director of my group. Cynicism, already a problem in medicine, will only be made worse by the use of official deceit. As physicians in a profession where high ethical standards are essential, deceit, however well meaning, is not a tool we should use.


anetto said...

I was once a mystery shopper patient for a chain of health clinics based in the US that was expanding to another country. My role was to report on location, signage, accessibility, waiting rooms, nursing staff and doctors. I usually visited for a legitimate chronic health problem but of course I had to pay cash and was reimbursed. A few times I was more adventurous and sought help for depression. That was not too convincing. One of the doctors commented that I smiled too much and was too animated for him to take my complaint seriously. To me that proved his skill.
It has been a help to me to have that experience with many doctors as I was too inclined to take the word of a medical professional as the final answer, to my own detriment.
By the way, the chain is long gone.

melinda said...

If I stretch my mind, I can maybe see the purpose of "mystery patients". But it seems to me to be very dangerous to choose Munchhausen's patients for this task - isn't that just perpetuating their illness? Wouldn't they be wiser to get treatment so that they will NOT come to the hospital so often?

It seems to me that it would be a far wiser choice for the hospital to do an "exit survey" of the patients as they leave the hospital - something like, "Thank you for choosing We Help You Hospital for your health care needs. In an effort to improve patient care, we would like to ask you a few questions about your stay at We Help You Hospital" followed by all kinds of questions about everything they want to know. The same could apply to ER patients or patients visiting for outpatient procedures. If the staff is doing a good job, then the surveys would reflect that.

But hey, that's just me.

The Samurai Radiologist said...

@ Annette:

Thanks for adding your perspective to this.

Re depression: A psychiatry prof in med school once gave me this definition : a patient with depression looks depressed, sounds depressed, and depresses the physician.

Re multiple doctors: I'm fine with that. I advise my friends to get a second (or even a third) opinion if the advice they get from their physician doesn't work or doesn't make sense to them.

The Samurai Radiologist said...

@ melinda:

I didn't mean to imply that actual Munchausen patients were being used as mystery shoppers. By "Munchausen management" I meant that the deceit was coming from a point up the food chain from the patient, i.e. the hospital or practice management. This is the sort of deranged management technique I would expect from Dilbert's pointy-haired boss.

I agree that acquiring this data from actual patients would be a much better strategy.

SHBB said...

About 30 yrs ago I worked at a med school. One of my job duties was to play the role of a patient with a specified psychiatric disorder in a practice interview with a med student. I don't know if the students knew I was not a real patient. My boss never told me and I didn't ask. Several of my co-workers in the psych dept also did roles for interview training. We did this a couple of times a year. I think it was better for the students to learn interviewing on us than on real psych patients. I do sometimes wonder if the video tapes of those sessions are still around somewhere. This was all pre-HIPAA, of course.

Stephanie said...

I am very upset and distressed to learn that hositals have time and money to waste on "fake" patients rather than use this same time and money to increase staffing and care for real patients.