AMA Journal of Ethics^®

Case

The staff at Urban Clinic had gathered for a morning meeting. Jim, the executive director, waited until everyone had coffee and had found a place to sit. Then he began, "Today I want to brief you on a new quality program. We're going to try a mystery shopper technique starting as soon as we can. You've probably heard about how this works in retail stores. I think it could help us improve patient satisfaction and office efficiency.

"What happens is, some trained market researchers will call the office to see how the phone system works and how the staff handles the calls. They'll make appointments and they'll arrive early and observe the staff and the environment. A few of them—pretty good actors I might add—will actually go through with a physician encounter.

"When we get the results from all this, we'll know a lot more about how to improve the quality of our patient experience. Any questions or comments?"

George, one of the internists, said, "It sounds okay Jim, but we're not exactly running a Wal-Mart here, are we?"

"Well, we aren't the first to try this. Massachusetts General has been running a similar quality improvement program for 8 years," said Jim.

"I'm still skeptical; we haven't got the money that some large institutions have, and it doesn't seem totally fair to be so devious," George mused.

Other staffers worried about the additional time it would take and who would be blamed or even fired if the results were bad.

Jim closed the meeting by saying he'd take all the comments into account before they rolled out the final version of the program. "Thanks for your input. Remember, we're in a competitive marketplace. And we owe it to our patients to do our best on all fronts."

Commentary 2

The use of a secret shopper to assess the delivery of patient care raises many ethical dilemmas, including the effect that this practice has on the patient-physician relationship, the stewardship of scarce health care resources, impact on the care given to patients, and exposures (e.g., to radiation, blood products, etc.) for physicians, staff, and the sham patient. 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. Introducing this competitive market tactic reduces the practice of medicine to a business model and will imperil both the members of the profession and its patients.

Trust

The traditional patient-physician relationship requires that both parties be open and honest. Edmund Pelligrino has defined the patient-physician relationship as a healing relationship that places a much higher fiduciary responsibility on the parties involved than a simple agreement or business contract [1]. The labels that we give to the parties involved reflect this; we are patients and physicians, not customers and providers. The difference is more than semantic [2]. The business adage "let the buyer beware" is reprehensible if applied to medical care. Trust and honesty on the part of both patient and physician are implicit in that covenantal relationship.

In our case scenario, appointments and time will be taken away from real people with real needs and illnesses so that sham patients can be seen. In some instances sham patients have presented to overcrowded emergency rooms with chest pain [3]. This type of complaint mobilizes a rapid and coordinated response from the entire health care team, leading to others' being triaged to lesser importance. How could the hospital administration defend this exercise to someone who suffers an adverse outcome while waiting his turn behind the person who is only pretending to be sick? Moreover, how would we justify using a hospital bed with all its attendant resources for a fake illness [4]? Again, what if that bed or the primary care nurse or respiratory tech were needed for a real patient waiting for care? The medical-legal implications are not inconsequential. Radiologic and laboratory testing are an integral part of our diagnostic tools. Consider the scenario where a nurse or lab tech gets a needle stick while treating this "planted" patient and develops hepatitis or HIV.

Institutional Review Boards (IRBs) are in place to protect our patients when human subjects research is proposed. The use of any form of deceit in medical research has been looked at with some suspicion by IRBs because of the history of ethical abuses in research [5]. I believe that the same level of concern should apply to this sort of patient encounter tool.

Medical Professionalism

Medical professionalism is in crisis [6], and the situation will only get worse if we use deceit in daily practice. Ethics in business is desirable. Ethics in medicine is essential. Patient advocacy is not an option for physicians; it is a necessity. Society recognizes this and has allowed the profession to be largely self-regulating. It is interesting—and sad—that in our case, this same level of autonomy is not granted intraprofessionally.

The executive director in our scenario informs the staff physicians that the "secret shopper" program is going to happen with or without their assent. These types of top-down declarations reduce physicians to tradespeople, not professionals, and the distinction between the two is significant [7].

Concerns about the use of secret shoppers have led the Illinois State Medical Society to ask the American Medical Association to further explore these practices [8]. Assessing our effectiveness in real patient encounters is important, and it is being done in a variety of ways that have proved effective and that do not endanger patient welfare. Peer QA, feedback from colleagues, and post-encounter surveys such as the Press Ganey questionnaires are helpful evaluation tools. In Peer QA, patient charts are routinely reviewed by other physicians, both internal and external, to asses the quality of care given. The Press Ganey survey allows institutions to assess the same concerns that secret shoppers assess, but relies on real patients. Use of these measures has resulted in behavior changes and has positively affected market share in this competitive environment [9].

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? Although it is becoming a lost art, our response to real suffering continues to be an essential part of our care [10].

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 ruthfulness. 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.