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.