Regarding “Can Unannounced Standardized Patients Assess...”


To the Editor:

The article by Zabar et al.1 euphemistically uses the term “unannounced standardized patients (USPs)” to describe individuals who fall into the category that has been referred to elsewhere as “fictitious patients.” The latter category includes actors and others who pose as emergency department (ED) patients for a variety of purposes, including patient satisfaction initiatives (so-called “secret shopper” patients), sensitivity training, medical school education, or other purposes. Zabar and colleagues use this approach in an attempt to meet the Accreditation Council on Graduate Medical Education requirement to assess communication and professionalism skills. While laudable in some ways (as are the other purposes), this approach to fulfilling this requirement presents ethical problems.

It should be noted that the American College of Emergency Physicians (ACEP) has as part of its Code of Ethics a policy that opposes the use of fictitious patients.2 In part, it states: “ACEP opposes the use of fictitious patients in emergency care units [sic]. Deception is unethical and may undermine the trust essential to the relationship between patients and emergency caregivers. Such practices may have unintended negative effects, such as delays in treatment for other patients, unnecessary administration of medications, and improper billing practices.”2

While the use of USPs in resident training as described in this study may not result in all of these problems, it may indeed lead to others. Surely, adding USPs into the mix of a busy ED may divert appropriate resources (space, time, etc.) away from real patients who are competing for the same resources. More troubling is that in this study, residents were aware of the possibility that some of their “patients” would be USPs, and 5 of 28 residents who did not see a USP thought that they did. This leaves open the possibility that some real patients might have been treated differently and received less medical care than necessary because there was the “suspicion” that they were USPs, similarly to some patients with real pain being undertreated for pain as the result of caregivers trying to detect “drug-seekers.”3 Residents and others should not be engaged in trying to detect which are the fake patients and which are the real ones. This demonstration project had a low success rate (62%), even as measured by researchers in this study funded by a grant from the Picker Institute.

Measurements of communications skills and professionalism are subjective, and one would suspect that residency directors can find better ways to assess these elements, including postencounter surveys, faculty surveys, or real-time observation of actual patient encounters.

Finally, while residents consented to participate in this research at their home institution during this study, as a whole they might be less willing to be deceived in other circumstances. Similarly, practicing physicians who must have communication and professionalism skills assessed as part of their Maintenance of Certification would very likely object to this type of activity. Engaging in deception is a less-than-ideal way to teach or assess professionalism, which is fundamentally grounded in honesty and fidelity. I believe that this approach should be abandoned in its infancy.