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with Rod Moser, PA, PhD

Stories from behind the examining room door, as told by Rod Moser, PA, a primary care physician assistant with more than 35 years of clinical experience.

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Monday, March 28, 2011

Do We Need Secret Patients?

Many years ago, one of our friends had a job as a secret shopper. She would be hired to go to various stores and report on her experiences, such as the courtesy of the staff and in some cases, their honesty. I think it is time that we consider using secret patients.

For a large part of my career, I was involved in medical education as the Director of Clinical Education. It was my job to physically observe medical students at their clinical sites. I would  sit quietly in the corner or watch them on a video monitor as they took a detailed medical history and performed their physical exams. After they finished their exam, we would retreat to a private area where we would discuss the case. The student would then return to the patient, often with new knowledge, and finish the examination and medical history components that they missed.

As you can imagine, being observed (for a grade) frightened the crap out of them. Students would sweat profusely and visibly tremble. I tried to tell them to relax, do their best job, and to try and forget that I was observing them, but this did little to calm those performance nerves.

After a while, after repeated site visits and other forms of clinical oversight, most students evolved into careful clinicians. Some, unfortunately, did not. If we could weed out the problematic students early in their clinical training, we could try and remediate deficiencies. However, there were some medical students who just could not make the transition into a clinical career. They were dangerous. I can remediate “stupid”, but I can’t remediate integrity. As careful as we were in the selection of our students from a large pool of applicants, we would still admit some real winners.

I used to be known as the Terminator, because I would expel one or two medical students every year for serious infractions, the most serious being cheating. Anyone caught cheating on a written test or failing a clinical evaluation by claiming they did a certain exam component and did not, would most likely get their walking papers.

Graduating medical professionals who were well-trained and honest was the least that I could do for the consumer. When they put on that white coat, drape that stethoscope over their shoulders, and enter the examination room alone, I have to trust that they do their best for the patients, because once they graduate, I have no further influence or control.

Bad clinicians will eventually end up causing harm. They may fail to take a proper history, cut corners on a busy day, and develop some very sloppy and half-assed examinations. If and when this happens, people may die due to their negligence.

Much to my horror, I have been a patient lately. I have seen several different doctors and dozens of staff (medical assistants, nurses, lab/x-ray technicians) in the last month. As much as I try to sit back and just “be a patient”, I cannot shake my past role as Director of Clinical Education or the fact that I am also a seasoned clinician.

Because my blog is often read by my colleagues, I will not name names, or give grades, but I can tell you that if many of these clinicians were students of mine, I would have given them walking papers. There were half-assed examinations, incomplete medical histories, and made-up explanations. Sadly, many of these clinicians knew that I was a clinician myself, so you would think that would try to impress me with their clinical skills, but no. Many of them did cursory examinations that were embarrassingly bad, such as listening to my lungs through my thick flannel shirt in only two places (should be at least six on the back; four in the front) — one in an area where I have no lung, and another directly over my spine! I had my ankles checked for edema…through my thick black socks while wearing shoes! The entire examination took less than thirty seconds. Oh, and he never washed his hands (before or after).

Years ago, another nameless physician saw me twice as a patient. He never once touched me; didn’t even shake my hand. Perhaps he was so brilliant, that he could diagnose and treat me just by glancing at me. To make matters worse, he also did not see the need to make any chart notes. Of course, what would he write about? Why would someone devote years in the study and practice of medicine, and do these sort of things? If you have lost your passion for medicine, lost your integrity, and are only there for a paycheck, it is time to find a different career.

More recently, I had to redo two different facial lacerations on kids — a week after they sustained an injury — because the urgent care physician had no idea how to properly repair a wound. It is okay to use that special glue (I never use it) to repair a wound, but you must do it correctly. You cannot fill up the laceration hole with glue, like spackle, and expect the wound to properly heal. Not only will the wound remain open, it will result in an ugly, permanent scar. Both of these children were little girls.

Nearly everyday on the Ear, Nose, and Throat community, someone will post about cursory (or no) examinations or improper medical care.

1. “He looked in my ear for a second and said I have a middle ear infection with fluid, and a complete wax impaction.”

2. “He glanced at my throat, saw the white patches, and said I have strep and put me on a Z-pak.”

3. “She said that she could tell I had a sinus infection when she walked in the room; didn’t need to examine me.”

Just to comment on these three:

1. In order to diagnose a middle ear infection (with fluid) you have to actually SEE the eardrum. If you have a complete wax impaction, this is impossible. In order to prove the presence of fluid, you need to use a pneumatic otoscope (observe the movement of the eardrum when little puffs of air are blown against it using an attached bulb syringe). When you can’t even see the eardrum, there is no way of doing this test — probably the most important examine component when diagnosing any ear infection, and the one most often completely skipped.

2. You can get an idea if you see certain clinical signs on a throat examination (like petechiae, not “white patches”), but you can’t definitively diagnose strep by just looking at it. You need confirmation by a lab test — either a rapid strep test or a culture. Studies have proven that the clinical diagnosis of strep (made by just looking) is wrong half of the time. The clinician could have just flipped a coin. To make matters worse, a Z-pak (azithromycin) is not the preferred treatment for strep and is likely to fail.

3. Any diagnosis made without any examination is dubious at best. Why not just have a vending machine in the lobby filled with antibiotics and allow patients to help themselves?

Maybe it is my age or the fact that I am in pain and not on my best behavior, or my nearly 40 years of clinical experience behind me, but I am becoming a militant medical zealot. I cannot tolerate poor medical care. Maybe it is time to hire Secret Patients. Maybe, if or when I retire, I will do this. I will get out my old check sheet and go undercover to various doctors and grade them.

My evaluation will start at the front desk. I expect to be treated courteously and efficiently. When the medical assistant calls me back, I do not want to be called by my first name. When I have my vital signs taken, I want them done properly. When the medical provider comes in, I would like him/her to be friendly (a smile would be nice), introduce themselves, and perhaps, shake my hand. I expect hands to be washed before I am examined, and washed afterward. I expect to have a thorough examination, based on the nature and complexity of my complaints. I expect a proper diagnosis, rationale for that diagnosis, and some patient education. If given a lab test or x-ray, I would like to know why. If given a medication, I would like to know the reason and have knowledge of any potential side-effects explained. I would like to know my prognosis — when should I expect improvement, and what to do if I am not improving. Finally, I would like to know if I should make a follow-up visit. I want my clinician to be respectful, regardless of my insurance, or lack of. I want them to be dressed professionally and be well-groomed.

I don’t think I am asking too much of our clinicians. Based on what patients (or their insurance companies) are being charged, we may not be getting our money’s worth. One of my recent office visits cost $444 dollars, and that did not include any tests…just the examination.

While in another clinician’s office yesterday, I could plainly hear the entire examination of the patient in the next room through paper-thin walls. It made me very reluctant to talk over a whisper when my turn came.

People are paying hard-earned dollars for medical care and that is what is deserved: CARE.

C – Competency beyond reproach
A – Absolute privacy
R – Respect
E – Excellent examinations

Posted by: Rod Moser, PA, PhD at 8:30 am

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