Session number: 1021
Abstract title: The Ethical Problem of False Positives: A Comparison of Standardized Patients and the Medical Record
Author(s):
TR Dresselhaus - VA San Diego Healthcare System; Department of Medicine, University of California, San Diego; and the VA Center for the Study of Healthcare Provider Behavior, Sepulveda, California
J Luck - VA Greater Los Angeles Healthcare System; Department of Health Services, School of Public Health, University of California, Los Angeles; and RAND, Santa Monica, California
JW Peabody - VA San Francisco Healthcare System; Department of Epidemiology and Biostatistics, and Institute for Global Health, University of California, San Francisco
Objectives: To determine if the medical record might overestimate the quality of care through false, and potentially unethical, documentation by physicians.
Methods: Twenty physicians in the primary care clinics of two VA Medical Centers were randomly selected among consenting residents and faculty (97% agreed to participate). We compared 2 methods for measuring the quality of care for 4 common outpatient conditions: (1) structured reports by standardized patients (SPs) who presented unannounced to the physicians’ clinic, and (2) abstraction of the medical records generated during these visits. Physician subjects completed 160 evaluations of SPs (8 cases x 20 physicians). To determine the false positive rate (FPR), physician entries were classified as false positive (documented in the record but no reported by the standardized patient), false negative, true positive, and true negative. A receiver-operator characteristic (ROC) curve was generated to compare physician subjects’ false positive rates (1 – specificity) and true positive rates (sensitivity). We also determined the FPR according to domain (history, physical exam, diagnosis, treatment), physician subjects, actor patients, study site, and medical condition.
Results: Compared to the gold standard of standardized patients, false positives were identified in the medical record for 6.4% of measured items overall. The FPR was higher for physical examination (0.330) and diagnosis (0.304) than for history (0.166) and treatment (0.082). For individual physician subjects, the FPR ranged from 0.098 to 0.397 and, for actor patients, from 0.06 to 0.396. Typical of a ROC curve, the FPR rose in a curvilinear, positive relationship to the TPR. The FPR was similar across study sites and conditions.
Conclusions: These results suggest that the medical record falsely overestimates the quality of important dimensions of care such as physical examination. This clustering suggests that these are not incidental occurrences or under-reporting by actor patients. Though it is unlikely that most subjects regularly or intentionally falsified the record, we cannot exclude the possibility that false positives were in some instances intentional, and therefore fraudulent, misrepresentations. Such fabrication would violate ethical standards essential to the integrity of clinical practice and propagate misinformation in the medical record.
Impact statement: These data indicate that some physicians may actually perform less care than they report in the medical record. Further investigation is needed to explore the questions raised but incompletely answered by this research.