Family physicians’ ability to detect a physical sign (hepatomegaly) from an unannounced standardized patient (incognito SP)

Comparison of Primary Care Patients' and Unannounced Standardized Patients' Perceptions of Care

The objective of this study was to compare unannounced standardized patient (USP) and patient reports of care. Patient satisfaction surveys and USP checklist results collected at an urban, public hospital were compared to identify items included in both surveys. Qualitative commentary was reviewed to better understand USP and patient satisfaction survey data. Analyses included χ² and Mann-Whitney U test. Patients provided significantly higher ratings on 10 of the 11 items when compared to USPs. USPs may provide a more objective perspective on a clinical encounter than a real patient, reinforcing the notion that real patients skew overly positive or negative.

Comparison of clinical vignettes and standardized patients as measures of physiotherapists' activity and work recommendations in patients with non-specific low back pain

OBJECTIVE

To validate clinical vignettes as a measure of physiotherapists' activity and work recommendations given to patients with non-specific low back pain.

DESIGN

Validation study comparing two methods for measuring aspects of health providers' clinical management: Clinical vignettes and unannounced visits of standardized patients (the gold standard).

SETTING

Outpatient physiotherapy clinics.

SUBJECTS

Physiotherapists (N = 59) who consented to see unannounced standardized patients in their clinical practice.

MAIN MEASURES

Clinical vignettes were used to initially measure physiotherapists' self-reported activity and work recommendations. Subsequently, actors performing as standardized patients visited physiotherapists in their clinical practice and rated the advice given by the physiotherapist regarding activity and work. A total of 23 standardized patients were randomly scheduled to physiotherapists. Physiotherapists were blinded towards the standardized patients. To test whether standardized patients were detected, physiotherapists reported if they suspected that they had treated an actor.

RESULTS

The 23 standardized patients visited 22 different physiotherapists. Physiotherapists detected 12 out of 23 unannounced standardized patients (detection rate: 52%). The estimated agreement between the two measures was poor, for both activity and work recommendations (weighted kappa coefficients: 0.29 resp. -0.21).

CONCLUSION

The poor concordance between clinical vignettes and standardized patients indicates the potentially limited validity of clinical vignettes as a measure of health providers' activity and work recommendations in low back pain practice.

[Clinical safety in primary care. The systemic approach (I)]

This collaborative work is consists of two articles. In the first we will analyse Clinical Safety from a systemic perspective. In the second, we will focus on specific medical errors, with particular attention to the diagnostic error. Epidemiological studies are based on clinical document audits, adverse event reports, standardised patients-who in turn may adopt the methodology of "unknown patients"-and direct observation of the clinical act. Institutional initiatives have been introduced from the APEAS and ENEAS studies, to create safer organisational environments, with emphasis on prescription safety. We examine these initiatives, taking particular interest in the strategies that are supported in the Electronic Medical Record, and which are able to improve the clinical act at the same time in which it occurs.

[Clinical safety in primary care: medical errors (II)]

The first article of this series on Clinical Safety was dedicated to the epidemiology and systemic preventive policies. In the present review we focus on medical errors with special emphasis on diagnostic type errors. These errors sometimes arise from the elusive characteristics of the disease itself, the way in which the patients present their symptoms, and the characteristics of the professionals themselves. If we consider a general practitioner as a diagnostic machine, --paradigm of "physician as a robot"-- it would be easier for us to accept some cognitive limitations and introduce institutional strategies that would humanise the treatment occasionally received. More specifically we will examine three strategies for improving clinical reasoning: recognising dangerous situations, metacognition, and an internal supervisor.