Secret Shoppers in Medical Practice

The fact that the AMA House of Delegates was planning to consider the use of “secret shopper ‘patients’” at its meeting earlier this month elicited a lively debate in Virtual Mentor, the AMA Journal of Ethics.

Dr. James Loden, founder and president of a vision center in Nashville, defends the use of secret shoppers on the basis of the ethical imperative to monitor and improve quality and the business imperative to compete effectively. (Dr. Loden’s practice competes with 53 eye specialists in the area and depends on patient to patient recommendations.) Secret shoppers offered a way to check on how his team, and he himself, performed when not being observed by others. He found that some staff was not following the expectation that they would explain to patients what was being done, and that he was leaving the exam room without asking if his patients had other questions. To make secret shoppers as secret as possible, Loden recommends that the decision to use them be made by the head of the practice and practice manager alone.

Dr. Richard Frederick, an emergency physician in Illinois, sees the use of secret shopper patients as unethical. Medical practice depends on trust, whereas the secret shopper methodology is based on deceit. And, if secret shoppers are sent into busy emergency departments, they could potentially block access for patients with true emergencies.

I think wise practice leaders will reject both these positions. The right first step is to engage colleagues – physicians, nurses, and support staff – in discussing how well the practice is serving its patients. Is it soliciting feedback? If not, why not? If the practice lacks crucial information for self-management, would secret shoppers provide what is needed better than other approaches? If so, I would proceed.

The primary value to be considered in deciding whether to use secret shoppers is quality of care. The secondary value is trust within the practice group. I can picture a situation in which (a) a practice has identified problems for which (b) secret shoppers might provide important information but (c) some members of the practice agree with Dr. Frederick that the methodology is intrinsically wrong.

In this situation I would recommend “processing” the disagreement within the practice group. The key issue is deepening the practice’s commitment to learning from their patients’ perspectives, not simply getting the secret shoppers’ observations. The wise practice leader will ask her anti-secret shopper colleagues – “if this methodology still offends you, how do you suggest we get the information we need…?

The idea of secret shoppers appeals to those who understand that medicine is an “industry,” with “customers” and “production processes.” The idea offends those who understand that medicine is a noble profession with long traditions of self scrutiny and self regulation. Both perspectives are correct. Neither is adequate without the other.

Even if a practice does not use secret shoppers, simply considering the idea can help those of us in clinical practice to step outside of ourselves and imagine our practice as it might appear to a trained observer.

The AMA Council on Ethical and Judicial Affairs presented an excellent report on secret shoppers to the AMA Delegates. (It has been referred to a further committee.) In my view the report hits the ethical nail on the head:

Physicians have an ethical responsibility to engage in activities that contribute to continual improvements in patient care. One method for promoting such quality improvement is through the use of secret shopper “patients” who have been appropriately trained to provide feedback about physician performance in the clinical setting. A sound secret shopper program should include the following elements:

(1) All relevant parties, especially those to whom secret shoppers will be making unannounced visits, should be notified that this mechanism is being implemented in their practice setting.

(2) The information collected by secret shoppers should be used only to identify areas of improvement and not as a basis for punitive actions. Third parties should not have access to information collected by secret shoppers that includes personally identifying data.

(3) Feedback from secret shopper “patients” should not be relied on as the sole source of data for evaluating clinical performance.

(4) The use of secret shopper “patients” should not be implemented in a manner that adversely affects access to medical care by legitimate patients. For example, the need for urgent care (such as in the emergency department setting) must always take precedence over secret shopper “patients.”