Patients go undercover to record encounters with doctors

Patients' health outcomes improve when physicians individualize care and take their patients' life circumstances into account, according to a new study by the University of Illinois at Chicago and the U.S. Department of Veterans Affairs.

The study is the largest ever to be conducted using real to collect data about their doctors' behavior using concealed audio recorders. It appears in the April 16 issue of Annals of Internal Medicine and was funded by the U.S. Department of Veterans Affairs.

"What our study really tells us is that the information that patients divulge during appointments about their is critical to address and take into account if we're looking for optimal health care outcomes," said Dr. Saul Weiner, professor of medicine, pediatrics and medical education at UIC and staff physician at the Jesse Brown VA Medical Center, who was lead author of the study.

A goal of the study was to determine if patient-centered decision making—identifying clinically relevant information about a patient's circumstances or behaviors—impacted health care outcomes.

The study recruited 774 real patients who secretly audio recorded their visits with 139 resident physicians at two Chicago VA facilities. The doctors had all agreed to participate in the study but were not told which patients were recording them.

"Incognito audio recording provides accurate information about how doctors practice that you can't obtain any other way," said Alan Schwartz, professor and associate head of medical education at UIC, a methodologist and co-author of the paper.

The researchers developed a coding method to score physicians based on whether they individualized a patient's care plan by taking into account key contextual factors, such as , transportation problems, competing responsibilities, social support and other factors. Inattention to such issues leads to what are called "contextual errors" in patient care.

For example, if a patient had missed a lot of appointments that would be a red flag. In other words, it is something the physician should be asking about because it is clearly interfering with the patient's care.

"If the patient has, for example, a chronic condition like diabetes or hypertension that's going out of control we would say that that's also a contextual issue and probably a sign that something is going on in that patient's life that needs to be addressed," Weiner said.

In the study, the researchers reviewed the patient's medical record and evaluated the recordings to determine if a care plan was patient-centered by answering three questions: Are there contextual red flags? If so, did the physician recognize the red flags and question the patient about contextual factors that could be addressed in a care plan or did the patient volunteer such information? If so, did the physician address the contextual factors in the recommended care plan?

The patients were followed for up to nine months to evaluate their health care outcomes and determine if the original red flag had been partially or fully resolved.

Each participating physician was repeatedly audio recorded until the researchers obtained three encounters with contextual red flags. The final data included 403 encounters with a total of 548 red flags. Among the 548 red flags, 208 contextual factors were confirmed either when physicians probed or patients volunteered information.

When contextual factors were essential to the care plan, physicians made a contextualized care plan 59 percent of the time; 41 percent of the time they did not.

In the cases where the physician made a contextualized care plan, there was a good outcome in 71 percent of the cases and a bad outcome in 29 percent of cases. When physicians did not develop a contextualized care plan, a good outcome occurred in 46 percent of cases and a bad outcome occurred in 54 percent of cases.

Weiner said while it may seem intuitive that if a patient is missing appointments and the physician discovers it's because the patient lost their transportation and refers them to a clinic-supported van service, it will result in fewer missed appointments. "But this is the first study to document an association between contextualizing patient care and patient care outcomes," he said.

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