Connoisseurs of care? Unannounced standardized patients' ratings of physicians

Background: Patient satisfaction surveys can be informative, but bias and poor response rates may limit their utility as stable measures of physician performance. Using unannounced standardized patients (SPs) may overcome some of these limitations because their experience and training make them able judges of physician behavior. Objectives: We sought to understand the reliability of unannounced SPs in rating primary care physicians when covertly presenting as real patients. Study Design: Data from 2 studies (Patient Centered Communication [PCC]; Social Influences in Practice [SIP]) were included. For the PCC study, 5 SPs made 192 visits to 96 physicians; for the SIP study, 18 SPs made 292 visits to 146 physicians. SPs visits to physicians were randomized, thus avoiding mutual selection bias. Each SP rated 16 to 38 physicians on interpersonal skills (autonomy support: PCC, SIP), technical skills (information gathering: SIP-only), and overall satisfaction (SIP-only). We evaluated SP evaluation consistency (physician vs. total variance p), and SPs' overall satisfaction with specific dimensions of physician performance. Results: Scale reliability varied from 0.71 to 0.92. Physician rhos (95% confidence intervals) for autonomy support were 0.40 (0.22-0.58; PCC and 0.30 (0.14-0.45; SIP); information gathering rho was 0.46 (0.33-0.59; SIP). Overall SP satisfaction rho was 0.47 (0.34-0.60; SIP). SPs varied significantly in adjusted overall satisfaction levels, but not other dimensions. Conclusions: These analyses provide some evidence that medical connoisseurship can be learned. When adequately sampled by trained SPs, some physician skills can be reliably measured in community practice settings.