The ethical problem of false positives: a prospective evaluation of physician reporting in the medical record

• Published in: Journal of medical ethics Vol. 28; no. 5; pp. 291 - 294
• Main Authors: Dresselhaus, T R, Luck, J, Peabody, J W
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group Ltd and Institute of Medical Ethics 01.10.2002; BMJ Publishing Group; BMJ Publishing Group Ltd; BMJ Publishing Group LTD; BMJ Group
• Subjects: Benchmarking - methods; Bias; California; Cardiovascular disease; Company business management; Deception; Documentation; Ethical aspects; Ethics; Ethics, Clinical; Ethics, Medical; Evaluation; False information; False negative errors; False positive errors; False Positive Reactions; Forms and Records Control - standards; Gold standard; Health care quality; Humans; Internal medicine; Management; Medical care; Medical conditions; Medical diagnosis; Medical ethics; Medical professions; Medical records; Medical Records - standards; Methods; Original; Patient Simulation; Physical examinations; Physicians; Practice; Primary Health Care; Prospective Studies; Quality Indicators, Health Care; quality of care; Quality of Health Care; R&D; Research & development; ROC Curve; Studies; United States; California; United States; Empirical Approach; Health Care and Public Health
• ISSN: 0306-6800; 1473-4257; 1473-4257
• DOI: 10.1136/jme.28.5.291

Objective: To determine if the medical record might overestimate the quality of care through false, and potentially unethical, documentation by physicians. Design: Prospective trial comparing two methods for measuring the quality of care for four common outpatient conditions: (1) structured reports by standardised patients (SPs) who presented unannounced to the physicians’ clinics, and (2) abstraction of the medical records generated during these visits. Setting: The general medicine clinics of two veterans affairs medical centres. Participants: Twenty randomly selected physicians (10 at each site) from among eligible second and third year internal medicine residents and attending physicians. Main measurements: Explicit criteria were used to score the medical records of physicians and the reports of SPs generated during 160 visits (8 cases × 20 physicians). Individual scoring items were categorised into four domains of clinical performance: history, physical examination, treatment, and diagnosis. To determine the false positive rate, physician entries were classified as false positive (documented in the record but not reported by the SP), false negative, true positive, and true negative. Results: False positives were identified in the medical record for 6.4% of measured items. The false positive rate 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 false positive rate ranged from 0.098 to 0.397. Conclusions: These data indicate that the medical record falsely overestimates the quality of important dimensions of care such as the physical examination. Though it is doubtful that most subjects in our study participated in regular, intentional falsification, we cannot exclude the possibility that false positives were in some instances intentional, and therefore fraudulent, misrepresentations. Further research is needed to explore the questions raised but incompletely answered by this research.