The ethical problem of false positives: a prospective evaluation of physician reporting in the medical record
- 1Veterans Affairs San Diego Healthcare System, University of San Diego, California, USA
- 2University of California Los Angeles School of Public Health and the Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, USA
- 3Institute for Global Health, University of California, San Francisco Veterans Affairs Medical Center, and University of California, Los Angeles School of Public Health, Los Angeles, California, USA
- Correspondence to: Dr J W Peabody, San Francisco Veterans Affairs Medical Center, c/o Institute for Global Health, University of California, San Francisco, 74 New Montgomery St, Ste 508, San Francisco, CA 94105, USA;
- Accepted 11 March 2002
- Revised 12 February 2002
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.