The periodic health examination provided to asymptomatic older women: An assessment using standardized patients

Objectives: To describe physical examination and cancer prevention services provided by primary care physicians in response to the request for a 'checkup' by an asymptomatic 55-year-old woman seeking to establish ongoing care; to assess the effects of two interventions (education and office organization) intended to improve these services; and to assess the feasibility of using 'standardized' patients to evaluate physician responses to such a request. Setting: Northern New England. Participants: Fifty-nine primary care physicians who were accepting new patients and were participating in a study of early detection and prevention of cancer. Design: Cross sectional; observations of patient visits. Interventions: Actresses trained to portray a specific patient role ('standardized' or 'simulated' patients) visited each physician once. Physicians were blinded to the simulated patients' true identities. Measurements: Actresses reported the components of the general physical examination and the cancer-related 'checkup.' Most interactions were audiotaped. Results: Fourteen physical examination components were measured, ranging from assessment of vibratory sense (5%) to measurement of blood pressure (98%). Provision of 10 services recommended by the National Cancer Institute to standardized patients included 16% being advised to reduce dietary fat; 53% to do monthly breast self-examination; 74% to quit smoking; and 89% to obtain a mammogram. Physicians spent from 5 to 60 minutes with the patients. Two physicians did not charge, whereas others charged from $24 to $108. Study group assignment was not associated with statistical differences in provider performance. Two standardized patients (3%) were detected by physicians. Audiotapes were used to verify the actresses' ability to replicate their scenario (consistently repeat their performance) and to verify physician performance. Conclusions: Physician responses to an identical patient request varied widely in terms of time spent with the patient, the services provided, and the cost of the visit. Using standardized patients is a feasible method for assessing physician performance of the periodic health examination while controlling for case mix.