Incognito Standardized Patients to Assess Physician Awareness and Capacity to Recognize Primary Syphilis Presentation...

Primary syphilis is frequently undertested in clinical settings due to its protean presentation. China is experiencing a mass syphilis resurgence, but medical community knowledge of syphilis remains low. We assessed clinical performance of Chinese sexually transmitted infection (STI) physicians using data collected by "incognito" or standardized patients (SPs).

SPs presented cases of postprimary syphilis to physicians who consented to visits in advance but were not told the timing. SPs reported details on diagnostics and examinations performed by the physician. Logistic regression models identified predictors of performance metrics, adjusting for HIV status and sexual orientation of presented cases.

One hundred twenty-three visits were conducted with 41 physicians. Physicians recommended syphilis testing in 84.5% of visits and performed at least 2 of 5 recommended clinical indicators in 31.7% of visits. Physicians were less likely to offer syphilis testing to patients with HIV, whether presenting as men who have sex with men (odds ratio [OR], 0.06; 95% confidence interval [CI], 0.01-0.57) or as straight men (OR, 0.13; 95% CI, 0.03-0.61). Those working >40 h a week were less likely to offer testing (OR, 0.3; 95% CI, 0.09-1.01), and those older than the median age were less likely to perform a thorough exam (OR, 0.34; 95% CI, 0.14-0.83).

Chinese STI physicians frequently test patients for syphilis but are less likely to conduct thorough physical examinations. The undertesting of patients with HIV exposes missed opportunities to address the HIV/syphilis syndemic. Future trainings must emphasize the public health importance of dual screening and address physician concerns about occupational HIV exposure.