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

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.

Northern New England.

Fifty-nine primary care physicians who were accepting new patients and were participating in a study of early detection and prevention of cancer.

Cross sectional; observations of patient visits.

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.

Actresses reported the components of the general physical examination and the cancer-related "checkup." Most interactions were audiotaped.

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.

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.