Eighteen SPs made 298 visits to 152 physicians in Sacramento (n
=101), San Francisco (n =96), and Rochester (n =101); six physicians saw only one SP. Two hundred visits (67 percent) were to general internists and 98 (33 percent) to family physicians, while 201 (67 percent) were to male physicians and 97 (33 percent) to female physicians. The average age of participating physicians was 46 (SD=9.8, range 30–81); physicians had practiced medicine for an average of 15 years (SD=9.5, range 2–47). Physicians returned 99 percent (296) of the detection faxes.
Prevalence of Detection
In 15 (5 percent) visits, physicians responded “yes, definitely” that they conducted an SP visit in the last 2 weeks, suspected the SP before or during the visit, and accurately identified the SP. Using a more liberal definition (yes definitely, yes probably, or uncertain that they had seen an SP over the past 2 weeks), the suspicion rate was 23.8 percent. In two visits, physicians misidentified real patients (one male, one black female) as SPs ().
Detection Rates, Timing of Detection and Physicians' Perception of Impact of Detection on SP Care Based on Detection Fax 2 Weeks Following Visit
Most common reasons for detection included “something about the way the person behaved during the visit” (45 percent), and “having a closed practice” (35 percent). Written comments explaining suspicion before or during the visit included: “The presentation was too classic,” “She seemed to be easily satisfied with the explanation I gave, unlike my other patients,” “too picture perfect, wouldn't do blood work.” Explanations for suspicion after the visit included comments such as “The request for medical records was returned as unknown,” or “Didn't follow-up with [behavioral health/nerve conduction/blood work].” “My staff told me” and “closed practice” were given as reasons for suspicion both before and after the visit. SPs mildly demurred requests for blood work or additional tests, saying they were pressed for time and would return to the office later. Physicians accepted SPs explanations that they had seen a gynecologist in the past year and in no instance applied pressure for gynecological exams.
Predictors of Detection
We operationalized detection in two ways. The “degree of suspicion” (DOS) measure categorized physician detection fax responses into three groups: high suspicion visits (physician responded “yes, certainly” or “yes, probably” on detection fax; HSV; N =57, 19 percent), moderate suspicion visits (physician responded “uncertain” or “no, probably not” on detection fax”; MSV; N =63, 21 percent), and no suspicion visits (physician responded “No, certainly not”; NSV; N =176, 60 percent), regardless of timing or accuracy of suspicion. “Meaningful detection” was defined as occurring if the physician responded “yes certainly” or “yes probably” that they suspected an SP visit, the SP was identified accurately, and suspicion was aroused before or during the visit. The assumption underlying the meaningful detection measure was that suspicions aroused before or during the visit would be more likely to influence treatment outcomes.
Meaningful detection occurred in 38 encounters (12.8 percent). Physicians rated these encounters as less realistic than other suspected visits (mean 1.82 versus1.39, p<.009). Physicians were marginally more likely to say there were minor or major differences in how they treated the meaningfully detected SPs (p =.057). However, there were no significant differences in prescribing, referral, or follow-up when physicians who reported treating the detected SPs “just like real patients” were compared with those who stated they “treated detected SPs differently” (p >.20).
Meaningful detection occurred in 1.69 percent (1/59) of visits at an HMO, 12.3 percent (9/73) of visits at solo practices, 16.1 percent (20/124) of visits at group practices, and 20 percent (8/40) of visits at university-affiliated practices. Having a closed practice was marginally associated with meaningful detection (p<.10, data not shown). In regressions that grouped suspected and detected visits together (N =70), practice setting (but not having a closed practice) was significant (F =2.90, p<.05); physicians practicing in HMOs were less likely to detect visits than physicians in solo practices.
Effect of Detection of Physician Behavior
Random effects logistic regressions analyzed whether detection affected the primary outcome measures of the SIP study: prescribing, referrals, or follow-up. Regressions were performed separately for DOS and meaningful detection as well as for each of the three physician behaviors (), controlling for role, actor, physician, and contextual variables. With the DOS measure, high suspicion SP visits but not moderate or no suspicion visits were associated with a significantly greater likelihood of referral (p<.05). There was a marginally significant main effect of meaningful detection on mental health referrals (p<.10). Detection was not associated with prescribing or follow-up.
Table 2 Mixed Effects Regression Controlling for Meaningful Detection or Degree of Suspicion Measure, Request, Condition, Request × Condition Interaction, Physician Gender, Speciality, Practice Type, Age Group, Number of Patients per Half-Day Session, (more ...)