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New Emphasis on Customer Service in Medicine

“Secret shoppers” help improve the real patient’s experience

En español | A middle-age woman flips through dog-eared magazines in the teeming waiting room of a doctor’s office. A man in his 60s arrives at a hospital emergency room describing the symptoms of a possible heart attack. And a patient recently diagnosed with breast cancer telephones a busy urban teaching hospital, confused about which specialist she should consult.

Although these sound like real medical encounters, they’re not: The patients are fake. Each is a “mystery shopper” hired to report back to management about whether their experiences meet the standards of the hospital or medical practice that hired them. Their work is aimed at improving your experience in the hospital, clinic or doctor’s office.

For more than half a century, mystery shoppers, also known as secret shoppers, have been fixtures in retail, hotel and banking businesses, surreptitiously scoping out how customers are being treated, where service falls short and why patrons may be fleeing.

Now, as competition for patients has intensified, customer service has assumed new importance in health care, too, and the ranks of mystery patients have swelled—although statistics documenting their number and use are sketchy at best.

How it works

Medical mystery shoppers generally focus on customer service rather than clinical skills, and they operate in much the same way. Most fill out detailed checklists and submit descriptions of encounters with everyone from telephone schedulers who are sometimes rude, to receptionists who ignore them to pursue long personal conversations, to doctors who are abrupt or who fail to wash their hands.

Some hospitals, among them Massachusetts General Hospital in Boston, deploy their own employees instead of hiring outsiders. Either way, the use of medical mystery shoppers is usually designed to “improve customers’ experiences so that’ll improve the bottom line,” says John Swinburn, executive director of the Dallas-based Mystery Shopping Providers Association, which has 150 member companies in the United States. “It’s very much about quality control.”

Swinburn estimates that revenue from the total mystery shopping industry will approach $1.5 billion this year. No one knows what percentage of that money is from medical shoppers. But, he says, “anecdotally, there does appear to be quite a lot of recent interest in medical shopping.”


The American Medical Association, the nation’s largest doctors’ group, has considered the practice of medical mystery shopping, but has not taken an official position.

Swinburn and officials of mystery shopping companies say shoppers must be careful to avoid diverting care from those who really need help.

That possibility is of paramount concern to Richard C. Frederick, M.D., a veteran emergency room physician who opposes the practice, which he regards as inherently dishonest and bad for morale because it breeds mistrust.

“Truthfulness is a core medical issue,” says Frederick, vice chairman of the emergency department at the University of Illinois College of Medicine at Peoria. Mystery patients may tie up scarce resources that real patients need, he says.

“I think that’s particularly unconscionable,” says Frederick, who teaches a course in medical ethics. He says in his emergency room “we have 42 beds and it’s not unusual for us to have 60 to 70 patients” waiting to be seen.

Nancy Berlinger, deputy director of the Hastings Center, a bioethics research institute in Garrison, N.Y., says she finds the use of mystery patients less problematic in settings outside of hospitals, such as doctors’ offices. But Berlinger has reservations about the practice because it is based on deception.

“Are we trying to play a ‘gotcha’ game or improve health care?” she asks. “And is there no other way we can understand what is going on?"

Scripts to follow

Barbara Gerber thinks there is not.

She is the founder and president of Devon Hill LLC, a La Jolla, Calif., firm that specializes in medical mystery shopping. Gerber, who sometimes sports disguises including a wig, has undergone lab tests and a mammogram. In her work for hospitals and medical practices from Montana to New Jersey, she gives detailed scripts to the two dozen people she regularly hires as sham patients and may send three people in to do a “shop” of the same place.

Gerber said she got the idea for medical mystery shopping after a bad experience as a hospitalized patient in the mid-1990s. She advises hospitals to alert their staffs in advance that mystery patients will be visiting “in the next weeks or months.”

“Once you tell the staff you’re doing it, it’s not really deceptive anymore,” she says.

While Gerber says that her shoppers do not routinely disclose who they are because it creates too much consternation, Jodi Manfredi, manager of health care client services with the San Diego-based firm TrendSource, said her contractors may reveal what they are doing if a patient comes in with an urgent problem.

Unlike Gerber, Manfredi said her contractors do not focus on care, but rather on experiences with the staff. “We focus on interpersonal skills, on doctors’ listening skills and whether they seem rushed,” she says. “Many patients will leave a practice because of the experience with the front office staff.”

Shoppers’ pay

Manfredi, who specializes in shopping dental and cosmetic medical practices, said mystery shoppers are paid anywhere from $25 to $200 per session, depending on the length or complexity of their assignment; hospitals and medical practices typically pay between $20,000 and $100,000 for a series of mystery shopping services, which include recommendations.

One hospital’s experience

At Beth Israel Deaconess Medical Center, a Harvard University teaching hospital in Boston that recorded nearly 700,000 outpatient visits last year, eight secret shoppers regularly assess staff performance by posing as patients on the telephone and in visits to its 51 waiting rooms.

The center employs its own shoppers, including those who telephone the hospital and have more than 100 scenarios they use—posing as a 55-year-old woman calling to make an appointment for a bone density test, a jogger experiencing heart palpitations who needs to see a cardiologist, and a woman newly diagnosed with invasive breast cancer who says, “I’m not sure what I’m looking for, can you help me?”

“We want to provide the kind of care each of us would want our own families to receive,” says Mark Zeidel, chief of medicine at the hospital and a champion of the program, which, he says, has “engaged our staff” and improved efficiency. “It is amazing how often calls get dropped and people can’t find the right person,” he says.

Shoppers get results

Hospital officials point to the tangible improvements they say are largely attributable to the use of mystery shoppers: Appointment waiting time has been cut from an average of 12 days to five, and telephone customer service ratings have improved. Waiting room ratings increased from 78 percent in 2007 to 90 percent in 2009; Zeidel says visits to outpatient clinics have increased 35 percent since the program was launched.

Sherry Calderon, manager of ambulatory services at Beth Israel, says: “I really feel like this kind of regular checking has driven change here that nothing else has.”

Sandra G. Boodman, a former staff writer for the Washington Post, writes regularly about health for the Post and Kaiser Health News.