Hospitals and health clinics are increasingly turning to these undercover patients to grade the health care experience being offered.
Now the ethics council of the American Medical Association is pressing the doctors group to endorse such practices. AMA delegates are expected to vote on the proposal, along with dozens of others, during their five-day meeting beginning Saturday.
Some doctors are outraged at the idea.
Dr. Richard Frederick, of the University of Illinois College of Medicine in Peoria, called it "official deceit" that could have disastrous consequences. He wrote a commentary in May's edition of Virtual Mentor, the AMA's online ethics journal.
"In some instances sham patients have presented to overcrowded emergency rooms with chest pain," he wrote. "How could the hospital administration defend this exercise to someone who suffers an adverse outcome while waiting his turn behind the person who is only pretending to be sick?"
The proposal to the AMA does include restrictions that address that and other concerns. The recommendation is to have a system that: makes sure fake patients don't interfere with treating real ones; gives doctors a heads-up that undercover patients might be visiting; and ensures that bad reviews aren't used to punish doctors.
And Dr. James Loden, writing an opposing view in the online journal, says undercover patients are neither "devious" nor "spying."
"Employees, including doctors, are paid to do specific tasks; if they choose to perform at a level that is less than acceptable, they need to improve or find other jobs," he wrote.
Loden, an ophthalmologist at Nashville, Tennessee-based Loden Vision Centers, started using undercover patients to evaluate his business two years ago.
The sham patients showed "that I consistently left the examining room without asking clients whether they had any questions," Loden wrote. He also learned that some employees didn't always introduce themselves or explain why tests were being performed.
The idea was to help the centers compete with others offering similar services including Lasik surgery. The centers have worked to eliminate the revealed shortcomings and Andy Patrick, Loden's chief operating officer, said client-to-client referrals have since increased.
"We don't always like what we hear, but it makes us get better and better," Patrick said.
Erickson-Trump, 37, works for Perception Strategies, an Indianapolis-based company that provides undercover patients to health systems in about 25 states. Her preferred job title is "mystery shopper," a service more familiar in the retail and food industries.
Brooke Billingsley, vice president of the company, said that when asked to evaluate a doctor's skills, the firm often tries to use undercover patients who really need a specific test, such as a mammogram.
When a hospital wants its emergency room evaluated, Billingsley said sometimes she'll schedule a fake patient with a real medical problem, such as pneumonia symptoms.
Occasionally, undercover patients have been asked to undergo invasive tests that reveal a surprise ailment, she said.
"Health care mystery shopping is so unique," Billingsley said. "It's just not like going and getting a Happy Meal."
Erickson-Trump said one memorable "shop," as she calls each job, was to a dentist's office, where she had her teeth cleaned and X-rayed.
The receptionist offered her gourmet coffee and the dental chair had a neck massage pillow, she recalled. "I was so surprised at the good treatment ... that I ended up making them my permanent dentist."
The MRI was also memorable "because it wasn't my favorite," she said.
Erickson-Trump said she exaggerated some minor back pain for that test, which requires patients to lie still inside a noisy cylindrical scanner while internal images are made.
She had no complaints about the MRI technician, but the office staffers didn't explain enough about what to expect.
"That's a very scary procedure" that can be claustrophobic, Erickson-Trump said.
On other jobs, she's been asked to evaluate how well the doctor listened, whether logical referrals were made, and how long she was kept waiting. "You can show up and sit for hours on end sometimes, and you're not sure why," she said.
Henry Ford Health System spends $35,000 to $60,000 a year on undercover patients to identify just that kind of problem at its Detroit area clinics.
"Industry research shows that the patient perception of quality of care is based upon their whole experience," and not just on their doctor's medical skills, said Henry Ford spokeswoman Rose Glenn.
Awards are given to staffers who get high scores, while education and customer-service training is given to those who fare poorly, she said.