Differences Between Real & Fake Patients

Each morning this week, I am rounding on a busy inpatient general medicine service in an academic hospital seeing real patients.  Each night this week, I am also studying for the internal medicine recertification exam where I am doing countless MKSAP questions which present the diagnostic and management conundrums of “fake patients.”   While there are a variety of things I could say about the process, one thing is clear- the real patients don’t ever come as neatly wrapped and easy to figure out as the pithy and succinct questions based on fake patients in the prep questions!   Perhaps the most distinct differences are that real patients suffer from real problems that plague real people…and that is of course why one of the most important lessons for our medical students is that being a good doctor is more than just how well you do on a standardized exam.  It is knowing how to mobilize a team and resources to tend to all of these problems in the same patient.   Here are just a few ways in which the real patients we see differ from testable “patients.”

  • Social problems trump medical problems – Many of the patients we see suffer from poor health literacy, lack of insurance, access to safe housing, affordable healthy food, and access to healthcare outside of the hospital that prevents optimal care and treatment of their medical conditions.  Understanding how to bring up and address these problems is equally important to design a customized care plan for a patient that will ensure their most optimal recovery and health outside of the hospital.
  • Caregiver support– Many older patients who are chronically ill are cared for by family members who suffer a lot of stress.  This stress manifests in different ways and sometimes you see that sigh of relief when they come to the hospital since they are in need of as much care and support as their family member.  Arranging home services and providing and ensuring caregiver support is a key part of hospital care these days.
  • Insurance compatibility – Most patients require services that go beyond hospital discharge, such as home IV antibiotics or short-term rehabilitation stays after hospitalization to recover.  In addition, patients often require close follow up after hospitalization. Unfortunately, arranging such things for patients who are uninsured or underinsured is increasingly difficult.  Perhaps this is one thing that we can hope to change with the implementation of the Affordable Care Act- lets at least hope so.  But for now, it’s sometimes a guessing game how to piece together the most logical plan that will also be optimally covered.
  • Medical necessity – These days, patients can’t stay in the hospital to “recover” unless it meets strict criteria for inpatient admission.  This process is audited by private contractors so hospitals are required to follow strict guidelines or face harsh penalties from Medicare.  The challenge is that for a variety of social issues documented above, patients may not be ready to go home (caregiver not ready, patient lacks understanding regarding illness, etc.) but they have to go home or be faced with footing the bill for their stay.   Given that rock and a hard place, it’s a difficult position for any doctor to be in.

Because medicine does change and evolve very quickly, we refresh our medical knowledge every 10 years by testing our clinical acumen through ‘caring’ for fake patients on a written exam.  But, a written exam can only go so far…Given the sea changes occurring on a daily basis in our healthcare delivery system, it is equally important to stay up-to-date on systems-level changes that influence how we can actually provide care for real patients.  After all, both are necessary for good doctoring.

Vineet Arora, MD



  1. Well said. I just did my re-certification exam last week where the patients on paper have rare diseases but classic presentations. In real life, the ROS is often long and there are many confounders which you described well. I mention this because as we rely more on sim centers and standardized patients, we always have to remember that they are not a replacement for learning from real patients and real care. Thanks for insightful comments.

  2. I also find that learners in a primary care setting don’t always recognize that they should adjust the information they are gathering based upon the patient (or family) concerns. Many learners just plow through “the list” of things they need to check off and skip past the subtle openings that patients give to talk abotu depression or anxiety or social concerns, etc. Also, textbooks and standardized patients also don’t prepare learners for how to deal with a family or patient who doesn’t except the diagnosis. I find this a lot in the teenagers who I see with leg pain or headaches or belly pain or “dizziness” who end up having anxiety. All the resources and case scenarios in the world tell you to consider anxiety when things don’t add up, but none of the prepare you with what to do when the parents don’t believe that anxiety is the answer.

    1. actually taking the core IM version -mostly it was an easier date for me to do than HM dates. also wasn’t sure about how to prep for HM since materials not available -MKSAP easy to review though.

  3. Hi Vinny – Great work on the blog and the social media.

    One thing, I don’t follow you on. You write:

    “These days, patients can’t stay in the hospital to “recover” unless it meets strict criteria for inpatient admission. This process is audited by private contractors so hospitals are required to follow strict guidelines or face harsh penalties from Medicare.”

    An admission certainly must meet medical necessity standards or it won’t be paid – are you talking about so called “social admits”?

    When you write “can’t stay in . . ” you make it sound as if there was a prescribed length of stay – and for a Medicare admission there mostly isn’t. As I understand it, Medicare pays for almost all hospital admissions on a DRG basis – a fixed price for the admission that covers all the charges for as long as a patient may need to stay (barring some outlier situations).

    That being the case, I doubt any outside RAC auditor had any interest in how long a patient stays. If the admission was legitimate in the first place, its length is up to you. Maybe your hospital administration cares, but not Medicare.

    1. hi Chris, thanks for your comments– and yes, “social admits” the key is that it did not start out entirely social – patients (esp seniors) come initially for a medical issue but it clears up quickly but have unresolved social issues…and sometimes that clear up occurs during their time of observation before they are technically “admitted” so its confusing and then they need to be “admitted” so its an issue. While some part of medical necessity assessment after admission is of course likely driven by institutional pressures everywhere, there is also a lot of fear of the RAC in the trenches! I understand the prospective payment point you raise so maybe the RAC fear is exaggerated? Hard to know – I haven’t been able to find any good information on the RAC process and so forth – at least I haven’t seen a good summary of it for clinicians. Now that I just finished service and took the boards, I can definitely say that even if you have a level of familiarity with health policy, its still difficult to figure out the forces at play for any given patient situation..but you’ve definitely given me something to think about though!

      1. Fortunately (or unfortunately, if you are in the revenue
        department), we now have subsequent observation visit codes for
        just this situation. On occasion, I have had a patient in the
        hospital for 3 or 4 days in observation status, just in order to
        assemble a reasonably safe discharge plan for the patient, even
        though they never met inpatient criteria. I’ve probably only done
        this two or three times ever, but sometimes it’s the right

  4. Awesome post, sometimes it’s not the medicine that’s hard but the psychosocial aspects which most of the time affects our health much more.

    Smoking, Drinking, Drugs, Environmental exposures probably contribute a much larger burden of disease to everybody than the rare zebras we spend our time studying about.

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