Medical impostors: Redesigning IDs a matter of security, efficiency and patient care

It’s the middle of the COVID-19 pandemic and you’ve just been admitted to hospital. A flurry of personnel in scrubs and personal protective equipment (PPE) flocks in and out of your room. They are a blur of masks, face shields and gowns. Some introduce themselves, but you can’t process what they’re saying. You try to catch a glimpse of their badges to discern the face, name and profession, but the tiny, faded letters and pictures escape your sight. However, one person stands out in your mind: a nurse who struggles to insert an intravenous (IV) line. You’re a bit surprised, but you chalk it up to an off day, inexperience or that you have difficult veins. Months later, you’ve returned home and are back to 95 per cent of your full health when you receive a call informing you that you’ve been treated by an imposter nurse during your recent admission. Your mind begins to race as you consider what could have and did happen: how the nurse that struggled to place your IV left your arm marked with bruises

That scenario is inspired by real life examples of medical impersonation that have occurred throughout Canada and around the world (see Table 1).  While there are countless instances where faux practitioners established their own independent physical and/or online practice, such as when a Toronto resident advertised themselves as a cosmetic surgeon, this article will focus on impersonation in recognized institutions like hospitals and clinics. The situation outlined above raises three questions:

1)    What is the prevalence of medical impersonation?

2)    What are the elements (factors and consequences) that allow medical impersonation to happen in the first place?

3)    What are the potential solutions to deter and make medical impersonation more difficult?”.

Though impersonations seem to be relatively rare, there does not appear to be any formal statistic on its rate beyond the unregistered practitioners lists that provincially recognized professional associations such as the College of Physician and Surgeons of Ontario (CPSO) publish. Even then, these lists contain limited details regarding the circumstances; the most comprehensive sources of information we could find were largely from news agencies with inconsistent levels of detail.

People have the power to verify the status and registration of health-care teams through each professional order, such as searching for your nurse through Québec’s Ordre des infirmières et infirmiers du Québec (OIIQ). As you can imagine, this would be a cumbersome process as patients receive visits from as many as 18 different hospital personnel per hour; even in cases where patients are suspicious of select individuals, these databases are likely not common public knowledge. There is the added complexity of provincial differences in protected titles within health care and the variety of medical professions that have nuanced, unclear and/or contested scopes of practice. For example: in the realm of sports, exercise and rehabilitation, “kinesiologist” is protected in Ontario but not in Québec and most would have difficulty clearly defining and differentiating the following:

• Occupational therapist
• Personal trainer
• Kinesiologist
• Physiotherapist
• Athletic/sports therapist
• .Among physicians: Sports medicine; Physical medicine and rehabilitation (PMR); Orthopedic surgeon

Health-care systems rely on a level of inherent trust from the public, and health-care impersonation (among many other factors such as previous negative personal or historical experiences with the medical system, etc.) erodes this trust and renders health-care delivery more difficult. In addition, this diverts precious resources (salary, funding, opportunities, etc.) away from certified and qualified professional colleagues.

Among the 16 cases in Canada and internationally mentioned in our research, the most common factors in impersonations were:

1. Stolen identity, accessed original or forged documentation/materials: Individuals were able to acquire certificates and registration information that were falsely created by themselves or diploma mills (where an estimated half of new United States PhDs are fake) or received original documentation from official certifying and regulatory bodies.
2. Incomplete training and/or training in another health-care profession: Having previous experience in the field helps impersonators limit obvious medical errors.
3. Impersonation at multiple institutions and/or impersonation after being caught: Oftentimes, individuals are caught and continue to work in either the same location or in other institutions.
4. Improper verification of CV/documentation: During recruitment and onboarding, administration and staff fail to identify irregularities and/or verify the validity of an impersonator’s dossier.
5. Psychiatric and/or intellectual disability:y: Individuals can be declared unfit to stand trial and have their cases dismissed due to their mental state.
6. Clothing: white lab coat, stethoscope, etc.: The appearance of a health-care worker is easy to simulate and the inherent trust that patients and staff have make it easy for impersonators to blend in.
7. Online impersonation: Social media, etc.
8. Staff shortages: The need for health-care workers both before (a 2010 study found that Canadian hospital nurse turnover rate was at 19.9 per cent) and exacerbated by the pandemic puts undue pressure on staff to quickly review applicant portfolios and fill gaps in care. It encourages impersonators to fill this gap for prestige, monetary gain or due to a sense of personal duty to help the public in a time of crisis. The president of the Canadian Union of Public Employees Local 204, Debbie Boissonneault, has stated “[Hospitals] should be having regular staff. They shouldn’t have these uncertified [workers] coming from all over. They really need to beef up their staff so this doesn’t happen.”
9. Whistleblower(s) fears: Potential reprisal and cultural, organizational and individual health-care factors prevent health-care workers from identifying both suspected imposters and/or malpractice. They may feel like they are “working against the team” and will cover for them instead.

Among the consequences in the 16 cases we examined, were fines, jail time, loss of employment, etc. (in 2019, Australia doubled the fines and added the possibility of three years prison time for impersonators of registered health practitioners); implementation of security practices, re-reviewing employee files, changing governing policies and protocols, etc.; and claim(s) of patient harm.

One of the simplest solutions for health-care organizations is to redesign employee ID badges. Health-care already places great importance on identifying patients and families, for the sake of greater communication, therapeutic relationship development, and delivery of high-quality care, so why not the same for health-care professions? Patients wish to know the roles of members of their health-care team and 88 per cent of patients say it is very important to know the training level of their emergency department doctor (medical student vs. resident vs. attending doctor). These are a crucial element of security that are often overlooked and that can also be repurposed at an institutional level to improve patient care and staff satisfaction and efficiency.

We explored health-care ID card designs of 15 sample IDs from various hospitals across three provinces in Canada (Fig. 1) and found some elements that should be standardized across the country:

1. Photo: This should focus on the face and limit non-crucial identifying elements (a person’s shoulders/chest). A sleeve or overlaminate should be considered to protect the integrity of the photo from cleaning (for infection control) and/or friction. This overlaminate can use holographic pattern or other security features to deter fraud. Allowing for easy visual identification from a distance will also allow for all institutional IDs to be used as a portrait on PPE. Laminated headshot portraits fixed to the outside of a health-care worker’s PPE humanize the alienating appearance of masks. Based on feedback from the use of more than 3,700 PPE portraits through PPE Portraits Canada, having the hospital ID badge become the de facto PPE Portrait has the advantage of reducing the self-consciousness of health-care workers and allows for PPE portraits to be commonplace during both pandemic and non-pandemic times.
2. Orientation: A vertical badge orientation is optimal for a larger image of the health-care professional while maintaining the essential elements of a hospital ID card.
3. Badge buddy: This is an additional identifier that hangs below the ID badge and is solely dedicated to the person’s title and/or position, with easy identification through colour-coding. These decrease misidentification of health-care professionals’ positions and roles as well as workplace biases and stereotypes, leading to greater inclusivity. For example, female emergency physicians are at an increased risk of feeling undervalued when having to specify their role and female residents are more likely to be misidentified – a badge buddy reduces gender-based aggressions. These badges can educate patients regarding the range of professions within their interdisciplinary care, allowing for greater recognition and appreciation toward all health-care workers. In a similar vein, a pilot study looked at displaying the health-care professional’s name and role on scrub caps/headwear in the operating room (OR). This inexpensive intervention was found to improve teamwork and communication within the OR; badge buddies likely would have similar benefits in other environments and situations where teams aren’t as familiar with one another (such as with rotating trainees) and/or whenever PPE is used.
4. Font size, colour, and bolding: This allows for contrast and emphasis on the most important information on the card. In some cases, the person’s last name would be bolded and/or larger than the first name and titles would be in a different color or be highlighted. Institutions should consider selecting a colour palette that accommodates for colour blindness.
5. Expiration date: This is an important detail for temporary workers and trainees that rotate frequently.
6. Multilingual: Necessary for greater local inclusivity.
7. Humanizing touches: One of the hospital IDs had a heart printed onto it, indicating an institutional philosophy (likely care being given from the heart). Though non-empirical in nature, one doctor felt that “Hello my name is” badges helped humanize colleagues in the emergency department, an environment where staff are often unfamiliar with each other and short on time and resources.
8. Removal of other element of unknown utility: hospital addresses; QR/bar codes; including both the hospital name and logo in addition to the affiliated-university’s name and logo.

Fig. 1B shows additional elements that we would include in our ideal hospital identification:

1. Pronouns: Gender-inclusive pronouns placed next to a health-care worker’s name. In addition to helping health-care professionals themselves, this can also help gender diverse patients and is a step forward to inclusivity. One example is Indiana university school of medicine offering pronoun badges.
2. Back of ID: This is often left blank but can be used for:
   1. Important hospital codes and/or telephone numbers.
   2. Fire safety RACE/PASS (Rescue/Alarm/Contain/Extinguish & Pull/Aim/Squeeze/Sweep) that summarize the steps to take if a fire is discovered and how to operate a fire extinguisher.
   3. Information that may be part of an institutional campaign to enact practice/methodology change or that may be unit-specific such as McGill’s “True Colours” campaign distributed lanyards designed with the rainbow flag and pronoun language cards or a suicide warning signs card based on the Columbia Suicide Severity Rating Scale that assesses suicide risk.
   4. Streamlining through programmable IDs: Oftentimes, HCWs require various badges or cards to access different areas or services. Having a programmable ID badge that carries multiple functions is not only more ideal but can help significantly lower the carbon footprint of ID badges with an estimated savings of 50g of CO₂ per ID card. Other benefits of single-sign on (SSO) badges include a cost-savings of more than $92,000 per hospital per year due to time saved by physicians and nurses; real-time location services to allow institutions to locate staff quickly and efficiently and limit delays in patient care; and a time savings for staff when a card combines parking, scrub, cafeteria, etc services.

One concern would be that if a card is lost and/or stolen, it would potentially give someone unfettered access. A robust, quick, and non-judgemental method of reporting, de-activating, and replacing a missing ID must be put in place. Moreover, in order to reduce costs to implement these changes, hospitals in a region should consider collaborating with one another to achieve volume discounts.

Though simple in concept and logistically complicated, redesigning health-care IDs can be one of many small steps to improve a systemic issue in health care while potentially saving costs.

The authors are executive members of Personal Protective Equipment (PPE) Portraits Canada (PPC), a student and volunteer-based organization that provides smiling headshot portraits to humanize health-care settings.