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The intervention of announcing a forthcoming mystery shopper audit was conducted three weeks before the second audit. A representative of the research project visited the clinics in the treatment group one by one to announce the mystery shopper audit. The announcement was made in person by presenting a letter containing information about a current project at Shandong University (see Fig. 3 for an English translation of the project description letter in Appendix E). The project is about quality evaluation of primary care services in Jinan, particularly service, professionalism, and adequacy of treatment. The clinics were informed that an anonymous patient would visit the clinics and collect information about the treatment decision and then evaluate the quality of care. To enhance the credibility of the research project, we offered the clinics three ways to receive feedback from the quality assessment: publicly available feedback (results published on the Shandong University website), feedback in private (results only received by the clinic) or no feedback.Footnote 5 The representative read the project description with the physician and ensured that the physician understood the project. In addition, Qilu Health Science Center, affiliated with Shandong University and one of the largest public hospitals (Qilu Hospital) in Jinan, provided an endorsement letter to support the project (see Fig. 4 for an English translation of the endorsement letter in Appendix E). The representative presented the endorsement letter to the physician and left both the stamped project description and the endorsement letter at the clinic.

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The mystery shopper audit has been used in the health care domain for decades and has been developed into a scientifically sound experimental method that provides unique and valuable knowledge to society in both developing and developed countries (see for example [16, 35, 53, 54]). The use of deception is controversial in science, and there is no unanimous classification across disciplines. The main ethical dilemma in our study is that the healthy pseudopatients provide incorrect information to the physician when describing their state of health. However, following the ethical analysis of Rhodes and Miller [17], it can be ethically justified as long as confidentiality of research subjects is ensured, risks to the research subjects are minimal and the research is potentially valuable to human knowledge. 041b061a72