Physicians should be concerned about malingering

Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs. The word “malingering” comes from the French word “malinger” meaning “poor or weakly” as these are the characteristics feigned or exaggerated by the malingerer. Malingering has been documented as far back as in the Bible when David feigned insanity to escape a king he was afraid of. There have many books written about malingering and thousands of research articles written about it.

Malingering and/or exaggeration for external gain are both common in society. For example, 18 people were arrested recently in New York State for workers compensation fraud. At a minimum, when one adds up how much money the state of New York paid out on fraudulent claims in these cases it comes to at least $243,000. To have pulled this off, it required physicians and other health care professionals to have signed off disability claims forms. While malingering can manifest by verbally feigning or grossly exaggerating symptoms, some people go through much greater lengths to malinger. For example, last week a California psychologist was accused of faking her own rape by splitting her own lip with a pin, scraping her knuckles with sandpaper, having her friend punch her in the face, and wetting her pants to give the appearance she had been knocked unconscious. The motive? To convince her husband to move from the neighborhood.

On 12/11/12, a Virginian woman was charged with fraudulently claiming that she had cancer to raise money from sympathetic supporters for personal reasons. She’s not the first to have done so. Earlier this year, a man was arrested for fraudulently obtaining almost a million dollars in sympathy donations by claiming he had cancer.

Physicians and other health care professionals should be very concerned about exaggeration and malingering because they are enabling the process if they are not taking reasonable steps to detect it and address it. Many health care providers do not address this topic in their exams or clinical notes for several reasons, included but not limited to, a) not wanting to deal with the “hassle” of identifying the problem, such as confronting someone (which can be uncomfortable) and/or dealing with complaints, b) extreme patient advocacy, c) not wanting to believe that some patients distort their presentations for external reasons due to an overly trusting worldview, and d) concerns that identification of this problem will harm the patient in some way (e.g., loss of benefits).

While false positive identification of malingering and exaggeration is a legitimate concern (of which there are many ways to address this in the scientific literature), not identifying it can harm other patients and society in two main ways. First, malingering and exaggerated presentations rise insurance costs for all citizens because the insurance company has to spent thousands of dollars on services/treatments that need not be provided or at least not to the extent that they were provided. Most importantly, however, patients with more genuine needs have delayed access to health care services because appointments are taken by people who are trying to game the system and/or who do actually need that particular service. Perhaps, for example, the patient exaggerating pain and other physical symptoms is actually in need of psychotherapy services they have never received instead of Fentanyl patches, hydrocodone, and a TENS unit.

While a public forum is clearly not the appropriate place to discuss malingering and exaggeration detection strategies, healthcare providers need to go to greater lengths to consider and assess response bias in their evaluations or at least refer to someone who will. There are many texts, research articles, conference workshops, and invited speakers that can be used as sources to provide healthcare providers with more information on the topic. A recent article written by myself and some colleagues discusses how to provide feedback about malingering and exaggeration to the patient.

Ultimately, you cannot effectively treat patients who do not want to get better and who do not actually have the problem you believe you are treating (or have it but to a much lower extent than they are claiming). This does not mean every patient is treated like a malingerer, but rather, that objective data combined with clinical experience and research knowledge should be used to guide clinical decision making as opposed to purely relying on subjective reporting, subjective impressions, and a desire to help. All of this can be done in a respectful, caring, and patient centered way.

Dominic A. Carone is a neuropsychologist who blogs at MedFriendly.com.

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  • fred trotter

    Ahh yes. What a wonderful argument. We should have doctors, who have very little psychological training begin guessing whether patients are malingering. That is -totally- what they are trained for. Of course, a very substantial portion of the time, “its all in your head diagnosis” are wrong, and are just a diagnostic failure mode for doctors.

    Any discussion about malingering is utterly and disrespectfully incomplete without data about how common malingering is. How often are patients who are told “its all in your head” actually really sick? How often does true malingering take place? If you do not know the answers to these questions then this article is pretty inappropriate.

    All that is being put forward here is “Doctors it is your job to decide if your patients are actors” without any discussion of the consequences of false positives vs false negatives.

    Your article says “false positives are a legitimate concern” without actually -addressing- the concern.
    Your article -must- do this, to make its case, because as soon as you honestly consider this issue you realize that patients in the false positive pile do not simply equal patients in the false negative pile.

    How many people with terrible pain, but with strange or abnormal affect, will need to go without pain medication in order to prevent one addict from getting some Vicodin? Given that the addict -will- be able to find another source to feed their addiction, society should be tolerating 10 or even 100 addicts rather than denying even one real pain patient help.

    • http://www.facebook.com/profile.php?id=1303196876 Wendy Schneider

      Thank you Fred Trotter for your comment or RE-mark especially about those “actors” who may really be sick or have the symptoms they complain about.   

      “ While a public forum is clearly not the appropriate place to discuss malingering and exaggeration detection strategies…..” Dr. Carone stated.  

      I’m very certain that Dr. Carone has angered many “false positives and/or false negatives” after giving himself and other Doctors that power to determine the intent of the ailing one.  I believe there is still so little known about many ailments or injuries.  Let’s talk about the patients who have been un-diagnosed or miss-diagnosed for years after which the medical community scratches their collective heads and state, “Oh, that’s what was going on in your body.” The human body is not like a Toyota that rolls off the line with all pieces in the same place.

      Just think, addicts, criminals, low income, psych patients even have medical problems that are difficult to diagnose.  Some who go untreated for years because they are afraid, once again, some Dr. is going to say, “It’s all in your head.”  Or better yet, to think that “actor” just wants $400.00 a month.  Then too, there are many who have not been treated for so many years, it has caused addiction, psychiatric disorders, etc.

      The conversation was started by you now continue it.  

      Wendy Schneider  

    • http://www.facebook.com/profile.php?id=1303196876 Wendy Schneider

      Thank you Fred Trotter for your comment or RE-mark especially about those “actors” who may really be sick or have the symptoms they complain about.   

      “ While a public forum is clearly not the appropriate place to discuss malingering and exaggeration detection strategies…..” Dr. Carone stated.  

      I’m very certain that Dr. Carone has angered many “false positives and/or false negatives” after giving himself and other Doctors that power to determine the intent of the ailing one.  I believe there is still so little known about many ailments or injuries.  Let’s talk about the patients who have been un-diagnosed or miss-diagnosed for years after which the medical community scratches their collective heads and state, “Oh, that’s what was going on in your body.” The human body is not like a Toyota that rolls off the line with all pieces in the same place.

      Just think, addicts, criminals, low income, psych patients even have medical problems that are difficult to diagnose.  Some who go untreated for years because they are afraid, once again, some Dr. is going to say, “It’s all in your head.”  Or better yet, to think that “actor” just wants $400.00 a month.  Then too, there are many who have not been treated for so many years, it has caused addiction, psychiatric disorders, etc.

      The conversation was started by you now continue it.  

      Wendy Schneider  

    • http://www.facebook.com/profile.php?id=1303196876 Wendy Schneider

      Thank you Fred Trotter for your comment or RE-mark especially about those “actors” who may really be sick or have the symptoms they complain about.   

      “ While a public forum is clearly not the appropriate place to discuss malingering and exaggeration detection strategies…..” Dr. Carone stated.  

      I’m very certain that Dr. Carone has angered many “false positives and/or false negatives” after giving himself and other Doctors that power to determine the intent of the ailing one.  I believe there is still so little known about many ailments or injuries.  Let’s talk about the patients who have been un-diagnosed or miss-diagnosed for years after which the medical community scratches their collective heads and state, “Oh, that’s what was going on in your body.” The human body is not like a Toyota that rolls off the line with all pieces in the same place.

      Just think, addicts, criminals, low income, psych patients even have medical problems that are difficult to diagnose.  Some who go untreated for years because they are afraid, once again, some Dr. is going to say, “It’s all in your head.”  Or better yet, to think that “actor” just wants $400.00 a month.  Then too, there are many who have not been treated for so many years, it has caused addiction, psychiatric disorders, etc.

      The conversation was started by you now continue it.  

      Wendy Schneider  

    • Anonymous

       I agree with you Fred Trotter. This article is WEAK. It also contains poor spelling and grammar.

    • http://pulse.yahoo.com/_GXO5UT3MGTPBRYKXHHFG6NCRO4 S

      Agree Dr Trotter
      This article is complete and utter crap.

    • Michal Haran

      very well said!

  • http://www.facebook.com/profile.php?id=762893788 Dave Miller

    Fred,

    You are proceeding from a false premise. Malingering is not an “it’s all in your head” diagnosis. Malingering is the opioid-addicted drug-seeker or the person seeking a disability claim even though they are fully capable of working or the person who is faking a whiplash injury after a car wreck to scam an insurance company. While there are cases where it’s tough to tell what’s going on, it’s often pretty cut-and-dried that the patient is faking or exaggerating symptoms, such as the disability claimant who is storming around the office demanding that their forms be filled out and signed when this is their first visit to this particular doctor. Then there’s the drug-seeker who spends all day calling different doctor’s offices and visiting different emergency rooms, always with a different story, claiming to be allergic to everything except for the drug they are seeking. My personal favorite is the patient writhing with apparent pain and withdrawal symptoms and asking for opioids that, when told that this clinic does not write opioid prescriptions, is magically free of symptoms and suddenly decides there is somewhere else they need to be.

    After you have spent time in the trenches dealing with malingerers, then come back and talk to us about how we’re not qualified to spot them or how inappropriate it is to address this situation. These people suck time, energy and resources from the entire system and yet docs are criticized for attempting to spot them and turn them out? Just imagine how much more time and energy we might have for YOUR next appointment if we were freed up from dealing with this silliness.

  • http://www.facebook.com/profile.php?id=529170324 Anna Lauriente

    I am aware that there are people who are trying to scam the system; however, I want to tell you my story. I was rear-ended on my way to school in 2010 by a cement truck at a full-stop, and my truck was a write-off. if my three-year-old daughter was in the back-seat (she normally is, but was sick that morning) she would have been killed. Since that accident, I suffer from neck pain, headaches, occipital neuralgia and ulnar neuropathy, I have lost 40% of the muscle-tone in my left hand and have about 50% strength left in it. I carry on every day finishing my RN degree as a single mom. I have no choice, as I was hit at the beginning of my third year, and now that I am at the end of my fourth year and still suffering, I am not sure that I will get any better than I am at this moment, regardless of all the different modalities I have used to heal myself.

     I work hard every day and go to practice and school regardless of how I am feeling. I take acetaminophen, ibuprofen, flexeril, lyrica and percocet to manage my symptoms. I use nerve-block injections, TENS and heat and ice, yoga, stretching and exercise. And if it weren’t for an incredibly understanding doctor, I bet I would be accused of malingering because I seem to be ‘coping’ well and am quite active. The thing is, I HAVE to be. I have two kids counting on me, and I have to finish my degree (I graduate in April) because I cannot do anything else with all of this education but work as a care-aide at this point. I looked into finishing yearly and challenging the LPN exam, but the RN role has the potential to be less physically demanding ie with my degree I might find something in teaching or administration, which would be easier on my body.

    To the untrained eye, I bet I look like I am a scammer. no-one sees me in tears at the end of the day because I am hurting physically. no-one is privy to the worry I feel as I have lost a lot of the use of my left hand, something I really need as an RN to be able to carry out my duties. i have adapted for the most part, but there are some technical skills that it is my duty to do, that I really struggle with.

    please be careful when you make assumptions. it is just too easy to believe the worst in people. be curious before you jump to judgement. 

  • http://www.facebook.com/profile.php?id=762893788 Dave Miller

    Fred,

    You are proceeding from a false premise. Malingering is not an “it’s all in your head” diagnosis. Malingering is the opioid-addicted drug-seeker or the person seeking a disability claim even though they are fully capable of working or the person who is faking a whiplash injury after a car wreck to scam an insurance company. While there are cases where it’s tough to tell what’s going on, it’s often pretty cut-and-dried that the patient is faking or exaggerating symptoms, such as the disability claimant who is storming around the office demanding that their forms be filled out and signed when this is their first visit to this particular doctor. Then there’s the drug-seeker who spends all day calling different doctor’s offices and visiting different emergency rooms, always with a different story, claiming to be allergic to everything except for the drug they are seeking. My personal favorite is the patient writhing with apparent pain and withdrawal symptoms and asking for opioids that, when told that this clinic does not write opioid prescriptions, is magically free of symptoms and suddenly decides there is somewhere else they need to be.

    After you have spent time in the trenches dealing with malingerers, then come back and talk to us about how we’re not qualified to spot them or how inappropriate it is to address this situation. These people suck time, energy and resources from the entire system and yet docs are criticized for attempting to spot them and turn them out? Just imagine how much more time and energy we might have for YOUR next appointment if we were freed up from dealing with this silliness.

    • http://www.facebook.com/profile.php?id=762893788 Dave Miller

      Apologies for the double-post.

  • Anonymous

    Malingering is extremely difficult to determine. Neuropsychologists can perform certain tests that may provide assistance.

  • Anonymous

    I find it odd that this article assumes and accuses patients of malingering.  The truth is a patient in the throes of a stress breakdown from domestic/work related abuse, bullying, mobbing causing PTSD, suffers a variety of increasingly disabling physical health symptoms like panic attacks, irritable bowel syndrome and other stomach problems, insomnia, weight changes, increased self destructive behavior like smoking, drinking, overeating, heart disease, respiratory illness, teen clenching and grinding and on and on.  Try to find a doctor or mental death expert who will admit the real problem!  If lucky, a general doctor may admit you have a physical problem only and help relieve each individually rather than admitting the real reactive stress/depression, PTSD related to abuse and bullying, which he/she will rarely if ever do!  Thus, the victim continues to deteriorate since the cause is left unaddressed and denied.   As far as biological psychiatry or the mental death profession, their whole bogus DSM junk science bible guarantees a blame the victim bogus stigma to further disempower, discredit, blame, harm, stress, invalidate, bully, abuse, gaslight, torture and collude with the original abusers in power and push lethal drugs to control the victim through a chemical lobotomy to shorten their lives by at least 25 years.  The latest fraud fad is bipolar disorder!  This will deny the victim of all justice, any disability or other EARNED benefits/insurance and eliminate her/him from the job market most likely permanently while the abusers/bullies rob all assets/gain promotions.  There are zillions of articles on the web now about work bullying, mobbing and abuse not to mention domestic violence.  Therefore, I find such “malingering” articles obscene, dishonest, cruel, abusive and the author(s), accusers as mere prostitutes for the power elite.   

  • Michal Haran

    Physicians are not and should not be trained to detect criminals. Further more they are obliged to give the best of care even to known criminals, including rapists, suicide bombers, bank robbers etc. Or enemies in the battle-field. 
    At the most they can honestly say (or document) their lack of knowledge and understanding of a given patient’s complaints or disease. This may be due to their own ignorance/lack of knowledge or the (current) limitations of medicine. 
    Different people respond to similar diseases in a very dissimilar way. The spectrum of normal human response to the calamities of life is enormous, and depends on multiple and complex factors. The spectrum of response to pain is also enormous. There are women who will ask for an epidural injection the moment they feel the first contraction in labor, and others who will go through a long and complicated labor, and still prefer natural child-birth. 
    There is an inherent conflict of interest between being your patient’s true partner and advocate to seeing him as a criminal or potential enemy at court. This is not our job to do that. 
    A patient should know that the decisions made by his physician are done with his best interest in mind. Serious and even fatal errors can arise if you take any different approach. 
    Physicians should leave the decisions regarding malingering or any other criminal act that causes damage to society in one way or another, to the judges and courts. And concentrate on the (hard enough) role of our profession: Do good, or at least cause no harm to your specific patient-the one who came to you for help and advice and not to exploit you. 

    • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

      You don’t have to be “trained to detect criminals”, just state facts.

      Inconsistent findings. That’s all you have to say. In the spectrum of factitious illness, few are committing deliberate fraud. The false-rape charges. The false cancer claim, not to mention a false AIDS claim, I’ve seen both in my practice.

      Most are exaggerating. Just report findings. The positive Waddell’s signs, Hoover test. Obvious wear and callouses on upper extremities when grip strength is a few pounds. Leg strength of a few pounds on a patient who walked into the office. The patient weighs more than ten pounds, how can you extend your legs with only five pounds of force. You’d collapse. No wheelchair, no braces, no cane, no crutches, the office is 200 feet from the parking lot, no one carried you in.

      You state facts, you don’t make criminal charges.

      I remain impressed how many people come in my office with disability claims, where they claim diagnoses that were never made.

      With persistent factitious illness, I will usually just follow the natural course of the illness. Had one in the hospital with complete paralysis, waist down like a pair of pants + stockings, bilateral, symmetrical. Without details, illness was factitious, and observed by another doctor in past, as well.

      OK fine, you can’t walk, you go to the nursing home, get long-term subacute rehab, see if you can go home in the future, with caregivers etc. “Threat” of nursing home got the person on feet fast. And I mean an hour after I told the patient in the hospital. Cursing me the whole time of course.

      Sometimes claimed impairment is so severe, it is reasonable to revoke driver license, they really are unsafe behind the wheel……if they really are as badly off as they claim. And yes, my state has reporting requirements and legal protection for reporting physician.

      • Payne Hertz

        Just report findings. The positive Waddell’s signs, Hoover test.
        Obvious wear and callouses on upper extremities when grip strength is a
        few pounds.

        You do realize the Waddell test is not designed to detect malingering right? Or that callouses don’t disappear months or even years after an injury, right? I had a  girlfriend who was born a peasant in Vietnam and worked the fields for years. Her hands were hard as rock and heavily calloused, even though she became a very successful restaurateur in the US and hadn’t done any hard physical labor in over a decade.

        But thanks for demonstrating how worthless these assessments are. People are malingerers and drug seekers if you say so, damn the facts.

        Without details, illness was factitious, and observed by another doctor in past, as well.,/i>Two wrongs make a right. Gotcha.

        • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

          Is there a fly in the room?

          • Payne Hertz

            Ineducable.

      • Michal Haran

        You say you just have to state facts, so let’s look at those facts: 

        1. Inconsistent findings- Have you ever seen a patient with Parkinson’s who starts to run normally when seeing fire? Have you ever seen a patient with stroke, who can’t smile but can laugh? Have you ever seen a patient with myasthenia who looks perfectly well, and ends up being in the ICU with a myasthenic crisis a few days later? Have you ever seen a blind person, who you wouldn’t know is blind by the way he walks and behaves?  
        Have you ever seen a patient with long QT syndrome who is fine most of the time unless she goes into cardiac arrest? Have you ever seen a patient with leukemia who looks completely healthy? 
        Inconsistency is part of most diseases. In fact patients who learn to live with their illness and not sink into despair are “inconsistent”. Rehab. is based on finding novel ways to perform daily activities utilizing the healthy parts, and bypassing the disability. Patients also learn to avoid obstacles or situations they know will make them worse and pace themeslves, so unless you push them, they can appear perfectly well. 

        2. Did you see the patient on the way to your office? Do you know how many times he stopped along the way to rest? Did you ask him to walk a similar distance, climb some steps, or just watched him walk a few steps in your office? Did you think that possible this patient’s pride and not wanting to be a burden on family and friends was the reason he made this enormous effort to come to your office, with the hope that you may be able to help? 

        3. Is it possible, that this patient was so offended and stressed by your attitude that he put enormous efforts to get out of the hospital and never see you again? 

        Try reading Chloe Atkin’s book and at least see what the results of your approach can be, if you happen to be wrong and reach the wrong conclusions based on your misconceptions. Think how many patients like her were not in the position to fight this system, and not in the position to write about it. 

        I myself when I became ill, met some physicians with your approach, but fortunately there were also others, and being a physician I could eventually judge for myself. But, what about patients who can’t? What about those whose life depends on your judgement and opinion. 
        What about those, who unlike Chloe Atkins when led to such despair do decide to kill themselves? 

        • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

          “….3. Is it possible, that this patient was so offended and stressed by
          your attitude that he put enormous efforts to get out of the hospital
          and never see you again?…”

          Where do you get off making assumptions about my “attitude”? Did I say anything about the extensive workup that was done? In a rural hospital, no neurologist, no cardiologist, hell no general surgeon for a year and a half. The other doctor, not in my practice, had the same thing happen when the patient was informed by a local lawyer that she was reaching the statute of limitations for claims on an old auto accident, suddenly she became paralyzed.

          It’s called taking the time to read the old charts, several inches thick, on a patient I inherited on a ER call. All for the pennies paid by Medicaid.

          After extensive workup, inability to move lower extremities for unknown reasons, imaging by the traveling MRI, taking the time to phone University neurologists, ruling out the dangerous stuff, it is perfectly reasonable to discharge to a nursing home and continue subacute care and workup. Or do you bring them home and put them up in your guest room, Mother Teresa?

          The same nursing home is good enough for my family when relatives needed it.

          I know full well that stuff like you describe happens, get off your high horse, I’m not impressed. When I find patients like that, I go out of my way to state the facts and make sure they get their benefits so fast that the same lawyer as mentioned above was amazed how fast it went through.

          “2. Did you see the patient on the way to your office?, blah, blah…..”
          YES I saw the patient walk out of the Ford-F150 pickup, cross the parking lot, into my office, as my office is solo and I can see the lot out my window. Then I saw the patient show inability to raise the leg to get on the scale, claiming weakness, then go back out, raise the leg high to hop into the pickup truck and drive off. Unassisted.

          I recognize that what you describe happens, I’m not sure you have the common sense to realize that symptom magnification and downright fraud happens as well.

          • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

            .

          • Michal Haran

            First, I apologize if I offended you. You are right, I do not know anything about your attitude just what you wrote-”most are exaggerating”

            Second, I agree with you that patients as people, come in all sizes and colors, and as such some of them are obnoxious, unfair or even plain criminals. One of my colleagues-a wonderful, caring and dedicated physician is being sued by a patient whose life he saved, and there are many other examples. 

            Third, I do not see myself as smart enough to be sure when someone is acting in a certain way, out of despair, previous horrible experiences or fear.
            I see my job description as being my patient’s advocate and that is all I try to do in the best and non-judgmental way. 

            Fourth, I am aware of the fact that some of my patients may not appreciate what I do for them, or even sue me for an inevitable judgement error I may make, but I don’t think there is anything I can do to avoid that. I know that the day in which I will see my patient as a potential enemy in court, and not as someone who came to me for help, is the day I will stop practicing medicine. 

            Fifth, possibly my own experience as a patient with an “unexplained illness” that ended up being a severe and life-threatening neurological disease, has made me even more concerned about those types of errors. And I want to do everything possible to protect others from such serious mistakes. The combination of disbelief and humiliation with true fear for your life, is something I think no patient in the world should ever experience. 

          • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

            Fine. Thanks. The other poster, the fly in the room, is beyond reach with facts or any form of common sense.

            I wasn’t clear, so let me clarify. You get patients with inconsistent findings. “Most are exaggerating”……..compared to malingerers. The definition of malingering I was trained with required DELIBERATE intent to deceive, and that’s unusual. I just use terms like symptom magnification or exaggeration, I don’t need to map out the psychodynamics behind it, I can easily be pride or some of the things you mentioned.

            It’s still important to point that out, because you don’t treat that by throwing Vicodin at it.

            Chloe Atkins is a Canadian as I recall, all that happened to her took place Up North……..these books always end up in a critique of “American medicine”……..had an unusual presentation of myasthenia gravis.

            So she had an unusual presentation of a relatively uncommon disease. I know some nice “caring” pain practitioners who would have given her Oxycontin 80′s, four, five a day………she’d be dead by now.

            But, no, I stand by what I said. Report facts. That doesn’t mean you have to stop looking.

            “Under the most precise conditions of environmental and behavioral control – the laboratory rat can be counted on to do whatever it damn well pleases.”

            I don’t know who to attribute that to………I use the joke and tell the patients that some diseases do whatever it damn well pleases as well. Then you look for the multiple sclerosis, and you know the drill, probably better than I, what to look for with neurologic desease.

          • Michal Haran

            If you are saying that an illness is a complex of the disease, the patient and the surrounding environment, and not just the biological process-I fully agree with that. 

            If you are saying that every patient has an emotional response, which is unique to him- I agree with that as well. 

            You are probably right that a patient’s pride and trying to hide his/her illness and not become a burden on those around him, may lead to confusion and medical errors, because this non-intentionally also miss-leads the physician. But, it is in fact the opposite of malingering and exaggeration even thought it creates inconsistencies. 

            I also agree that giving medications to patients, without understanding what you are treating, is not good practice and can cause more harm than good. 

            I am not sure that you agree with me, that the way to address this is by compassion, respect and getting to know the patient and the way his illness affects him and those around him, and mostly providing non-judgmental support and a healing environment. 

            Also knowing that not everything you can’t understand or doesn’t fit your known paradigms or diagnostic tests is not real. 

            I loved that- ”Under the most precise conditions of environmental and behavioral control – the laboratory rat can be counted on to do whatever it damn well pleases.”

            I fully agree that many diseases do exactly that, not caring what is written in our evidence-based literature and medical text-books. 

            But, some physicians forget that it is the disease that does that and not the patient. 

          • Payne Hertz

            The other poster, the fly in the room, is beyond reach with facts or any form of common sense.

            If you offered any facts or common sense the fly in the room might be impressed. i see nothing here but uninformed opinion and sophistry of lesser worth than that which usually attracts flies.

            I wasn’t clear, so let me clarify. You get patients with inconsistent findings.

            Inconsistent findings are perfectly normal. Anyone who knows anything about pain knows that symptoms are not set in stone and can change considerably over even a few moments time. I have a bad toothache now and the tooth is due to be pulled on Friday. Sometimes when I blow my nose, I feel an intense stabbing pain in the tooth in question. 10 seconds later when I blow my nose again, I may feel no pain at all. Is this evidence of malingering, psychogenic pain or just normal variation in symptomology? Is it morally justifiable to simply report this “inconsistency” knowing full well that it will be seen as evidence of malingering? Please respond.

            The assessment of “inconsistent findings” is too subjective and prone to operator bias to have any meaningful scientific validity. You might get inconsistent results for no other reason than you didn’t precislely touch the same spot that elicited a pain response before or you did not use an equivalent amount of stimulus. Or the patient may be blocking the pain response the second time as we are expected to be stoic in our society. Your attitude towards pain patients in general certainly plays a role.

            These assessments are about as objective,  scientific and meaningful as Applied Kinesiology.

            I just use terms like symptom magnification or exaggeration, I don’t need to map out the psychodynamics behind it, at least not to start, it can easily be pride or some of the things you mentioned.

            These are terms which lack any scientific precision whatsoever. The assessment of “symptom magnification” is pure opinion, not “fact,” as you claim. To accurately determine whether someone is truly magnifying  their symptoms or not, you would first need an accurate diagnosis, something which is often if not usually absent. Then you would need a complete and thorough understanding of how that condition manifests itself in patients behaviorally which simply doesn’t exist in science given our current knowledge of pain and disability. Then you would need to account for natural variation in symptomology which is simply impossible.

            I will say it again: the idea you can assess disability or pain through such subjective, scientifically imprecise and unproven measures is quackery, pure and simple.

            Of course, no doctor who does disability exams is going to put his license on the line by making concrete statements about a patient like “This person is clearly malingering.” or “The MRI shows no evidence of spinal stenosis.” Instead, they will go for vague, subjective assertions like “this patient displays considerable symptom magnification upon examination” or “the degree of spinal stenosis revealed in the MRI does not account for the severity of pain and impairment this patient reports.” These assessments are subjective enough no one can say the doctor is lying even when he is.

            Yet despite the purely subjective nature of these alleged “findings” they are used as objective evidence of malingering in Workers comp cases and other litigation. A good lawyer could easily demolish these “findings” on cross examination if any of them were interested in doing so, but for the $70 most are paid here in NY State to represent an injured worker in court, few are interested in playing Perry Mason and seriously challenging this nonsense or obvious IME fraud.

            It’s still important to point that out, because you don’t treat that by throwing Vicodin at it.

            You don’t treat it by refusing to throw Vicodin at it, either.

            So she had an unusual presentation of a relatively uncommon disease. I know some nice “caring” pain practitioners who would have given her Oxycontin 80′s, four, five a day………she’d be dead by now.

            Pure nonsense. Perhaps some nice “caring” doctor should imply she is malingering by accusing her of exaggeration or symptom magnification, then she wouldn’t have to run the risk of dying from imperfect pain relief with narcotics but could instead opt for perfect pain relief with a bullet to the temple.

            But, no, I stand by what I said. Report facts. That doesn’t mean you have to stop looking.

            What “facts?” Look at your story about the guy who couldn’t get on the scale. The scale at my local VA CBOC has two thick iron loops bolted into the floor next to it to provide support for patients. I don’t know what that tells you, but it tells me a lot of patients who are capable of standing and walking have difficulty getting on that scale. I often have trouble myself even though I have no particular neurological deficit I am aware of. It is easy to see how someone suffering from intermittent “Foot Drop” due to spinal stenosis or a neurological impairment might be able to easily ambulate into your office, but then after a long wait in an uncomfortable chair has his foot drop symptoms flare up to where he can’t get on a scale easily. Then, because most people with this condition can usually lift their knees if they have enough clearance to do so (ie, they are not trying to precariously balance themselves on one foot while facing up against a scale placed up against a wall with no room to lift their knee up and provide clearance for the bad foot) the same person who had difficulty getting on a scale would have little difficulty climbing into a truck.

            There are often perfectly rational reasons to explain apparent inconsistencies, “fakery,” or “symptom magnification.” Jumping to conclusions based on mere opinion or pseudoscience when a person’s life and health are on the line is ethically bankrupt.

          • Michal Haran

            Thank you for this excellent explanation. 

            You also made a very important point- subjectivity of physicians is seen as objective (unless they are the patient), whereas subjectivity of patients is seen as unreliable. 

            The reality is that both physicians and patients are people and inevitably influenced and biased by their preconceptions, hopes, fears and frustration. 

            This is what Eliot Slater wrote many years ago: 

             “The
            diagnosis of ‘hysteria’ is all too often a way of avoiding a confrontation with
            our own ignorance. This is especially dangerous when there is an underlying
            organic pathology, not yet recognized. In this penumbra we find patients who
            know themselves to be ill but, coming up against the blank faces of doctors who
            refuse to believe in the reality of their illness, proceed by way of emotional
            lability, overstatement and demands for attention … Here is an area where catastrophic
            errors can be made. In fact it is often possible to recognise the presence
            though not the nature of the unrecognisable, to know that a man must be ill or
            in pain when all the tests are negative. But it is only possible to those who come
            to their task in a spirit  of humility.            

            -”In the main the diagnosis of ‘hysteria’
            applies to a disorder of the doctor–patient relationship. It is evidence of
            non-communication, of a mutual misunderstanding … We are, often, unwilling to
            tell the full truth or to admit to ignorance … Evasions, even untruths, on
            the doctor’s side are among the most powerful and frequently used methods he
            has for bringing about an efflorescence of ‘hysteria’… Looking back over
            the long history of ‘hysteria’ we see that the null hypothesis has never been
            disproved. No evidence has yet been offered that the patients suffering from
            ‘hysteria’ are in medically significant terms anything more than a random
            selection. … The only thing that hysterical patients can be shown to have in
            common is that they are all patients”In the current medical environment, many physicians are being abused by the system. They are expected to take care of people, make (at times very complex) diagnostic and management decisions in a very limited time; They are expected never to make any errors (which is obviously impossible) and even wonderful, caring and dedicated physicians are severely punished for one error in a life-time of giving.  So, unfortunately they take their frustration out on those who are most vulnerable-the patients. And it is true that some patients are very demanding, have totally unrealistic expectations and expect their physician to perform unreasonable miracles. Because they too are influenced by adds promising them the ” fountain of youth”  if they only come to this and this hospital, have this and this test or take this and this medication. This, in my opinion, is a very unhealthy environment that doesn’t promote healing or physician’s satisfaction. And one we should find the way to change. 

    • Payne Hertz

      Brilliantly stated. Thank you. I wish your attitude was more common. Sadly, it isn’t.

      • Michal Haran

        I wish so too, and trying to do what I can to make that happen. 

  • Michal Haran

    I recommend that you read this book, which describes the possible horrible consequences of your approach- 
    http://comcul.ucalgary.ca/news/congratulations-chloe-atkins-0

  • Michal Haran

    During my residency in internal medicine I worked in an inner city hospital. We had many patients with sickle cell disease, who were mostly seen as drug addicts by the ER team, but were many times admitted just to “make sure” that they are not in a real crisis. 
    One day, when I was about to go home the nurse told me that we have one of those “drug addicts” which was just admitted from the ER. It took me exactly one minute of looking at the patient to realize that she was very ill. I was later congratulated by my attending for saving this patient’s life-she had acute chest syndrome and would have possibly died within hours if not given proper treatment. 
    I believe that the reason I detected what was missed by the entire ER team, is that I did not grow up in the US and was much less affected by the prejudice against certain ethnic groups living in inner cities. 
    I could look at this patient as I would at any other patient, without any preconceptions. 
    This made me realize how physicians (including myself) can make serious errors based on misconceptions. It made me much more cautious in making “spot diagnoses” based on stigmas of dress, behavior etc. 

  • Michal Haran

    During my residency in internal medicine I worked in an inner city hospital. We had many patients with sickle cell disease, who were mostly seen as drug addicts by the ER team, but were many times admitted just to “make sure” that they are not in a real crisis. 
    One day, when I was about to go home the nurse told me that we have one of those “drug addicts” which was just admitted from the ER. It took me exactly one minute of looking at the patient to realize that she was very ill. I was later congratulated by my attending for saving this patient’s life-she had acute chest syndrome and would have possibly died within hours if not given proper treatment. 
    I believe that the reason I detected what was missed by the entire ER team, is that I did not grow up in the US and was much less affected by the prejudice against certain ethnic groups living in inner cities. 
    I could look at this patient as I would at any other patient, without any preconceptions. 
    This made me realize how physicians (including myself) can make serious errors based on misconceptions. It made me much more cautious in making “spot diagnoses” based on stigmas of dress, behavior etc. 

  • Anonymous

    I very much agree with your premise and see patients regularly who have had a physician label them disabled, but manage to engage regularly in activities they enjoy.  I wish we had a more clear way to diagnose patients as malingering.  It certainly robs our society of valuable resources.

    And then I have days like today.  Saw a patient that two months ago I was convinced was malingering, threatening to sue everybody and asking to be off work.  Begging for narcotics.  Vague symptoms, inconsistent exam, normal initial testing.  Except now more thorough testing suggests the diagnosis is probably one of those awful conditions you wouldn’t wish on your worst enemy.  Please excuse my vague story, I want to protect the patient’s privacy.

    The fact is there are patients who are malingering.  But in order to provide all of our patients with good care, physicians must assume that patients are truly ill.  As other posters have mentioned, it is up to attorneys and courts to decide who is disabled.  Rather than doctors being asked to make these decisions, maybe we should train physicians specifically to do this (like a lot more occupational medicine docs) and help discern between truly awfully ill patients like mine and those who just want to work over the system.  Because you’re right – us primary care docs are not that great at telling the difference.  And we’d really like to not have that responsibility anymore.

    • http://twitter.com/spookiewon Pjay (Patti) Pender

      So if one is disabled one is never again permitted to “engage regularly in activities they enjoy?”  Seems a bit like maybe I’d just rather be dead.  The fact is–I am disabled.  It has a serious impact on my life.  I walk with a cane on good days, a walker on bad ones, and when I travel I need a wheelchair and assistance to get through the airport.  I also work full time and live alone in my own home.  I feel entitled to do those things I enjoy which I can still do, and to do them as regularly as you do the things you enjoy.  How dare you suggest otherwise?

  • Sapphire Storm

    Are you kidding me? The process of getting worker’s compensation and trying to live on the meager restrictions of that income result in worsening mental and physical health!  The poor poor insurance companies who delay and deny treatment might have to deal with a few “malingerers”.  This is ridiculous.

  • Anonymous

    Discharge planners seem to sniff out the maligering patients.  Ha.  The one time they’re useful.

  • Payne Hertz

    Great. The last thing we need is to encourage doctors to be even more distrusting and hostile to their patients than they currently are, or to believe in the ludicrous fantasy that they are able to detect malingering and drug seeking in their patients based on unproven, pseudo-scientific checklists.

    Let’s be real here. There is not a single scientifically-proven test that can reliably prove that someone is faking pain or malingering. Not one. Consequently the widespread use of such tests for this purpose is quackery and malfeasance. This is particularly true of the Waddell test, which was originally designed to separate “organic” from “nonorganic pain, and not to detect malingering. Never mind that this alleged dichotomy between “organic” and “nonorganic” pain is itself based on questionable science, its author has repeatedly repudiated its use as a means of detecting malingering in workers comp and other litigation claims.

    Pain Behavior Testing in Personal Injury Insurance Examinations: Criticisms by Orginator, Dr. Waddell

    http://www.adlergiersch.com/personal-injury-articles/personal-injury-articles/pain-behavior-testing-in-personal-injury-insurance-examinations-criticisms-by-orginator-dr_-waddell

    As it stands, that test is over 30 years old and is based on outdated conceptions of pain. “Nonorganic” pain and “exaggerated” pain responses are easily explained by comorbid conditions like fibromyalgia, myofascial pain syndrome, central nervous system sensitization and generalized deconditioning, all of which can result from untreated pain and disability. It is significant to note that Waddell sings are equal in litigant and non-litgant patients, but higher in the victims of failed back surgery syndrome, indicating that these “signs” are more likley physiological responses to the increased pain associated with that condition.

    Even if these tests were based on objective science, which they clearly are not,  there is a built in confirmation bias in the fact that they are used to detect malingering, but never to detect non-malingering. Doctors who use these tests are trained to look for “inconsistencies” which allegedly indicate faking, but never to note the consistencies that might indicate the opposite.

    There is nothing particular about having a medical degree that qualifies someone to detect malingering or drug seeking. Quite the opposite, most doctors are poorly trainnd in pyschology and the assessment and treatment of real pain, let alone detecting fakery.

    Add to this the overwhelmingly hostile, reactionary and misanthropic attitudes far too may doctors have towards patients with pain. The idea that you can get objective results from jaded doctors using pseudo-scientific tools is a farce.

    The fact of the matter is the idea that malingering and drug-seeking can be reliably proven is a scam pushed by the insurance industry as a means of denying people who are injured their rightful claims to disability benefits and pain treatment. This is where the real fraud in Workers comp is, as I will get to in the next post: the use of these bogus tests by unscrupulous insurance companies and rent-a-quack doctors who are paid to lie about claimants’ medical problems.

  • Payne Hertz

    The question was asked: how common is malingering? Unfortunately, the author failed to address this question so let me attempt an answer: not very common at all.

    “Conning & Co., an insurance research firm, put claimant fraud at about 1.9 percent of premiums paid–or $477 million.”(“Workers comp: Falling down on the job” Consumer Reports, February 2000)

    http://www.injuredworker.org/forums/injuredworker/posts/1652.html

    Even then, the fraud workers usually commit is to claim that an injury they received off the job was received on the job. The injury itself is real and they are not usually faking it. Dr Gordon Waddell, who authored the much-abused Waddell Test, states in a 1998 article in Spine that:

    “Conscious deception by a patient undergoing an examination is thought to be extremely rare.”

    http://www.adlergiersch.com/personal-injury-articles/personal-injury-articles/pain-behavior-testing-in-personal-injury-insurance-examinations-criticisms-by-orginator-dr_-waddell

    As I stated in the last post, the real fraud in workers compensation cases in not by the claimants, but by the carriers and the mercenary “independent” medical examiners they hire to lie about patients. Workers compensation IME doctors are notorious for softpeddling and lying about the degree of injury or disability suffered by injured workers. Many injured workers are denied benefits or receive benefits that are far lower than they should be getting for the degree of injury they have suffered. NYS State has gone so far as to institute an IME fraud law to counter the widespread abuse of workers comp med exams, but the workers comp board lacks the personnel and the will to enforce this law.

    This NY Times article is illustrative of the problem. I strongly recommend you read it:

    “If you did a truly pure report,” he said later in an interview, “you’d be out on your ears and the insurers wouldn’t pay for it. You have to give them what they want, or you’re in Florida. That’s the game, baby.”

    Exams of Injured Workers Fuel Mutual Mistrust
    http://www.nytimes.com/2009/04/01/nyregion/01comp.html?_r=2

    I knew a guy who was impaled through the chest by the blade of a forklift at work. It went straight through his body, but he somehow managed to survive this horrific injury. A workers comp IME doctor rated this guy as being only “partially” disabled, meaning he was capable of doing at least some work, and denied him the physical therapy he needed to “open up his chest” and allow him to breath. He was forced by economic necessity and typical insurance company stonewalling to accept a settlement, which was less than $60,000 total to last him for life for an injury that destroyed his life and capacity to work.

    Despite the fact that over 30,000 workers are killed on the job every year in the US, fewer than 1 percent of injured workers in NY State are ever awarded “total” disability, which is the only assessment that grants you full disability benefits. A workers comp attorney once told me the only people who get total disability in NY State are quadraplegics.

    So you want to talk to us about fraud? You are pointing your radar entirely in the wrong direction, sir, and doing a gross injustice to patients everywhere perpetuating insurance industry propaganda and the ludicrous notion that malingering and drug-seeking can be detected through behavioral cues, the way people dress, or any other nonsense contained in these assessments.

  • http://twitter.com/bergamotley Dorothy Pugh

    I suspect that detectives have a better chance of identifying malingering than doctors who barely know their patients and see them for 5-10 minutes at a time. The most obvious malingering type is the employee who calls in sick and then attends a very active public event that day. Another type, more likely to fly under the radar, is the person who uses a diagnosis to get sick time off and a handicapped parking permit by claiming to be weak and in pain, and winds up on the front page of the society section for obviously energetic community work (some of which was done during work hours). 

    Others may be less obvious because of their apparent motivations. A patient who expresses fears of losing his/her job because of the problem, for instance, deserves careful consideration. I think it’s helpful for patients having difficulties getting a pressing problem diagnosed to bring good recent job evaluations (if they have them) with them to doctors’ visits to make the point that they have more at stake than immediate pain or disability. Perhaps it would be useful for doctors to offer patients this opportunity if concerns about malingering arise. In any case, the patient has the right to know if s/he is under suspicion of malingering.

    I believe that if a once normally active person starts spending a lot of time in bed or reduces participation in life, there’s a good case to be made that that person is ill, whether it’s from depression, an untreated illness or from new environmental stresses, especially double-bind situations. I believe very few people in normal health would choose to live this unhappy existence. A physician who approaches this patient with compassion rather than contempt may be more likely to get the full story. But it takes time, patience and talent to get a complete, individualized medical history.

  • http://profiles.google.com/leejcaroll Carol Levy

    Anecdotes are not evidence.
    The example of  “Perhaps, for example, the patient exaggerating pain and other physical symptoms is actually in need of psychotherapy services they have never received instead of Fentanyl patches, hydrocodone, and a TENS unit.” is particularly disturbing to me as a chronic pain patient and advocate for women in pain awareness.  Research has shown that women in pain have a harder itme being believed, giagnosed and receiving adequate treatment, including medication.  This is in spite of the fact women have higher incidences of  disorders that have pain as a main or sole complaint – rheumatoid arthritis, CRPS, Fibromyalgia, trigeminal neuralgia, MS, etc.
    Many of these either have no ‘objective findings” – often for instance there is no found cause for trigeminal neuralgia – a pain disorder that relies upon presentation as sign and symptom(s). (Disclaimer I have this – surgery proved it was from a vascular birth defect but often there are no findings, including surgical.)
    CRPS (RSD) was considered, for many years, to be nothing more then people, usually women, being hypochondriacs or malingerers, now it is a recognized pain disorder.
    For sure there are fraudsters, maliingerers, liars but when your mindset is to think of them as the majority your patients should be wary of you.  The last thing on your mind if you approach patients as drug seekers, disability desirers, workman;s comp liars, is treating them like patients in need.
    And how sad, for both of you.
    Carol Jay Levy, B.A., CH.t author A PAINED LIFE, a chronic pain journey Women In Pain Awareness Group https://www.facebook.com/?ref=home#!/groups/111961795481256/The Pained Life, 30 years, and counting.http://apainedlife.blogspot.com/accredited to the U.N. Convention on the Rights of Persons with Disabilities member U.N. NGO group, Persons With Disabilities

  • http://twitter.com/spookiewon Pjay (Patti) Pender

    This type of thinking places those of us who live is excruciating pain in an impossible “damned if you do, damned if you don’t” position.  If we come in to your office looking obviously in distress and complaining about how it interferes in our life activities, we are told our pain is the result of, or exacerbated by, “depression” and we are treated for depression (using psychotropic drugs of questionable effectiveness which arguably do more harm than good even for true depression) rather than being treated for our pain.  If we fight hard to maintain working and personal lives in spite of the pain we are told the pain can’t possibly be that bad, or our lives would be more severely impacted.

    • Michal Haran

      I fully agree with what you say. But, I think this is not out of cruelty, but because of lack of understanding of what it means to have a disabling illness. Healthy people see disability in  black and white colors. Disability in their mind is a devastating situation with makes you totally incapable of leading anything that could resemble a meaningful life. People like Steven Hawking are seen as the exception not the rule. When in fact, every person with a disabling illness can be Steven Hawking if given the proper medical and social support.