How to Spot Patients Faking Illness or Disability
Catching a patient who's acting sick or injured is "about using your powers of observation as a doctor," says Mark Pilley, MD, a family physician in Omaha, Nebraska, who performs Social Security disability exams. "Basically, these are not unfamiliar skills for doctors. They already use these skills to diagnose and treat patients."
Sometimes identifying a fake condition can be surprisingly easy. "When I interview patients, my first question is, 'Why do you think you're totally disabled?'" Pilley says. "Some people are very revealing. They might say, 'Because I want to retire.'"
Other fakers are better at deception. For example, they often claim they are in a great deal of pain, but it's difficult to objectively measure pain, and the doctor often has to take the patient's word for it. However, exaggerated pain can give the patient away, Pushkin says.
"The patient hit his knee on a desk 3 months ago and tells you the pain is at 10 on a scale of 1 to 10," he says. "That seems unlikely, so you check it out." This may involve getting a urine sample and seeing whether the patient is taking pain medication, or reviewing the patient's statements about the pain to look for inconsistencies, he says.
Fakers who know all the right things to say can be very difficult to catch. Going to medical websites on the Internet, these people can review the correct presentations for a certain condition and mimic the right behavior, being careful not to exaggerate the symptomology.
In these cases, other methods of detection are in order. One effective method is to interview the patient for a prolonged period. This "may induce fatigue and diminish the person who is malingering to maintain the deception," wrote David Bienenfeld, MD, a psychiatrist at Wright State University in Ohio, in a 2017 Medscape article.
In addition, "rapid firing of questions increases the likelihood of contradictory or inconsistent responses," he wrote. "Asking leading questions may induce the person to endorse symptoms of a different illness."
But are treating doctors prepared to use these methods? One problem is the extra time that is needed. Pushkin estimates that doctors would have to lengthen the appointment by 10-15 minutes to do this work. He concedes that this would be hard for all the doctors who are under pressure to keep their appointments short.
Lack of Enthusiasm to Catch Fakers
Judging from the billions of dollars in improper payments for workers' compensation and Social Security disability coverage, many treating physicians don't easily identify fakers.
One significant type of malingering involves patients who have been legitimately getting disability payments and are now due to go back to work, but want their benefits extended. Pushkin says treating physicians are often quite willing to give them extensions based on little evidence.
As a peer reviewer for insurers, Pushkin calls up treating physicians and asks them why they extended the benefits. "They say the patient was still complaining of pain," Pushkin says. "So I ask them, was there any objective evidence that the patient was in pain? And they say, 'Well, no.' They took the patient's word for it."
"Doctors are often unaware that patients could be lying about workers' comp, so they don't even look for it," Pushkin says. Catching fakers requires a certain amount of mistrust, and many doctors do not want to mistrust their patients.
"The reason doctors went into medicine was to help people, not to catch them in a lie," he says.
In fact, many doctors are markedly uncomfortable with challenging patients. "Am I to doubt my patient who says they can't work because of illness, or somehow question the degree of illness or their experience of it?" wrote Lee A. Resnick, MD, president of the Institute of Urgent Care Medicine. "Most urgent care providers will believe the patient, and rightfully so, as we're not the illness police."
When patients come in, physicians start with the assumption that they have a real complaint. This faith in patients' veracity drives doctors to press hard for the right diagnosis, according to an article on identifying drug-seeking patients.
When identifying pain in particular, it's hard to tell the real from the fake. Recent research showed that even after training, people could not detect real versus faked pain more than 55% of the time.
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Cite this: Leigh Page. How Some Patients Fake Illness or Injury and Get Away With It - Medscape - May 14, 2019.