Is My Patient Faking?

This article was initially published on MedPageToday, found here.

I remember walking into one of my jails and seeing a patient on the floor of his cell twitching and shaking. “Don’t worry about him,” said the sergeant on duty. “He’s faking it.”
Boy, that spun me up! Nothing will make me more anxious than hearing “he’s faking” or its close cousin, “he’s malingering.” I hate and fear those words. Now, I know that medical personnel, both in my jails and in the emergency departments where I used to work, get upset when they think that they are being deceived or manipulated by a histrionic patient. But charging a patient with “faking it” is almost always a bad and dangerous idea.

There are three reasons for this. First, the charge of “faking” gets you and everyone else so emotionally charged up that no one is thinking clearly. Second, you might be wrong — and heaven help you if you are! Third, calling someone a “faker” is counterproductive to your real goal of getting the patient to stop doing whatever it is he is doing.

The first important consideration of calling someone a “faker” or a “malingerer” is that these words cause yourself and others to have a strong emotional reaction instantaneously. When you say that a patient is faking or malingering, whether you are correct or not, what that patient and others understand is that you are calling him a liar. This accusation elicits an immediate powerful visceral response. You might argue: “I am using the term ‘malingering’ correctly according to its definition in the dictionary.” Nobody will care. The patient and everyone else hears “He’s a LIAR!” Those are fighting words! When people hear those words, they stop thinking and go into fight-or-flight mode.

So, ask yourself this: Is the medical information I am conveying when I say that a patient is faking so important that it outweighs the inevitable backlash of anger, frustration, and contempt? Such emotions will ruin what otherwise might have been a fine day. But more importantly, they will get in the way of good medical practice. If you are feeling anger and contempt towards your patient, you are unlikely to provide very stellar medical care for them — or for your next patient, for that matter. I don’t know about you, but when I get angry and frustrated at work, my brooding sometimes makes me less attentive to my patients. And I might even go home and snap at my wife as well!

The second important item to think about before calling someone a faker is this: What if you are wrong? Most of the time, you cannot know for sure whether a particular patient is really deliberately faking or not. Consider, for example, a man in an airport who is having a panic attack about the prospect of getting onto an airplane. He is rocking back and forth, hyperventilating. His heart rate is over 150, and he is dripping sweat. He will not speak to those around him. These are pretty dramatic symptoms, but I’ll bet that no one would say that this man is “faking it!” His panic attack is real. With this in mind, are we 100% sure that the patient in the jail cell who is twitching and incoherent is really faking it? If you get this wrong, you have a set-up for disaster.

I have consulted on several medical liability cases in which a patient was thought to be faking, was subsequently ignored, and had a bad medical outcome. If a patient is histrionic when he says, “My belly hurts,” his dramatic presentation can be mislabeled as “malingering,” and his acute bowel obstruction will be missed. Similarly, “I can’t breathe!” leads to “He looks fine to me,” which leads to “He’s faking.” And pretty soon, you are doing CPR. Anytime you hear the words “he’s faking” or “she’s malingering,” you have entered an area of high medico-legal risk. Be wary!

But what about patients who really are faking their symptoms? There are admittedly a lot of these in jails and in ERs. Let’s assume that our jail patient twitching on the floor really is faking his symptoms. Let’s also assume that he is doing this deliberately with the goal of getting out of jail so that he meets the definition of malingering. Now, correct me if I am wrong here, but isn’t our goal for him to stop faking? We want him to stop doing that twitch-and-moan thing and cooperate with us — in other words, behavioral modification. With this in mind, how likely is it that saying to him “I know you’re faking” will make him stop? To the contrary, malingerers who are accused of faking tend to redouble their efforts in order to convince you that you are wrong and that their symptoms are real! When a person has been publicly called a “liar,” he will want to regain his besmirched honor.

I have seen such patients try to force medical providers to believe them by being ever present in clinics with the same complaint, and by filing grievances and even lawsuits. Labeling a patient as a “faker” (even if you are right) has recast your relationship as adversarial. You are no longer on healthy terms of patient and caregiver. You are enemies now. How can anyone be on good terms with someone who has accused them of lying?

Let’s return to our patient in the jail who is shaking and incoherent on the floor of his cell. There are three possibilities as to what is going on with him. He could indeed be faking. Alternatively, he could be having something akin to a panic attack, which, of course, is not the same thing as faking. Finally, he could be having a serious medical event. The only way to know is to do a complete medical evaluation and intervention. With enough patients like this, you are eventually going to see all three. It turns out that no medical evaluation had been done yet on this patient because, well, “he’s faking it.” Once we did a physical exam and got vitals, we found that he had a heart rate of 158, a blood pressure of 83/60, and a blood sugar of 875. Off to the ER he went with a diagnosis of diabetic ketoacidosis. This was a narrowly averted disaster.

How could this mistake have happened? Well, once the patient had been labeled a “faker,” rational thought ceased. Nobody considered the possibility that they might be wrong! But another mistake was made as well, and that is this: doing nothing is the wrong approach, even if the patient is, in fact, faking it.

Fortunately, there is one very good solution to this conundrum, and that is for us not to use the word “faker” even if we strongly suspect it. Don’t even go there! There are other, better ways to approach a histrionic patient with a strange presentation. If we give up the judgmental attitude, then we’ll all feel better. More importantly, we’ll also practice better medicine.

As always, what I have written here is my opinion, based on my training and experience.  I could be wrong! 

Do you have an opinion or experience dealing with this issue?  Please share in comments!

11 thoughts on “Is My Patient Faking?

  1. Another excellent topic and a legal minefield. Also, beware of the “malingerer” assessment spreading among staff, including security. A medical person’s opinion that an inmate is malingering carries a lot of weight with non-medical staff.

  2. I am aware of a situation where this occurred and the patient died. Long legal battles and much money spent. NEVER conclude that a patient is faking. Always best to assess!

  3. Correctional medicine is definitely different. I spent my first year and a half out of school working as a float nurse in a local hospital. I feel like I really improved my assessment skills there, but I had no idea how refined my assessment skills would need to be in this environment. I read a number of books on manipulation of correctional staff early on. Games Criminals Play and the Art of being manipulated stand out as great reads. That being said I always assume that the complaint the inmate has is real and let my assessments prove otherwise. If I cannot find anything that backs up their claim I might just refer them to sick call as at night we can only address emergent issues. Occasionally something will feel off and I won’t hesitate to call the on call provider for a second opinion. EKG’s, checking troponin levels, and a variety of other tools all help in eliminating life threatening vs “seeking” complaints. Some of the other medical staff have been around the inmates longer and they find it easier to just say the person is full of it. I hope to never become that nurse and am always willing to assess, listen, and give the benefit of the doubt. I still have no problem telling an inmate I can’t do anything when my assessment comes back negative.

  4. Excellent topic! We always share the concept that patients might be manipulative in a habitual way that sometime they don’t even know they have a real serious condition going on. The professional way is proper assessment.

  5. As someone who *looks* a lot less disabled than I actually am and has been through the “you’re faking it” experience in ER once for sure, your advice to use non-judgmental language and actually properly evaluate inmates who appear to be having a medical crisis gets a RIGHT ON from me.

  6. I agree one hundred percent. I’ve been in Corrections or Mental Health for almost 35 years. I hate the term malingering and am often asked by officers to charge the offender with malingering but I won’t. I tell them if they want to say that to go ahead but in no way relate it to medical. I have charted that I “cannot find any objective findings to support subjective complaints” however I assess everyone. One facility I worked at would answer emergency grievances without even seeing the offender. I would have them bring the offender over to medical and would do a quick assessment prior to answering the grievance. The other nurses would get angry with me telling me that the offender “got his way” because I saw him. My answer to them was “He was seen, evaluated and determined not to be an emergency and he was instructed to submit a sick call request”. At least when I went home I knew that the emergency complaint “I can’t breathe” was not an emergency because the offender was able to take a deep enough breath to be able to yell at me at the top of his lungs complaining that I would not do a sick call right then. I’ve also found offenders who had been labeled “malingerer, complainer” with stroke like symptoms. I guess even a complainer or malingerer can have a stroke!

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