Most people have heard of Munchausen's syndrome, a fascinating condition in which patients try to fake a condition in order to draw attention or sympathy.
There are a few syndromes that doctors need to keep in mind, some of which are quite fascinating, in which the patient tries to fool the doctor for various reasons. Here are some of those conditions, how the patients fool the docs, and how the docs avoid being fooled.
1. Drug-seekers
What are they –
In a sentence, the bane of any ER physician's existence. They're either addicted to pain meds, or obtain and fill prescriptions then sell them on the street to addicted people for a huge profit.
How they fool doctors -
Drug seekers can be very slick. I have seen a patient had another doctor vouch for them, one who wore their full police uniform, an adorable 80-year-old church organist, and even nurses and doctors ... all of whom were found to be getting prescriptions for pain medications and selling them illegally.
How doctors recognize them -
Besides being highly suspicious of any patient who asks for narcotics, some regions have databases that doctors can use to determine if a patient has filled a suspicious number of pain prescriptions. However, some drug seekers raise a lot of suspicion on their own. They'll claim to be allergic to every non-addictive type of pain medication, which is statistically unlikely. Others are just bad actors. They’ll shriek and cry at the lightest touch when a doctor pokes their back to find out which part hurts… then later, the doctor will give them a friendly pat on the back, and find that the supposedly painful spot no longer seems to hurt.
2. Malingerers and Insurance Hopefuls
What are they -
A "malingerer" is defined as a person who fakes an illness with the intention of avoiding duty or work. I'll lump these in with patients who fraudulently fake or exaggerate illnesses to try and get insurance payouts.
How they fool doctors -
Malingerers will seem to have a lot of pain, and some actually are suffering from very real pain. They use this, however, to prey on a doctor’s empathetic side. They can also be quite convincing actors when they demonstrate just how incapacitated they are.
How doctors recognize them –
By knowing the physical exams and anatomy very well, doctors can get suspicious if the results of a few different tests of the same joint or muscle aren’t consistent. Some malingerers, though, can be fooled quite easily. Even I have had my suspicions raised with a patient who struggled to raise her arm a few inches when I asked her to demonstrate her range of motion. When I then asked her to show me how high she could raise it before her accident, she effortlessly shot her arm up high above her head!
3. Psychogenic nonepileptic seizures
What are they –
This is a term for people who appear to be having seizures, but it turns out that they are actually not suffering from epilepsy – for various reasons, they’re faking the seizures.
How they fool doctors –
Anybody in a doctor’s office or emergency room who is having what appears to be having a violent seizure, will obviously get the benefit of the doubt. In fact, in some cases, it is many years of investigating and giving high doses of seizure medications before a doctor realizes that the patient has been having nonepileptic seizures the whole time.
How doctors recognize them –
Research has shown that nonepileptic seizures occur more commonly in a doctor’s office or waiting room, or when there is a witness around. Some medical textbooks suggest giving such patients a sugar pill or an injection of water while telling them that this medicine has been known to cause seizures, and seeing if the patient starts shaking. While this can seem deceitful, the lie isn’t usually necessary: some patients still have these fake seizures even if they are told that they are being given something that can induce both real and fake seizures. Other things doctors look for are things such as where the patients bite their tongues, which is often in a different location for real and fake seizures, and the length and frequency of the seizures.
4. False comas
What are they –
Hopefully I don’t need to explain what a fake coma is. I will mention though, that people fake comas for a variety of reasons. Some people with psychological conditions feel safe in a hospital, and fake a coma so they are surrounded by doctors and nurses. Others have been found to fake being knocked unconscious on a ski hill, because they can’t afford a bus ticket home and would instead prefer taxpayers pay for a helicopter to fly them to the nearest city.
How they fool doctors –
By laying very, very still.
How doctors recognize them –
While there are some non-invasive tests that can be done to determine if a coma is indeed real, sometimes doctors aren’t even trying to “catch” a fake coma when they do their neurological exam and find that some results don’t add up. Also, patients who appear to be in a coma but resist the doctor opening their eyes, or flinching when the doctor’s stethoscope swings close to their face, obviously raise suspicion. Obviously to determine legitimacy it’s important the doctor knows what is normal, because strangely enough, patients with legitimate comas have been seen to do odd things such as cross and uncross their legs.
That’s not to say, however, that these “fakers” don’t need help. While the financial gains for drug-sellers or insurance scammers are usually based on greed alone, people who are addicted to drugs, or feign comas and seizures, can have very real and complex psychogenic conditions (to give you an idea of how complex these conditions can be, some patients may not even be aware they are faking). While they can make a doctor’s work more challenging, at the end of the day all of these people do need real treatment – not with narcotics or anti-seizure medications, but with psychological counselling to determine the underlying reasons that are compelling them to fake these conditions.
Friday, September 19, 2008
When patients try to fool doctors - four interesting types of fakers
Saturday, May 31, 2008
One patient, five minutes, I'll never forget
Even though we only had about six hours a week during which we saw actual patients in our first two years, we’ve seen enough by now that the details of individual patients start to blend into each other and fade away.
As for some patients I’ve met, though, I won’t forget them as long as I live.
It was during one of our many small-group clinical skills sessions that I met one of those patients. The goal of this particular session was to apply some of our neurology physical exam skills by practising them with some chronic paediatric patients who displayed neurological symptoms.
Memorizing a set of symptoms suggestive of a lower motor neuron disease (as opposed to an upper motor neuron disease) can be mundane when you read it in a library (or on a blog), but it can be life-saving in an emergency room – learning the intricate connections between the brain and the muscles is one way a doctor can tell if a patient’s sudden-onset drooping face could be because of a harmless palsy that will settle back to normal in a couple days, or if it might instead suggest a life-threatening blood clot cutting off the oxygen supply to the patient’s brain.
On the paediatrics ward, we went from room to room, playing with the cute kids, meeting their parents, and checking reflexes, feeling for stiffness, and looking for other neurological symptoms. At the same time, my efforts to keep my eyes open competed with my efforts to remember the relevant physiology. It was sad to see a number of children who are bedridden and have severe cognitive deficits…but everyone has seen a child in a wheelchair at some time or another, and the pre-exam study blitz was starting to take its toll on my sleeping habits.
Then we entered her room.
As he had done in all the rooms before, the doctor asked us to check for reflexes and stiffness as he started to tell us about the reason the girl was in the hospital. “Chloe came to us about six months ago after a non-accidental injury, suffering from cigarette burns, broken limbs and a fractured skull.”
I suddenly wasn’t sleepy anymore at all.
“What did he say?!” I thought to myself. “Non-accidental injury??!”
The doctor had already moved on and was talking about the clinical signs. “Notice the hyperreflexia, and positive Babinski sign on her feet,” he continued, but I couldn’t get past what I thought he had said.
“Non-accidental injury?? What, like abuse?” I thought.
That’s exactly what the doctor meant. After going over some more of her symptoms, we asked for more details about what the doctor meant by “non-accidental injury.” I regretted asking that. The doctor went on to explain the atrocious abuse this poor, beautiful young girl had suffered at the hands of her stepfather.
I was shattered. She was about nine years old, in a purple dress, with her blonde hair tied up in cute piglets, sitting in a tiny wheelchair just the right size for her small figure. I looked into her big, blue, eyes… they didn’t work quite in unison after being struck in the head so many times, but every so often she would look right at me, and smile so big, and I actually felt like crying. I was looking at a beautiful young girl who will never be able to live up to her full potential, because some utter idiot could find no better way to take out his rage than to use her tiny head as a punching bag. Honestly… can someone sink any lower?
It was then I realized I could probably never work in a chronic care paediatrics ward. I don’t have what it takes. I based that on my sudden urge to want to find out who the person was that did this to Chloe, hunt him down, and beat him utterly senseless. Nothing so far in my medical training has made me so angry as seeing the effects of the abuse on this poor girl.
Apparently Chloe had recovered immensely since she first came in to the hospital. She had been in a coma then, and here she was four months later sitting up, making noises, responding to people calling her name – much more than any of the doctors thought she would be able to do by now.
I hope she continues to recover beyond expectations, and that her life’s potential isn’t completely obliterated because of the useless sack of dirt who abused her. And I have high hopes for her, because despite the fact that she cannot talk, or walk around her own, she’s already making a life-changing impact…in those few minutes, without so much as a word, she left an impression on me more unforgettable than any conversation I’ve ever had.
Monday, July 23, 2007
Stolen moment, shattered life
"Before you interview this next patient, Vitum, there's something you should know." While this story is based on an actual experience I had in a hospital, and the effects of sexual assault on a person are real and devestating, the patient and experience depicted here is entirely fictional. Confidentiality of my patients is my highest priority, just as it would be if you were my patient. For more info, please see the disclaimer at the bottom of the page.
"Sure, what is it?"
The doctor closed the door to his office, and handed me the patient's chart.
"This patient came to me a couple of years ago. He's a very successful architect, he lives downtown, and he's overall quite healthy. But before you go in there, I just wanted to give you the heads up - he was sexually assaulted when he was a young boy. Just, you know, so if anything along those lines comes up in your interview you can be sensitive to that."
Ha, I thought. Warning me so that I don't put my foot in my mouth. Again. I guess he knows me better than I thought.
I appreciated the warning, even though the patient was there for something entirely unrelated and that issue never came up in the interview. The guy was obviously very successful, clean-cut, and seemed quite confident and professional. He took good care of himself and seemed to have a really good head on his shoulders. I wrapped up with the interview pretty quickly, told him the doctor would be in to see him, and then went back to the doctor's office.
When the doctor is with another patient and I'm waiting, I'll generally review my class notes if I've got them, brush up on a few drugs, look over the drug samples in the office wondering if I could just take some pills just to try them out. Or I'll look over the various diagnostic journals piled high on the doctor's desk, or read a patient's chart if I've got it. Not really thinking of the warning the doctor had given me, I habitually cracked the patient's chart and began reading.
In just a few minutes, what I learned about the lingering effects of child abuse will stay with me forever. I caught a snapshot of how a brief moment stolen from this poor man's childhood has in one way or another affected every aspect of this patient's life.
The chart read like a paperback story that would be too depressing to ever make it to print. It was packed full of the effects about how this patient's life had been dramatically and irreperably changed because of this incident. Here were the carbon copies of emergency room charts depicting the patient's multiple visits for anxiety attacks, thanks to post-traumatic flashbacks of the experience. There were the notes from a psychiatry consult that the patient had undergone shortly before, which contained more terrible, heartrending details of not so much the experience, but how it had affected him.
The patient had initially told his brother, his closest friend, about what their hockey coach had done to him. His brother's response? He didn't believe him. That's pretty much the worst thing you can do if someone approaches you saying they've been assaulted. After that, the patient didn't bother telling anybody else about it, until he needed to seek medical attention for the stress; even still, there are only a few people that he's told.
Now, he suffers from frequent flashbacks, most of which land him in the ER with anxiety attacks. He has trouble with commitment (more than the average guy) or sexual intimacy - I wonder if he'll ever be able to settle down with someone. He can't be alone in a room with an older male - must be hard to have a job interview under those circumstances. He can't have anything to do with hockey games, arenas, or the game in general - that must make it difficult to go to a bar with the guys.
I had heard that sexual abuse can be a tragedy that significantly affects a person's life, but I had had no idea that it was that pervasive. My heart went out to this patient when I finally went in with the doctor. I was one of maybe five people on earth that knows about his secret, and as much as I wished I could do something to help him get back to a normal life, I couldn't. All I could do was be shocked at how unbelievable it is that one brief, disgusting, selfish action that lasts a brief moment can literally ruin a victim's life. It literally made my stomach turn.
The worst part is, the creep who did this is still free, probably still working with young kids, quite possibly still assaulting children, ruining lives by taking one moment at a time.
One of the things that attracted me to medicine is how a doctor is much more than just one thing - a doctor is an expert in chemistry, biology, pharmacy; a manual labourer, a thinker, a problem-solver; a teacher, an advocate, a counsellor. I'm not sure, but judging by how nervous I am to have to someday be the listening ear to someone who confides in me the details of their painful past, that last one might be the hardest one.
