Medico-legal reporting: detecting the professional malingerer

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Hello Colleagues,

From time to time I am called upon by various agencies to report on the status of a patient in connection with fitness to work, insurance claims, post-operative recovery issues etc.

Once in a while I find a patient I believe is faking symptoms. When investigations are normal and clinical tests reveal little. When the only evidence is vague, and confined to a subjective complaint from the patient who says there is "foot pain"; "it hurts all the time" etc. Or when there are some findings but the connection with the alleged pain is all but tenuous.

I will be interested to know if as a profession there are 'pearls of wisdom', e.g. clinical assessment tests etc. that can be deployed as evidence to the suspicion of a malingering patient, with a known or hidden agenda.

For example, I have spoken to a back specialist who has devised tests that can expose the faker from the genuine. Can the Podiatrists / Podiatric Surgeon devise similar tests to help with this? And, if necessary, is such evidence robust enough to withstand the legal test?

What is it that makes me hesitant about condemning a patient outright? Simply because I have to accept there are patients with foot pain who cannot be easily diagnosed. There is a small cohort of patient with such foot pain, who has no other motive (that we know of) other than to return to a pain free foot.

I have previously considered posting this enquiry - but it is an open forum and internet savvy patients harbouring any such plans could easily also learn from this exchange. And perhaps this is more suited to a PM reponse.

What are your experiences of this type of work? And have you found a good strategy to deal with this type of patient and enquiry?

 

Hello Dieter,
Usually malingering is found is injured workers and not in sports/other injuries. Injured workers who seem to never get better typically have one of two motives. One motive is psychological--the worker may fear the work place, may hate his/her manager, may dislike his/her coworkers, may feel disrespected or may feel overworked. The second motive is financial or other gain--time off, time to care for babies, increased financial settlement money or similar. Both types of complications exaggerate symptoms.
In the event of psychologic complications delaying recovery, the patient will be consistent in his/her symptoms unless highly distracted (a child gets hit by a car and they rush to the scene). Over time these patient will develop physical complications from disuse and over-protection.
The people who are attempting to manipulate you for financial or other gain are not consistent in their performance. For example, they are seen at the grocery store walking normally and then when coming to the medical office, they get out the crutches and limp and grimace.
Taking a little time to talk to the injured worker about their view of their employer, their lives and so forth should give a preliminary indication. Psychologic injury may not be something you wish to treat; referral to an occupational psychologist may be in order. As for the patient who is manipulating you for financial gain, this is not a medical condition, it is a legal one. You cannot 'fix' these people. They are not patients.
I have 30 years experience in treating injured workers with musculoskeletal and nerve injuries. Hope this was helpful.

 

If you can find no evidence of ongoing pathology to explain the limitations in returning to normal activities, then you could recommend to the insurer (who you I suspect would be paying your fee) to obtain an undercover investigation with footage of 'normal daily activities'.

I have come across this technique being used to sucessfully counter claims against podiatric surgeons for postoperative complications, and may be the only objective evidence that can be used in these cases.

Insurers routinely retain the services of these licenced investigators in cases of suspected medical disability fraud.

LL

 

LL is correct in that insurers use sub rosa investigators. Other options include getting the patient back to work in a light duty capacity at the same employer so that the gain of staying home is lost. Another option is to start a work-related 8 hour per day 5 day per week therapy program, so that return to work looks better than therapy. Sophe

 

Sophe/ LL

Thanks for this feedback. Any experience / thoughts about the value of psychometric tests in this context?

 

Regarding psychometric tests: I have not identified any that are superior to careful observation and documentation of the patient's behaviors and comments. I would be interested in the opinions of others, too. Sophe