|By Jeffrey E. Keller MD|
I went to the always excellent NCCHC spring convention in Nashville last month. One of the many outstanding presentations was done by frequent lecturer Deana Johnson. Deana talked about the risks of using the word “malingering.” Her basic message was to be very careful about saying that an inmate is malingering—in fact, perhaps we should never use that word.
I was surprised by the degree of spirited disagreement from several members of the audience. They pointed out that “malingering” has a specific medical meaning and sometimes—even often—it is an appropriate medical diagnosis. They pointed out that malingering is listed as an official diagnosis in DSM-5 and that outside medical agencies, like mental hospitals, use the term malingering. If we can’t say that an inmate who is clearly faking is malingering, what are we supposed to say?
Today in Jail Medicine, I am going to tackle the term malingering. It turns out that there is indeed a correct and proper way to use the term malingering in correctional medical practice—but it is tricky and most often (in my experience) done incorrectly, with resultant bad consequences.
There are three important reasons for this. First, most people have an inaccurate idea of what malingering actually means in a medical sense and so use the term inaccurately. Second, the use of the term “malingering” also carries with it an emotional definition that MUST be taken into account when it is used in a medical document. Finally, use of the term “malingering” has important consequences for patient relations, patient behavior and time management.
The bottom line, in my opinion, is that “malingering” is a term that should very rarely be used in correctional medicine. There are better and more precise ways to convey medical information. But if you do absolutely want to use the term “malingering,” you need to know how to use the term correctly.
In my opinion, the most important consideration of the term “malingering” is not its actual definition. The most important part is its emotional meaning. This is a word that causes others to instantaneously have a strong emotional reaction. When you say that a patient is malingering, whether you are using the term correctly or not, what that patient (and others) understand is that you are calling them a liar. This reaction is instantaneous and creates a powerful emotional response. You might argue “I am using the term correctly according to its definition in the dictionary.” The patient will not care. The patient hears “LIAR!”
This emotional reaction places the word “malingering” in the company of other notorious words in which the emotional reaction they generate far overshadows their dictionary definition. Examples are the “N” word or the “F” bomb. If you drop the “F” bomb in your next professional case conference, you will not save yourself by arguing “Well, I used the term correctly according to its definition in the dictionary.”
“Malingering” is like this. “Malingering” is the “M” word.
So ask yourself this: Is the information I am conveying when I say that a patient is malingering so important in a medical context that it outweighs the inevitable emotional backlash?
The Definition: Three Requirements
To answer that question, we need to look at the precise definition of the word “malingering.” Here is the Dictionary.com definition: “to pretend illness in order to shirk one’s duty or avoid work.”
Here is a longer psychology definition: “the purposeful production of falsely or grossly exaggerated complaints with the goal of receiving a reward, such as money, insurance settlement, avoiding punishment, work, jury duty, the military or some other kind of service.”
So. In order to satisfy this definition, you need to establish three things:
First, the patient must be pretending or feigning an illness.
Second, the patient must be doing this deliberately. It must be planned in advance.
Three, the patient must have the goal of obtaining something significant through the deception. Traditionally, malingering was done to shirk duty, such as military duty. In correctional medicine, a comparable example would be to get out of jail or have charges dismissed.
Let’s apply these to a couple of scenarios (based on my own real life experiences).
Feigning? Or Exaggerating?
Patient one has a history of back pain and back surgery, that led him into opioid addiction, which landed him in jail. He shuffled into my clinic bent over and limping because (he said) he was in so much pain that he could not function. The thing he needed was another back surgery, which could not be done while he was in jail. In the meantime, oxycodone was the one thing that worked for his pain and he expected me to prescribe it.
When I declined this request, this patient became quite upset and stormed out of the clinic room threatening litigation. I could not help but notice as he left that he was not bent over and was no longer limping. He was striding along purposefully without any of the apparent disabilities that he had before.
So here is the question—was this patient malingering?
Well, to qualify as malingering, one must feign an illness. But based on my review of his MRI and surgical history, I have no doubt that this patient truly did have low back pain. He was not feigning an illness that he did not have. Instead, he was exaggerating the disability this pain caused him. That is not technically malingering. Instead, this behavior is more properly described as “symptom magnification.” It would have served no purpose for me to say in the chart that this patient was malingering. Instead, I documented the discrepancy between the way the patient walked into the clinic and how he walked out and said that it appeared there was no significant disability.
What good would it have done for me to use the M-word?
Calculated and Deliberate?
Here is a second example. A patient in my jail (we’ll call him MJ) said that he must be released from jail because he had cancer of the blood diagnosed by a university cancer clinic in another state. He demanded to be released immediately so he could return to this out-of-state university to begin chemotherapy.
This is the sort of investigation that the nurses in my jail love to do! In this case, they discovered that MJ had indeed gone to this university cancer center claiming to have leukemia. However, a complete work up done by them had been negative! The nurses also discovered that this patient had been to several other cancer centers with the same claim and the same result!
Would it be appropriate to say that this patient was malingering?
The answer, again, is No. In order to qualify as malingering, MJ’s deception had to be deliberate. In this case, the patient truly believed that he had cancer! His “cancer” was a persistent psychiatric delusion.
What is the Goal?
I had a patient in my jails (Cory, let’s call him) who faked seizures. These were not the Psychogenic Non-epileptic Seizures I have written about before, but truly and deliberately faked (I know this because he eventually admitted it). Cory could do an excellent fake seizure, right down to biting his tongue and peeing his pants! Many patients with pseudoeseizures also have real seizures, but after extensive investigation, Cory was not one of them.
So—was Cory malingering?
Feigning a nonexistent medical illness—check. Doing so deliberately—check. But the goal being sought doesn’t fit. Traditionally, malingering was done to avoid going into combat or going to work or to get a disability payment that was not deserved. But Cory had nothing that impressive in mind. Cory faked seizures because, well, he liked to fake seizures. He liked the attention and commotion and being in charge. Technically, this is not malingering. This is what is called “factitious disorder.” It would be incorrect to apply the M-word to Cory.
Here’s another example. Throughout my career in both the ER and the jail, I have frequently encountered patients who have some variation of this common complaint: “I have chronic pain and the pain medication I am being prescribed is not working. I need something stronger! Something like, __________ (fill in the blank here—Oxycodone! Tramadol! Gabapentin! Lyrica!).”
In this case, even if I can show that they are grossly exaggerating the degree of their pain, the goal being sought does not qualify for the term malingering. Traditionally, malingering was done to avoid going into combat or going to work or to get a disability payment that was not deserved. If what the patient wants is stronger pain medication that you are offering, that does not qualify as malingering. This behavior is so common that to call it the M-word would negate the meaning of the word. The goal has to be greater than med seeking, at least in my mind.
In the end, it can be truly hard to know for absolutely sure that a patient is malingering. You have to be able to say that this is not symptom magnification—the patient really has no symptoms at all. You have to be able to say that the patient is perpetrating this falsehood knowingly and deliberately. And you have to know what it is the patient wants—something more than better pain killers. When you use the M-word, you are rendering a final judgment about all of these things.
What If You Are Wrong?
This is the single most important item to think about before you use the M-word: What if you are wrong? One of my ER partners had a young man present with sudden atraumatic loss of feeling and function from his waist down. He seemed weirdly unconcerned about this sudden catastrophic development. His interaction with his parents suggested attention seeking. Most patients with such a story end up being diagnosed with a conversion reaction or factitious disorder or some other psychiatric cause. My partner sent him home, telling the parents “He’s faking.” Only . . . he wasn’t. This patient had a rare congenital AV malformation and was indeed a new quadriplegic. You can guess the result of this fiasco, Lawsuit. Recriminations. Disciplinary actions. It got ugly.
What is the Goal You Want to Accomplish?
Correct me if I am wrong, but for all of these patients I have presented here–the exaggerated back pain guy, the “I Have Cancer” guy, Cory with fake seizures, the multitiude of “I want stronger pain meds” patients–for all of them, the true ultimate goal is for them to stop complaining! Stop exaggerating your symptoms! Stop believing you have Cancer when you don’t! Stop faking seizures! Stop bugging me for stronger pain meds you shouldn’t have!
How likely is an accusation of malingering affect this goal? Here is what I believe: if you accuse a patient of malingering, that patient is unlikely to stop. In fact, I think they will be more likely to do the exact opposite and accelerate their complaints, all in an effort to convince you that they are telling the truth. They will want to regain their besmirched honor! In fact, many of them will try to FORCE you to believe them, via grievances, lawsuits and being ever present in your clinic.
Simply by using the M-word, you have re-defined your relationship with these patients as being adversarial. From a time management standpoint, you will spend a lot of time arguing, answering grievances, and attending case management meetings.
I venture to say that none of this is really what you want! Getting these patients to stop their egregious behavior requires behavioral modification techniques, which is a totally different kind of Verbal Jui-jitsu. The M-word does not appear in these techniques.
In the end, in my opinion, medical practitioners in corrections should rarely, if ever, use the M-word “Malingering” in their documentation. Most of the time, the cases we are talking about do not meet the strict definition of malingering: The patient really has a problem. He may be exaggerating, but he has underlying disease. Or there is no true deception—the patient believes what he is saying. Or the goal being sought is not significant enough to satisfy the definition.
Also, using the M-word defines our relationship with our patient as being adversarial. We do not want to be enemies with our patients. Enemies may retaliate by using grievances and lawsuits.
Use of the M-word will tend to make inappropriate behaviors worse, when we really want them to stop.
Using the M-word will almost invariably be a time drain, because you will have to repeatedly justify its use, over and over and over again.
It’s just not worth it—most of the time.
Next time on JailMedicine: The Right Way to Document Malingering! (Yes, there are rarely times when “malingering” is appropriate and not “The M-Word”)
As usual, what I have written here is my opinion. I could be wrong! If you disagree with anything I have written, or if you have an example of the use of the M-word gone awry, please comment!
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