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(I accidently put this in the wrong thread, I had intended to put it in its own thread).
I am very frustrated with the lack of orthodox and conventional guidelines written for this subject.
And the lack of orthrodoxy leads several docs to disagree on what to do, and that lack of agreement makes it difficult to take appropriate action.
What do you do with a patient where there is strong suspicion of malingering? E.g. a homeless patient who goes to an expensive hotel, gets the most expensive services, then when told to pay pulls the suicide threat and actually cuts themself. That patient is then brought to the ER, gets out of paying the bill (all the while has a smile on his face), goes to the hospital, is observed for several days, is discharged, the hospital psychiatrist slaps the patient with a depression label for billing purposes (the hospital makes no money with a malingering diagnosis), even though that psychiatrist doesn't believe the patient is depressed, then the patient simply repeats the behavior.
So now, you're the ER psychiatrist and being that your colleague now slapped a depression diagnosis. and being that this patient is actually willing cut themself to continue this lifestyle, are you going to confront the patient, being that the patient will cut themself, and refuse to continue the erroneous depression diagnosis on the patient's record?--> and under such circumstances, managed care will not pay for inpatient treatment for malingering. Or are you going to refuse this patient from gaining admission to the hospital, write in the record that this is malingering--risking the patient cutting himself, which in turn will get the hospital upset at you, then force the patient back to the ER, where you'll have a very upset ER attending, or do you just continue the faulty diagnosis because then it'll get the patient into the inpatient unit of the hospital, then it's now someone else's problem?
When should psychiatrists put their foot down? Why will no one openly discuss this issue?
Why for example isn't there an established standard of care to address this issue (at least as far as I know), especially for patients who are openly practicing malingering in a fraudulent manner.
I asked several of my attending doctors what should I do in this situation. Unfortunately all gave me a different answer, making me believe there is no established standard of care on this risky diagnosis. Further, Kaplan & Saddock doesn't provide any definitive guidelines either.
I am very frustrated with the lack of orthodox and conventional guidelines written for this subject.
And the lack of orthrodoxy leads several docs to disagree on what to do, and that lack of agreement makes it difficult to take appropriate action.
What do you do with a patient where there is strong suspicion of malingering? E.g. a homeless patient who goes to an expensive hotel, gets the most expensive services, then when told to pay pulls the suicide threat and actually cuts themself. That patient is then brought to the ER, gets out of paying the bill (all the while has a smile on his face), goes to the hospital, is observed for several days, is discharged, the hospital psychiatrist slaps the patient with a depression label for billing purposes (the hospital makes no money with a malingering diagnosis), even though that psychiatrist doesn't believe the patient is depressed, then the patient simply repeats the behavior.
So now, you're the ER psychiatrist and being that your colleague now slapped a depression diagnosis. and being that this patient is actually willing cut themself to continue this lifestyle, are you going to confront the patient, being that the patient will cut themself, and refuse to continue the erroneous depression diagnosis on the patient's record?--> and under such circumstances, managed care will not pay for inpatient treatment for malingering. Or are you going to refuse this patient from gaining admission to the hospital, write in the record that this is malingering--risking the patient cutting himself, which in turn will get the hospital upset at you, then force the patient back to the ER, where you'll have a very upset ER attending, or do you just continue the faulty diagnosis because then it'll get the patient into the inpatient unit of the hospital, then it's now someone else's problem?
When should psychiatrists put their foot down? Why will no one openly discuss this issue?
Why for example isn't there an established standard of care to address this issue (at least as far as I know), especially for patients who are openly practicing malingering in a fraudulent manner.
I asked several of my attending doctors what should I do in this situation. Unfortunately all gave me a different answer, making me believe there is no established standard of care on this risky diagnosis. Further, Kaplan & Saddock doesn't provide any definitive guidelines either.
), or states he's suicidal, and has absolutely no history of ANY kind of self harm--I call him "the crack addict who cried wolf." He comes in when he can't get EtOH or crack, is happy to get a little Seroquel or anything else, and gets d/c'd the next day. After doing this with this pt twice, and confirming his utter lack of credulity with his case manager, I refused to see him--twice--when paged by the ED (all the ED docs with huevos would d/c him without calling psych, but a few well-known "dispo dumpers" always try to get psych to see these guys). He is truly notorious in this city. It's always easier to d/c a malingerer when you have history--when they're new to you, it's harder to do (but I still do it if I think they're full of crap!). Once they know you're on to them, it gets easier to talk them out of their DTO/DTS claims. Document, document, document!
