I don't admit patients who I have strong suspicion to think are malingering. Sometimes I have had aggressive patients who have threatened to kill themselves forcibly escorted off hospital grounds by security. The problem with tests in medicine is that they have led to a general deskilling which is why US physicians have such woeful clinical skills. If you can no longer rely on your clinical acumen to decide that the pt is malingering how can you rely on the test to gel with your clinical impression? Tests have FP and FN too and there are lots of variations to take into account.
Psychiatry has being moving in the direction to become more "objective" but the very basis of psychiatry is subjectivity itself. As I wrote recently:
The Myth of ‘Objectivity’ in Medicine
Psychiatry by its very nature deals with subjectivity. Patients present with experiences; experiences that I can never know, nor ever see.13 The field has come under criticism for lacking objectivity, and not having blood tests or imaging or other confirmatory markers for the existence of illness or disorder. In a misguided attempt to look more scientific and objective, psychiatry has turned to the ridiculous task of looking for blood tests or biomarkers for depression and other such mental states. Quite apart from just how absurd it would be to ‘diagnose’ someone with depression or psychosis from a blood test or brain scan, the reliance on so-called objective indicators of disease is a hermeneutical nightmare. The technologization of medicine has led to spiraling healthcare costs, the devaluing of relationships and narratives, and the deskilling of doctors.14
Take the example of hypertension. This is a risk factor rather than a disease, but it is ‘objectively’ measured and thus the point at which blood pressure is considered hypertension in need of treatment should be uniform based on the scientific evidence. Yet if you live in the US and had uncomplicated hypertension, you would be treated when your blood pressure is above 150/90mmHg.15 In the UK, you would be treated if your blood pressure is above 160/100mmHg.16 What constitutes hypertension in need of treatment cannot then be based on science alone. It is constrained by interpretation, an act which itself is constrained by the surrounding social, political, and economic space.
Turning to cancer, which most people would consider a diagnosis made through objective means, the story is even more frightening. One test that has been used in the US until recently to screen for prostate cancer is the prostatic specific antigen (PSA). Screening identifies cancers in people who are not ill, do not need or benefit from diagnosis and are ultimately harmed by treatment. Overdiagnosis of prostate cancer is as high as 50% in those diagnosed with prostate cancer. In one of the largest studies of its kind involved 182000 men, 1410 men had to bee screened and 48 unnecessarily treated in order to prevent one death.17 Complications of treatment of prostate cancer routinely include impotence, urinary incontinence, and radiation proctitis. The largest study of its kind to review the effects of mammography for breast cancer found that over a 30 year period 1.3 million women were unnecessarily diagnosed and treated for breast cancer, with 70 000 women in 2008 alone unnecessarily diagnosed with breast cancer.18 Mammography routinely identifies disease in those who would never become ill (have symptoms), or where the cancer would never pose a threat to life. The use of objective tests in medicine is rife with their own problems because they need interpretation. Where there is interpretation, there is error.
Diagnostic tests in the majority of cases were never meant to ‘make’ a diagnosis but to support a diagnosis, which is made from carefully listening to the history of the illness and through physical examination. As medical practice has become more litigious and we have become more reliant on tests to make diagnoses, doctors spend less time listening to their patients, and no longer trust their clinical skills. I went into psychiatry because of the focus on subjectivity, narrative, meaning and relationships. Because these are no longer valued in medicine, they are also less valued in psychiatry.
