It happens much more frequently than you realize, however, it seems many fellow physicians are either too busy (probably the most common reason), don’t chart review (probably the second most common reason), don’t care, believe the silly mantra of “always believe the patient” that they teach you in med school and residency, have no common sense, and/or are extremely gullible. If I had to estimate the number of times I care for a malingering/factitious disorder patient, it’s probably once every 4-5 shifts at a busy ER. I have no doubt a few slip through that I don’t realize, too. Anytime a patient starts trying to dictate care in a way that makes formal workups for the CC impossible and throwing out convenient allergies, I immediately call BS until proven otherwise, and usually tell them up front that I will work them up and treat them as I deem appropriate regardless of things like “contrast allergies”*, and will not prescribe narcotics unless I find objective evidence of acutely painful pathology. That usually gets 90% of them to leave AMA immediately.
I’ve lost count now of the number of people I’ve caught faking sickle cell to score pain meds who have completely normal hemoglobins. Like how does an ER doctor see a hemoglobin of 15 and then keep pumping them full of Dilaudid? This will go on for months or years of checking in several times a week and scoring meds with normal Hgb levels before I finally catch them and it always blows my mind. The best is when they are 40-50 years old and have no medical comorbidities. Like, come on, have you ever seen a legit 40-50 yo sickler? They typically look like death with fake hips, prior strokes, on dialysis, heart failure, and/or blind.
I also had a 20 yo girl fake hematemesis by wiping her period blood around her mouth and pretend to pass out in the bathroom. I found blood under her fingernails and on her hand. Blood was smeared around her mouth and absolutely nowhere else except the hands, and she admitted to being on her period. Nurse caught her when she checked back in the next day. Had to have security escort her out when she faked a seizure after I told her I was discharging her. The doc that saw her the next day was actually going to admit her for a scope despite a completely normal hemoglobin and vitals until the nurse caught her. Didn’t even read my note stating I suspected she was doing that.
Then you have your pseudoseizure patients who check in monthly for “seizures” to score benzos and attention, and somehow a few of them have been intubated several times by colleagues, have had 10 prior continuous EEG monitoring that is always completely normal, and amazingly never fake a seizure while on EEG monitoring despite daily seizures. They are also typically somehow only on keppra despite “uncontrolled seizures” because no neurologist believes these are actual seizures, although occasionally some outpatient neurologist is even tricked into giving them more than just keppra. The only on keppra despite “uncontrolled seizures” is always the obvious tell, because that is the only anticonvulsant us ER docs are comfortable initiating a patient on.
Maybe I chart review more than most? Maybe my BS detector is much more honed than most, or I’m just skeptical by nature, especially when a patient hits one or several of my red flags (multiple allergies, numerous prior visits without admission or with very short admissions, loudly crying or moaning which stops when distracted, multiple psych diagnoses, refusing very specific studies, contrast allergies, feel like I’m being manipulated during the interview with phrases like “but you’re the doctor, I’ll do whatever you say” after trying to dictate care, talking with the benzo/opioid slur, etc.).
*Side note, I’ve given iodinated contrast to 100s of patients that claim anaphylaxis to contrast in my career, and not once have any of them had a single reaction. Literally not once. Most of whom I’m not premedicating either unless I have a particularly annoying rad tech working that shift. Obviously that is due to contrast reactions not being a true antibody mediated reaction and premedication being ineffective at preventing severe reactions, but I see so many colleagues forgoing appropriate studies due to the fear of contrast allergies. I’ve had numerous colleagues transfer me someone for an MRI because they needed a contrasted study but were “allergic to contrast” who I then just did the contrasted CT and discharged them. The other day, I had a rad tech refuse to give contrast because a patient claimed they got seizures from contrast. Had to call her supervisor to come in the perform the study.
