In the psych emergency room, dow do you personally deal with the malingering patient.

[MacDonaldTriad]

A long time ago, there was talk about making it a sub specialty in psych, but the decision was no. There may be an informal fellowship in it somewhere and there is a national organization.

http://emergencypsychiatry.org/

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[WingedOx]

A long time ago, there was talk about making it a sub specialty in psych, but the decision was no. There may be an informal fellowship in it somewhere and there is a national organization.

http://emergencypsychiatry.org/

I had a pretty comprehensive emergency psych fellowship a number of years ago.

It was called "my intern year"

 

[MacDonaldTriad]

If you google it, more than half a dozen pop up. Because of the hours and demand, it is hard to keep psychiatrists in ERs. There are just too many 9-5 M-F jobs out there.

 

[FlowRate]

without using the word countertransference

Just curious why not?

Because of the hours and demand, it is hard to keep psychiatrists in ERs

I've seen attendings who work psych ED (more specifically, psych for a general ED, not a PED) half-time. I guess they are on supervisory call overnight sometimes, though. Does the usual psych in an ED work more/more unusual hours than that?

 

[splik]

Just curious why not?

1. because it's not necessary
2. because it requires belief in psychodynamic concepts which are not going to go down well in court
3. because descriptions of countertransference belong in your personal psychotherapy notes and never in the medical record

 

[HarryMTieboutMD]

A "psych ED" fellowship and board certification would be a colossal waste of time (as is every psych fellowship besides child and forensics). I'm sorry, but if a residency training program doesn't provide adequate training/experience in emergency psych issues, then your PD needs to do some soul searching. Getting comfortable with discharging malingerers/repeat offender borderlines/other people who wouldn't benefit from admission is a skill set every psychiatrist should have. And the "emergent" psychiatric issues should be taught and retaught in residency. If you love being an ED psychiatrist, when you are done with residency look for a job in ED psychiatry.

 

[WingedOx]

A "psych ED" fellowship and board certification would be a colossal waste of time (as is every psych fellowship besides child and forensics). I'm sorry, but if a residency training program doesn't provide adequate training/experience in emergency psych issues, then your PD needs to do some soul searching. Getting comfortable with discharging malingerers/repeat offender borderlines/other people who wouldn't benefit from admission is a skill set every psychiatrist should have. And the "emergent" psychiatric issues should be taught and retaught in residency. If you love being an ED psychiatrist, when you are done with residency look for a job in ED psychiatry.

Seriously. I'm biased because I came from a program with a very front-loaded call schedule, but if I can't trust your judgement about patient triage by the end of intern year, I'm getting seriously worried. It's one of those "You need to know this before you can do anything else" type of skills.

 

[Doctor Bagel]

Seriously. I'm biased because I came from a program with a very front-loaded call schedule, but if I can't trust your judgement about patient triage by the end of intern year, I'm getting seriously worried. It's one of those "You need to know this before you can do anything else" type of skills.

For such a gray area, though, it's hard to know if your outcomes re: these decisions are good/bad/right/wrong. Even with a lot of experience, I think there's a lot of room for self doubt or worry.

 

[WingedOx]

For such a gray area, though, it's hard to know if your outcomes re: these decisions are good/bad/right/wrong. Even with a lot of experience, I think there's a lot of room for self doubt or worry.

Yeah, but that's part of the game, sadly, and happens more than just the ED. I had a patient of mine in my office a month ago that I didn't admit on a Friday, who OD'd by Monday morning. It's a ****ty feeling for sure, but one that happens to all of us. FWIW, of all my suicide attempts that happened as an attending, this was the only one that didn't come out of left field. I'm more in tune with my zeroing in on every possible risk factor when I'm clearly in a crisis situation.

What I hammer home to people early in training when I work with them is simply being comfortable with making decisions. You don't have to know that you're 100% right, but if you can justify you reasoning to yourself, justify it to other professionals, and document it clearly in writing, you've mastered the basics to run ED consults without me worrying. (justifying it to patients is a harder skill, ironically enough).

 

[HarryMTieboutMD]

Yeah, but that's part of the game, sadly, and happens more than just the ED. I had a patient of mine in my office a month ago that I didn't admit on a Friday, who OD'd by Monday morning. It's a ****ty feeling for sure, but one that happens to all of us. FWIW, of all my suicide attempts that happened as an attending, this was the only one that didn't come out of left field. I'm more in tune with my zeroing in on every possible risk factor when I'm clearly in a crisis situation.

What I hammer home to people early in training when I work with them is simply being comfortable with making decisions. You don't have to know that you're 100% right, but if you can justify you reasoning to yourself, justify it to other professionals, and document it clearly in writing, you've mastered the basics to run ED consults without me worrying. (justifying it to patients is a harder skill, ironically enough).

Love this. MD=My Decision, and I see too many doctors lacking in confidence in decision making. When I interviewed at my program, the chair told me, "we will force you to become a decision maker." I am so thankful that our PGY2 year is Q7ish overnight ED call and an additional month of ED days, where we do not run decisions by the attending (similar autonomy is allowed on consults as well). Initially calling the on call attending to run through decisions is permissible but after a couple of months it raises concerns among the faculty if a resident persists. I now only call in the cases of administrative BS interfering with my decision (ie, some administrative internal med Dr forces an inappropriate admission- then I get my attending involved). Bottom line, when I recommend discharge with people who would not benefit from admission begging/pleading with me ("Im gonna run into traffic if I leave!") or become so agitated they require police escort off the premises, which sometimes causes the general ED attendings to question my judgment, but I feel completely comfortable in my decision making (knowing it's a grey area and I could be wrong- but I can document my reasoning).

 

[Doctor Bagel]

Yeah, but that's part of the game, sadly, and happens more than just the ED. I had a patient of mine in my office a month ago that I didn't admit on a Friday, who OD'd by Monday morning. It's a ****ty feeling for sure, but one that happens to all of us. FWIW, of all my suicide attempts that happened as an attending, this was the only one that didn't come out of left field. I'm more in tune with my zeroing in on every possible risk factor when I'm clearly in a crisis situation.

What I hammer home to people early in training when I work with them is simply being comfortable with making decisions. You don't have to know that you're 100% right, but if you can justify you reasoning to yourself, justify it to other professionals, and document it clearly in writing, you've mastered the basics to run ED consults without me worrying. (justifying it to patients is a harder skill, ironically enough).

Looking back at your previous post, you mentioned being worried if you can't trust someone else's judgment by the end of intern year. I think that's fair. I think it's more trusting your own judgement in these gray area situations, and I honestly think some people are never going to be comfortable doing this type of work -- that the trade offs and risks of making the wrong decision don't make up for the benefit. That's OK. We probably don't disagree on that. I wonder how many of my bad outcomes I don't hear about, and I wonder how I'd feel if I did.

 

[WingedOx]

Looking back at your previous post, you mentioned being worried if you can't trust someone else's judgment by the end of intern year. I think that's fair. I think it's more trusting your own judgement in these gray area situations, and I honestly think some people are never going to be comfortable doing this type of work -- that the trade offs and risks of making the wrong decision don't make up for the benefit. That's OK. We probably don't disagree on that. I wonder how many of my bad outcomes I don't hear about, and I wonder how I'd feel if I did.

Yeah, I wonder a lot about some of my long-term patients from my previous job quite a bit. I also know I've made plenty of mistakes along the way, and also plenty of "right" decisions that made the patient worse-off. I came to accept that this is a decision-making profession along the way.

I think bizarrely enough the first time I ever felt truly comfortable in residency was working nights. It was just me alone down there but it was nice to know that I could just focus on myself and my decision-making and patient counseling and not worry about putting on a performance for an attending (particularly since that caused me so many problems in med school. "Looks disinterested" seemed to go on all my M3 evals).

 

[MacDonaldTriad]

For such a gray area, though, it's hard to know if your outcomes re: these decisions are good/bad/right/wrong. Even with a lot of experience, I think there's a lot of room for self doubt or worry.

Of course self-doubt and worry are important traits and if they are missing, bad things happen. It is all about how you respond to your first bad outcome. Most don’t, but some psychiatrists become paralyzed and refuse to make decisions. They transfer, admit, they delay until the next shift, they will do anything to avoid taking any chances. They also dilute the efficacy of the system and thereby do more harm, but harm in ways that are less obviously their fault. They also complain the most about the lack of resources because if your strategy is dominated by fear and avoidance, not enough beds is the only firm limit to this behavior. Micro psychiatry is learned in clinical rotations. Macro psychiatry takes experience in multiple settings and perspective that doesn’t always develop when we are too risk adverse.

 

[whopper]

1) Determine if a) likely not malingering vs b) suspicion of malingering.
You can ferret out a malingerer in the ER but only if it's blatantly obvious. Some ERs have PESs and/or sections where psychiatric patients can be observed for hours. If this is the case you can possibly detect malingering while the patient is sitting there for hours. During this time a social worker could also work on getting collateral information.

If a) proceed as usual. If you have significant reason to believe the patient is malingering proceed down.
2) a) Blatant malingerer: discharge but this can be difficult. They might act out in anger and attack someone. I tell them they will be discharged but offer some type of token such as addressing their needs. E.g. if they are homeless and that's why they are malingering a referral to the homeless shelter or offering them to stay for another 1-2 hours to make phone calls for someone to pick them up. I still give a psych referral because someone so desperate to malingering likely is in need of some type of psych service thought inpatient is likely not appropriate.

2) b) Suspicion of malingering but not sure. Hold them for at least a few hours for observation. This might not be possible in several ERs. IF you're still not sure admit. Write on your progress note reasons why you have to suspect malingering in a diplomatic manner and don't use the word malingering.
E.g. "Although the patient alleged to be depressed, while being observed for hours in the ER they showed signs inconsistent with depression such as a euthymic affect, lack of psychomotor ******ation, and there are factors suggesting possible secondary gain." Also call the clinician on the inpatient unit to alert them. This will accelerate the malingering detection process on the inpatient unit and you won't be setting the inpatient team up for failure if they kick the patient out. I've been in situations where the doctor that gave me the patient specifically wrote the patient was very sick but then under the table told me they were malingering. WTF!?!?!?!?
In doing so you just made it 10x harder for me to kick out the patient.

In fact a problem I had with my last job was some of the doctors were too chicken to discharge malingerers (that they even knew were malingering) and literally told the residents to dump the patient to me while writing down on the chart that the patient was truly mentally ill. When I brought it up in a faculty meeting that this is preventing me from getting the patient out aside that this is insurance fraud no one really addressed the issue I guess because everyone wanted to be PC and not point fingers (though I was willing to point fingers).

I had one guy I had to keep in there for an extra week and get a psych consult on the patient for the above reason. The psych consult was needed to get another doctor's verification because if it ever went to court between me and the other doc it'd be a 50-50 thing. I wanted to make it 66 to 33 thing. I was infuriated because the previous doctor even admitted to me he thought the patient was malingering but littered the chart with comments that the patient was mentally ill and needed to be in the inpatient unit.

Another thing in the case was the malingerer was dangerously impulsive (not in an Axis I manner but in an Axis II cluster bmanner). So I had strong reason to believe he was going to do something dangerous had I discharged him (which I did).

If the suspected malingerer gets to inpatient and is confirmed to be malingering the inpatient doctor has to write this down in good detail so if the malingerer returns there'll be a record of it. Another problem I had in residency was the inpatient doctors wrote down the patient was truly mentally ill they argued for billing purposes despite that it was dishonest and insurance fraud. Also do no write down malingering in the chart unless you have very strong verification of it becase you can be sued just for using the world.

What I write down instead is something to the effect of I have reason to believe the patient wants hospitalization for secondary gain and cite the reasons for doing so and that I have reasonable medical opinion to back it up while putting down a dx of Adjustment Disorder with Disturbance of Conduct.

I would not put too much into psychological testing in the ER setting. Why? Some of the tests are very long and not compatible with the quick pace of the ER. They are, however, compatible with inpatient.

While some of the tests are quicker such as the M-FAST if you start M-FASTing everyone the malingerers will figure out the test. You do not pull out the psychological testing too often because malingerers teach other what they've experienced on the inpatient unit.

In lectures I've compared psychological testing to magic tricks. You use the same trick too often the audience (or in this case the testee) figures out how it works.

 

[FlowRate]

you can be sued just for using the word.

I thought this was interesting and did some googling. The closest hit I could find was this article where a woman sued an NP for documenting that the NP thought the woman was malingering. The lower court and supreme court dismissed the woman's case.

Anyone can sue for anything, but have you heard of anyone losing a lawsuit for mentioning malingering?

 

[smalltownpsych]

I thought this was interesting and did some googling. The closest hit I could find was this article where a woman sued an NP for documenting that the NP thought the woman was malingering. The lower court and supreme court dismissed the woman's case.

Anyone can sue for anything, but have you heard of anyone losing a lawsuit for mentioning malingering?

I would just think in these days of increased access to records, I wouldn't want a patient to see that word in their record. Even if they don't sue, I could still be at increased risk.

 

[whopper]

AAPL recommends not putting malingering as a dx unless there's psychological testing. I'd further add that this could be put down if you have definitive proof. E.g. the patient admits they were malingering. At the AAPL board review course and in Resnick's lecture of malingering that is outside the course he mentioned there are cases where doctors were sued simply for using the word malingering and lost. Add to this that some insurance companies do not want to cover the doctor for malpractice because they state that this was not poor practice but literal character assassination. Insurance companies have specific exceptions written into contracts where they will not cover a doctor for a malpractice lawsuit.

While at my last job the psychologist in the department told me she knew of cases where patients were dx'd with malingering in the chart, sued, and won.

I too did a search on google and did not find specific cases of this except for 1 and it's likely the same one you found because there was the same outcome. I'd recommend a Lexis-Nexus search which is the equivalent of a pubmed search but it goes through legal documents. I don't have current access to Lexis Nexus so I can't do it myself.

 

[HarryMTieboutMD]

Most of the malingerers in our ED don't have the wherewithal to actually obtain their records, let alone file a lawsuit. And their motivation is further diminished from chronic weed smoking (no pun intended, especially on April 20). Nevertheless I agree that malingering conceptually is not a psychiatric diagnoses and is highly speculative unless 1) the patient admits to it or 2) the patient is well known and frequently presents with clear secondary gain

 

[Guyton]

Here is fatal example of how NOT to diagnose malingering. "Detention officers, nurses, and even a jail psychiatrist accused Williams of “faking” an illness."

http://www.thedailybeast.com/articles/2016/04/19/cops-taunted-black-veteran-as-he-died.html

 

[notdeadyet]

I agree with Whopper. Malingering is not psychopathology. What you document is the lack of psychopathology. If someone does not have a mental illness that would benefit from treatment, you are under no obligation for treatment.

Recognizing malingering is helpful because it stops you from making an inaccurate diagnosis. But the output in recognizing malingering is documenting the absence of psychopathology. Playing the "to catch a liar" game says as much about where the doc is coming from as the patient.

 

[Merovinge]

I agree with Whopper. Malingering is not psychopathology. What you document is the lack of psychopathology. If someone does not have a mental illness that would benefit from treatment, you are under no obligation for treatment.

Recognizing malingering is helpful because it stops you from making an inaccurate diagnosis. But the output in recognizing malingering is documenting the absence of psychopathology. Playing the "to catch a liar" game says as much about where the doc is coming from as the patient.

That sounds great in theory and should be kept in mind but the standard VA ED malinger myself (and I am sure many others) are encountering are opening by saying "I am homicidial, suicidial, hearing voices, and seeing things". I had multiple pts state that same mantra, word for word, to the triage, then ED attending, and then myself. You can obviously document how their mental status does not match up with their words, but the ED note will absolutely detail those complaints and if you don't use secondary gain/hx of previous presentations in the assessment, I find it hard to believe you can come up with a compelling note for discharge (of course you can also go how I often see done and admit the patient for the 50th time).

 

[whopper]

Here's an example of something I'd write on a patient I believe was malingering.

"Patient was seen for 3 days and during this time did not show signs consistent with mental illness but did consistently present with symptoms endorsing depression such as being suicidal. The patient was seen on several occasions exhibiting behaviors not consistent with someone being depressed such as making sexual advances on other patients, smiling, laughing, not showing negative/vegetative signs, and has several factors that are consistent with someone wanting secondary gain such as being homeless and unemployed. The case was discussed with the treatment team and the majority do not believe he is mentally ill. At worst I believe with reasonable medical certainty that he may have adjustment disorder from the stress of being homeless but does not suffer from major depressive disorder.

For the above reasons I am discharging this patient today. He was given a referral to the homeless shelter and a referral to continue psychiatric services if he wishes to do so. I did tell the patient my concerns that hospitalization may not be appropriate for him and I fear that further hospitalization could in fact make his situation worse because he may then connect that it is appropriate for simply being homeless."

Or another example:
"Although I do not believe the patient's motivation to be in the hospital is based on an Axis I mental illness I do see a risk with him being violent upon discharge because he exhibited antisocial traits such as poor frustration tolerance, anger when not being given what he wanted, and continue desire to stay in the hospital. Keeping him here I fear will worsen his condition by reinforcing his desire to use the hospital simply as a means of shelter."

Or another example:
"During group therapy today the patient expressed her desire to stay in the hospital simply was for housing and not to treat mental illness. Further she specifically stated her desired date of discharge is the day she will obtain housing from a friend. For these reasons and because she has not showed signs consistent with depression I am discharging her today."

 

[doctorpilgrim]

Another thing to consider with PES malingering is that it looks more difficult as a rotating medical student or even resident than when you spend a significant amount of time there.

Most folks who abuse the system are known to the PES docs. This doesn't eliminate risk in managing malingering, but it reduces it. When you have someone that you think is malingering but is unknown to PES, you definitely hedge your bets and are more likely to admit.

Automatic admission ER = automatic uselessness. Just my opinion, we need to practice psychiatry out there people. Jesus Christos.

So this situation is probably seen only in PES. What I encounter more is an anxious patient or anxious family who dont want discharge or a patient wanting detox.I have a couple of questions.
Are 1 in 3 admissions from emergency room, of those needing to be seen by psychiatrist? What are the common diagnosis in the other 60 to 70 percent of patients who dont need admission?
What is the incidence of malingering to get psychiatric admission? What are some of the common reasons that patients prefer being locked up on a psychiatric unit?

 

[JamesPhilly]

Yeah, one program I interviewed at this year has a dedicated psych ED but the residents bragged about how they only have a 30% admission rate. I did not take this is a super encouraging sign wrt the institutional culture.

Jesus, our admission rate is probably half that. That is, if you look at psych inpt only. If you include sending them off to detox or rehab, then we might reach 30% on a good day. Mind you, two nights ago I evaled 16 people in an overnight shift (average is around 12-20/shift) and put in maybe 3 people.

Also, if a place only has a 30% admission rate, it means that they are treating and stabilizing patients sufficiently to discharge them instead of just being a transit center that takes down information and admitting.

This is very true. I remember a real sense of panic the first time I saw a belligerent person in our crisis center in police handcuffs, screaming at me. Now it's nothing, I joke with the officers who I've become friends with, and it's actually fun. In general I feel comfortable treating a wide range of emergencies, as does the staff, even if they're cases that do not warrant inpt psych, but are urgent matters just the same. I also learned a great deal about other treatment options include subacute, recovery homes, 3a vs 3b vs 4a vs 4b, partials, etc.

Also, and I should have added this earlier: dealing with malingers in our psych ed has made me a stronger person in my normal day to day life. I was the sort of guy that when a salesman would knock I would feel obligated to listen to their spiel. Now, not so much. I look pan handlers in the eyes now, and sometimes I'll tell them about soup kitchens that are nearby. And unhelpful Verizon or Comcast customer service reps? I deal with them so much better now.