Ethical Dilemma

[MrChance2]

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I came across an issue today. I inherited a patient with a Dx of MDD with psychotic Fx. Upon speaking to her it was very clear she was malingering to get disability. This became more clear with chart review. She was not on an antipsychotic. My attending agreed with me that she is malingering but states because she already carries this diagnosis but is not on an antipsychotic and I should start 2.5mg Abilify otherwise the previous notes could cause potential trouble. I disagree as I do not want to diagnose and treat a condition that patient does not have but he stated that he was right and I need to learn to do this even though he agrees this is malingering. What are your thoughts? How would you respond to this?

 

[MBBSMOM]

How do you know the pt is malingering? Have you done psych testing? If the pt is malingering it is highly inappropriate to treat a condition they don’t have. I would not start the abilify at all . Are you a resident?

 

[splik]

You should talk to your attending about what they want you to document. I almost never allow my residents to use the term "malingering" unless there is a clear documented history of feigned symptoms with obvious external reward, and the benefits of documenting malingering (e.g. to avoid unnecessary hospitalizations) outweight the harms (e.g. stigmatizing the patient and ensuring they will forever receive poor care and scorn from other clinicians). It sounds like your attending is saying you should continue to diagnose and treat the patient. They may be concerned that there might be a bad outcome and be held negligent if you don't treat given prior documentation of a diagnosis of psychosis. They may be concerned from a billing perspective (the visit won't be covered if the only dx is malingering). They may be concerned about harming the patient's changes of getting disability (while we should not enable patients to fraudulently seek disability, it's not a treating physician's job to obstruct the process either) or the threat of litigation from the patient. It may be that the patient is partially malingering and also has a mental disorder. This is most common in the clinical context. It would be rare in this kind of setting to see someone malingering mental illness without any history. I think you need to discuss this case further with your attending to see what their rationale is and what they want you to document.

 

[Mass Effect]

How do you know the patient is malingering?

 

[MrChance2]

Good questions and thanks splik, I always appreciate your posts. yes I am a resident. I also want to be sure I learn from this situation if I’m not thinking through it correctly. The interview was too long and specific to publicly post here.

But basically think along the lines of a patient walking into a clinic and saying they are paralyzed from the waist down and need disability for it. Then asking for disability for 5 other things there is no evidence for for all while asking for Benzos and not wanting to take other medication. Then stating bizarre psychotic symptoms without any negative symptoms that really don’t present with eachother and are not consistent with patient’s previous reports.

The attending agreed with me that he does not think the patient is psychotic.

I think my main issue is these patients see a lot of different psychiatrists and most don’t review all the notes and especially the subjective part. I feel if I don’t write something in the assessment this could go on for a long time with a lot of unnecessary treatment but my attending did not want me to document anything in the A+P section regarding possible secondary gain.

 

[Mass Effect]

Good questions and thanks splik, I always appreciate your posts. yes I am a resident. I also want to be sure I learn from this situation if I’m not thinking through it correctly. The interview was too long and specific to publicly post here.

But basically think along the lines of a patient walking into a clinic and saying they are paralyzed from the waist down and need disability for it. Then asking for disability for 5 other things there is no evidence for for all while asking for Benzos and not wanting to take other medication. Then stating bizarre psychotic symptoms without any negative symptoms that really don’t present with eachother and are not consistent with patient’s previous reports.

The attending agreed with me that he does not think the patient is psychotic.

I think my main issue is these patients see a lot of different psychiatrists and most don’t review all the notes and especially the subjective part. I feel if I don’t write something in the assessment this could go on for a long time with a lot of unnecessary treatment but my attending did not want me to document anything in the A+P section regarding possible secondary gain.

Listen to your attending. Frankly, your post is too vague for us to actually comment on whether or not the patient is malingering (and your attending may have just agreed it's possible or that you might be right), but a resident seeing a patient for the first time being convinced the patient is malingering isn't a selling point for me. The patient could be in remission, could also be severely personality disordered, or could be malingering, I don't know. But either way, I would listen to your attending and if you don't get it, then ask your attending for some time to fully discuss it. You should be learning from the case and if you're not (which it seems you're not), you should rectify that.

 

[birchswing]

I am not sure what it means to ask for disability for 5 things.

There are two welfare disability programs in the US, neither of which requires a doctor saying a person has a disability. There is SSI for a person who demonstrates a profound disability and inability to work and is impoverished. And there is SSDI for a person demonstrates a profound disability and inability to work who has accrued enough work hours to receive payments based on their work history.

In both cases the application process involves submitting medical records. The federal government hands off the case to a Disability Determination Service which is local to each state. They make the final decision based on reviewing medical records, not based on a doctor signing off on anything.

 

[clausewitz2]

Agree with this.

A) Depending on what you mean by negative symptoms there is a reason why factor analytic approaches always pull out negative sx and positive sx clusters as separable.

B) malingering label on the basis of this information is basically mind-reading

C) the people who most frequently embellish psychotic sx are people who have had previous psychotic experiences

D) refusing an antipsychotic if the patient wants one in this particular situation is more likely to make them tell you to die in a fire than establish at least a bit of an alliance that would allow you to actually work out what is going on and have a come-to-jesus as appropriate

E) outpatient is the long game. If it is not a crisis you don't have to do everything all at once. You will probably see them again...and again...and again.

F) some folks with chronic SMI are used to talking very frankly and openly about disability because they have been socialized to do so. You would not be the only person to feel some kind of way about this.

 

[FlowRate]

Good questions and thanks splik, I always appreciate your posts. yes I am a resident. I also want to be sure I learn from this situation if I’m not thinking through it correctly. The interview was too long and specific to publicly post here.

But basically think along the lines of a patient walking into a clinic and saying they are paralyzed from the waist down and need disability for it. Then asking for disability for 5 other things there is no evidence for for all while asking for Benzos and not wanting to take other medication. Then stating bizarre psychotic symptoms without any negative symptoms that really don’t present with eachother and are not consistent with patient’s previous reports.

The attending agreed with me that he does not think the patient is psychotic.

I think my main issue is these patients see a lot of different psychiatrists and most don’t review all the notes and especially the subjective part. I feel if I don’t write something in the assessment this could go on for a long time with a lot of unnecessary treatment but my attending did not want me to document anything in the A+P section regarding possible secondary gain.

I don't know what sort of "disability" your patient is on. That said:

I don't generally think of SSI as secondary gain. It's a way of getting minimal needs met. I would not want to live on just SSI for the rest of my life.

It's different when you have someone who used to work an 80k+ job who suddenly seems to report incongruous symptoms as a way of collecting SSDI or even private disability insurance.

 

[PsyDr]

Not a psychiatrist.

1) You may want to consider the potential for surreptitious non-adherence. You would have no way of knowing if the patient was actually taking the aripiprazole in an outpatient setting. This may affect how you balance the risks and benefits for such treatments. While this is in no way scientific, I have seen many litigants and defendants who have admitted that they fill the rx and then flush them.

2) Malingering does NOT exclude an actual diagnosis. Remember that malingering is production OR EXAGGERATION of symptoms for secondary gain.

3) If you're wise, you'll at least read the Wadell & Burton review of the effects of work. This will absolutely affect your take on disability.

4) Remember that the AMA Guides to Causation and AAPL say that treating providers should not opine about forensic issues, which includes disability.

 

[NickNaylor]

I would be highly resistant to attributing symptoms to secondary gain the first time you see a patient. Even in cases where malingering may be "obvious," in the absence of a clear pattern of behavior as well as your own familiarity with the patient, you're veering into dangerous territory and potentially harming the patient by not treating them appropriately.

If there are specific things that you believe are inconsistent with the patient's reported symptoms, why not ask the patient about them directly? I do this frequently with patients. Someone may report feeling extremely "depressed" and yet is quite pleasant and reactive on exam. I will often highlight this for them and ask them what they think about this observation or if they disagree. Often that conversation will lead somewhere meaningful and I learn something about the patient that can help clarify my thinking about them. The key with these "confrontations" is to make clear that you are genuinely being curious and want to understand the patient, not that you are trying to "catch" them (which I don't think is your job).

With respect to medication prescription, you do not have a duty to prescribe medications if you do not believe they are indicated. However, you should document as much as you need to be able to justify your decision-making medicolegally if there is a bad outcome.

 

[Merovinge]

Beyond everything above, the patient does not need to have psychosis to make adjunctive Abilify reasonable. If there is clear treatment resistant depression it remains highly reasonable in the absence of psychosis.