Malingering in Milmed

[John1513]

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SDN seniors:

What are some successful ways you have documented malingering?

What is our role and what is our lane as Milmed doctors in this regard?

 

[DD214]

Malingering is a clear violation of the UCMJ, but good luck getting anyone to back you when the malingering patient complains to your chain of command, files a Congressional or goes to the press

You'll become the villain because no one wants to be a part of any scandal and the patients will likely be given the benefit of the doubt or an undeserved psych diagnosis to make them go away

 

[pgg]

Hard to prove, even when flagrant.

The experience I had with a handful of Marines in my GMO days is that those guys typically also had performance problems, personality disorders, and/or disciplinary issues. They were generally looking for a way out of the Marine Corps that wasn't a dishonorable discharge, and the command was generally looking for a way to get rid of them.

Most got admin sep'd eventually.

I had one who faked sudden hearing loss during a field exercise. He didn't realize that it's a genuine medical emergency and that I would evac him immediately. I think he just figured it would be good for a few hours back in the air conditioned aid station. A couple days later the ENT who received him sent him back with thorough documentation of proof of normal hearing. He was livid and wanted him prosecuted for malingering.

Psych saw him, called it a conversion disorder. Now it was a medical problem, not a legal problem. He eventually got ad sep'd.

If it's a young person, the best thing to do is probably to steer them to psych so they can get evaluated. They usually have mental health needs. This often facilitates the adsep everyone secretly wants.

If it's someone trying to milk some disability % off their retirement, probably the best you can do is not sign off on it, and move on with your life.

 

[DondeEstaElBano]

The one time I saw any mention of malingering in a medical chart was by a GMO who documented having to ‘counsel’ the patient multiple times on the appropriate use of sick call over months of complaints of cough, malaise, musculoskeletal pain, etc.

It ended up being disseminated coccidioidomycosis. He was in the ICU for more than 2 months before finally getting off the vent, needed experimental treatment, was medically retired, and probably is still not the same today.

Not saying to not call a spade a spade, just giving the flip side. I’m not a physician so I don’t know the weight of making that kind of decision. But I still think about that case years later.

 

[Perrotfish]

I've seen patients that were strongly suspected to have malingering/psych issues turn out to be pneumonia, rhabdo, femoral neck stress fractures, leukemia, and Guillain-Barre syndrome, to name a few. As a generalist you really should never call a spade a spade. If they say its not getting better they go to subspecialty care, no matter how obvious you think it is. If you are the subspecialist its a little more complicated and I think pgg's advice about involving psych is solid.

I always recommend the bouncebacks series to residents. Its written by an ER doctor who documented cases of patients who bounced back to the ER with something that initially looked benign but ended up being serious. The take home message is that every time someone comes back with the same complaint you do more tests and elevate their care. One of the author's better lines: "the third time the pizza guy comes to my house, I admit him".

 

[Gastrapathy]

I saw an abdominal pain "malingerer" with a appy that had ruptured months ago, several others with Crohns. People get labeled by some IDC without a workup because he "can tell". So, you better be right.

 

[244913]

Malingering is almost impossible to prove. I got a couple of guys on it in my unit- support/supply people of course- when they walked into the aid station dragging their legs and wearing a neck brace and then were caught throwing accouterments in the trash on the way out and walking normally after they had gotten profiles etc.

Pysch is almost never supportive, although they backed me in these cases

JAG would usually lean on the kids, threaten UCMJ and then they would be chaptered out which worked out for everyone involved

- ex 61N

 

[usma05]

Agree with most above....hard to prove and not at the top of differential initially for me. Though it does occur, and listening to command about problem soldiers is important, the 'malingerers' can have real pathology too. Having to fight to evac a guy with acute pericarditis from a remote training site and send a guy to landstuhl for additional workup for acute symptomatic anemia (a nurse practitioner called it bacterial PNA causing his chest pain and a small left shift on his WBC while ignoring the H/H of 6/18 on the same cbc...then he saw me) from Afghanistan are the cases the recur in my mind from prior experience....

 

[pgg]

Agree with the other posters.

The problem with malingering is that it's the ultimate diagnosis of exclusion. If you make that diagnosis and you're wrong, it really harms the patient and it will probably harm you too.

And the upside to calling it right? Some aha-caught-you moment?

These people don't confine their douchebaggery to the medical realm. They're turds in all aspects of their lives. Let their unit can them for easily documented work performance issues. Everyone's safer that way.


As an aside, trying to catch malingerers and punish them is a classic example of how officer-first-doctor-second dogma is harmful.

 

[TheEarDoc]

Agree with the other posters.

The problem with malingering is that it's the ultimate diagnosis of exclusion. If you make that diagnosis and you're wrong, it really harms the patient and it will probably harm you too.

And the upside to calling it right? Some aha-caught-you moment?

These people don't confine their douchebaggery to the medical realm. They're turds in all aspects of their lives. Let their unit can them for easily documented work performance issues. Everyone's safer that way.


As an aside, trying to catch malingerers and punish them is a classic example of how officer-first-doctor-second dogma is harmful.

I agree. I hate malingerers as it wastes my time when I could use that appointment slot to see someone with a real problem. Being in such a pin hole specialty as I am though I am afforded the easier ability to catch malingering especially with normal hearing people using physiological tests that are quick. So my opinion and catching of malingerers is much easier than say general med would be.

I always try to allow malingerers an out when I let them know in nice ways they've been caught. Then again I am working with the civilian population so not much you can do. Sure you can threaten to report them to OIG for attempted fraud of the compensation system, but good luck getting OIG to do anything and then all you do is end up with a pissed off patient in a small room with you.

Now in the military I would agree with the above posters most of these folks are A-1 jerks not only in a medical office. I would simply alert their NCO and let them sort them out.

 

[Perrotfish]

As an aside, trying to catch malingerers and punish them is a classic example of how officer-first-doctor-second dogma is harmful.

Really well said.

 

[HighPriest]

I agree. I hate malingerers as it wastes my time when I could use that appointment slot to see someone with a real problem. Being in such a pin hole specialty as I am though I am afforded the easier ability to catch malingering especially with normal hearing people using physiological tests that are quick. So my opinion and catching of malingerers is much easier than say general med would be.

I always try to allow malingerers an out when I let them know in nice ways they've been caught. Then again I am working with the civilian population so not much you can do. Sure you can threaten to report them to OIG for attempted fraud of the compensation system, but good luck getting OIG to do anything and then all you do is end up with a pissed off patient in a small room with you.

Now in the military I would agree with the above posters most of these folks are A-1 jerks not only in a medical office. I would simply alert their NCO and let them sort them out.

That's amazing of you, because most of my audiologists just corner me in the hallway and tell me that they caught someone on a stenger, and then I have to actually confront the patient.

 

[TheEarDoc]

That's amazing of you, because most of my audiologists just corner me in the hallway and tell me that they caught someone on a stenger, and then I have to actually confront the patient.

I'm sorry to hear that. I guess years of compensation and pension exams roughed my skin up a little to where I just don't play games. I inform them it's inconsistent. They refuse to play ball, well they can read the report later.

I'm shocked your audiologists have a problem with confronting a patient and telling them the results aren't reliable. I can understood a newly minted audiologist or young officer, but still come on be the professional and own the encounter.

 

[John1513]

Cadre, these responses are simply amazing and pertinent. Spot on, and the collective wisdom will definitely help junior docs thrive.

It is so humbling to be reminded that even the most flagrant offenders could still end up having leukemia.

I have eaten humble pie when that one sleep study that was reluctantly ordered actually came back with Severe OSA: “I’m retiring soon, and wife says I snore....”

Conversely, I am emboldened when I see a positive Cardiac stress test return on a warfighter previously dismissed with just anxiety.

Keep it coming, SDN seniors. Thank you all.

 

[notdeadyet]

Speaking from the psych side, malingering is common in milmed. I'm ARNG, but from conferring with counterparts, it doesn't seem any different in big Army.

Outright malingering chaps everyone's hide, and I don't think there's anything wrong with that. I also don't think it's an officer vs. physician thing. Malingering is problematic in the civilian setting as well. Not confronting malingering is essentially passing the buck. It's a not-small component of the opioid epidemic.

I think it's helpful to blow the dust off the Step 1 cobwebs when you face cases to divide them into one of three basic categories: Somatoform, Factitious, or Malingering. Because next steps are important.

Somatoform is the unconscious production of symptoms. This is more common than folks give credit for. Individuals get physical symptoms without a physical etiology. A benign example would be getting nauseous before giving a big speech. You can experience a wide variety of somatic symptoms that are most likely caused by mental health distress. Refer to psych where it's best treated in conjunction with sympathetic primary care. I've had good results with treatment and folks with somatoform tend to be compliant with treatment regimens (though you get flare ups).

Factitious Disorder is the conscious production of symptoms for intrinsic gain. The person embodying the sick role for sympathy is the classic example. A very different animal than somatoform, since it's intentional. Also merits a referral to psych and can also respond to treatment once the provider can identify the unmet need (usually after a fair bit of therapy). This disorder can result in administrative action, depending on the lengths the service member goes to embody the sick role.

Malingering is conscious production of symptoms for extrinsic gain. This is service members seeking something positive (pension, time off) or avoiding something negative (excused from duty, explanation for violation). This is not a mental illness and a referral for psych is not necessary. This requires administrative action.

The reason I'm belaboring this is that if you identify something as Somatoform or even Factitious Disorder, they are legitimate mental illnesses that psych can treat and potentially return a service member to productive duty (and I've seen it happen). For Malingering, it requires administrative action, not mental health help and the latter can prolong the problem.

The challenge that I face is that when soldiers are malingering and psych documents it and refers the soldier to his/her unit for administrative action, commands will often just ignore it and wait for it to go away on it's own (for the soldier to run out his enlistment).

My big fear is if the military implements this 12-months-non-deployable-and-you're-out thing. We're going to see a huge uptick in malingering cases since riding out 12 months and getting a full medical is going to be invented and command will see it as a great way to get rid of problem children.

 

[TheEarDoc]

The challenge that I face is that when soldiers are malingering and psych documents it and refers the soldier to his/her unit for administrative action, commands will often just ignore it and wait for it to go away on it's own (for the soldier to run out his enlistment).

My big fear is if the military implements this 12-months-non-deployable-and-you're-out thing. We're going to see a huge uptick in malingering cases since riding out 12 months and getting a full medical is going to be invented and command will see it as a great way to get rid of problem children.

Oh I can almost guarantee that with the new rule coming into play that the med board numbers will skyrocket. Most folks naturally if you are going to force them out of the military are going to hold a grudge and they would be stupid to not fight it kicking and screaming and leave with a huge med boarding and retirement. That's just human nature. So yeah I agree when someone gets profiled say for busting tape and they can't drop the weight and they start the paperwork for separation due to being non-deployable for 12 months they will just file for everything under the sun and demand med boarding. There are so many easily malingered conditions that are subjective that it would be pretty easy to walk out the service with 50-75% medboard rating and disability rating.

 

[Perrotfish]

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[Perrotfish]

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[pgg]

Malingering is conscious production of symptoms for extrinsic gain. This is service members seeking something positive (pension, time off) or avoiding something negative (excused from duty, explanation for violation). This is not a mental illness and a referral for psych is not necessary. This requires administrative action.

Don't you think a lot of these guys have personality disorders (mainly cluster B antisocial) and would benefit from a psych referral?

We ad sep'd a whole bunch of people with personality disorders. Having an opinion from psych really helped that process.

 

[notdeadyet]

Don't you think a lot of these guys have personality disorders (mainly cluster B antisocial) and would benefit from a psych referral?

We ad sep'd a whole bunch of people with personality disorders. Having an opinion from psych really helped that process.

You can ad sep someone for antisocial behavior a lot easier than ad sep someone for antisocial PD.

Due to the most recent regs, if I diagnose someone with a personality disorder, they are afforded a degree of protection. I need to recommend reasonable accommodations for their command to implement. Ad Sep proceedings can’t proceed until those accommodations are afforded (within the constraints of the given environment).

This came in after a lot of bull$hit Personality Diagnoses were given to separate bad apples by the Army. On later review, a lot of those cases were determined to be PTSD and other causes. The threshold for diagnosis of a personality disorder is (and should be) quite high. For something like Antisocial Personality Disorder, you really need a lot of pre-service collateral to make the diagnosis, since one of the requirements is evidence of ASPD-like behavior from before age 15. The Army has a lot of bad psychiatrists throwing around Personality Disorder diagnoses WAY too easy.

So if you suspect an actual personality disorder, by all means, refer to psych. But lying, cheating, stealing, violence, etc. are MUCH more often characterological than true personality disorders. The best help psych can do for someone with these traits is confirm what is most likely: that this is evidence of bad character rather than true psychopathology.

 

[pgg]

Clearly a lot I don't know about psych. 🙂

 

[notdeadyet]

Yeah, well, you don’t want me managing your COPD. Viva la collaboration.

 

[j4pac]

I've seen patients that were strongly suspected to have malingering/psych issues turn out to be pneumonia, rhabdo, femoral neck stress fractures, leukemia, and Guillain-Barre syndrome, to name a few. As a generalist you really should never call a spade a spade. If they say its not getting better they go to subspecialty care, no matter how obvious you think it is. If you are the subspecialist its a little more complicated and I think pgg's advice about involving psych is solid.

I always recommend the bouncebacks series to residents. Its written by an ER doctor who documented cases of patients who bounced back to the ER with something that initially looked benign but ended up being serious. The take home message is that every time someone comes back with the same complaint you do more tests and elevate their care. One of the author's better lines: "the third time the pizza guy comes to my house, I admit him".

I’ve advise everyone to heed @Perrotfish wise words. How would I recommend dealing with malingering? I’d assume it doesn’t exist. I’d also assume that you don’t know what you don’t know. I’d refer the patient to a subspecialist for an opinion. If they can’t define something organic, get a second opinion (ideally from someone outside of military med). If they can’t find anything organic I’d refer the patient to mental health.

My command was EXCELLENT in regards to the medical side of things...which is probably more common in the aviation community, but I’d still occasionally get malingering evals now and again. I’d say most of the time the patient was found out to have something organic. In the cases it wasn’t organic, it was usually something more along the lines of a chronic pain/fatigue syndrome (including fibromyalgia) and conversion disorder...all of which have a very different management than malingering. The malingering patients usually have something psych going on...so they’d benefit from mental health.

You really have to do your best to remember that your job first and foremost is to be a physician and not an administrator.

 

[Kingfisher]

Malingering is a clear violation of the UCMJ, but good luck getting anyone to back you when the malingering patient complains to your chain of command, files a Congressional or goes to the press

You'll become the villain because no one wants to be a part of any scandal and the patients will likely be given the benefit of the doubt or an undeserved psych diagnosis to make them go away

Your active duty will not be going to the press to complain about his/her care without clearance from their PAO. If they do, they will no longer be coming to see you as they will likely be facing disciplinary proceedings.

Congressionals are not to be feared if you have done nothing wrong and have done everything for the patient that you can including excluding other possibilities in the Ddx.

Don't worry about your COC. If you have done the above, you will be fine.

Malingering is an incredibly difficult thing to prove and hold them accountable for. I have seen it. The best chance you have is to do your best and their work issues will catch up to them eventually.