Are you talking about true malingering, or something like factitious d or just run of the mill somatizers, or even just your general personality disordered person? If you are talking about true malingering, it is usually relatively feasible to tell if you do a thorough psychological assessment on them. Now, those somatizers are a different story. I agree with you - telling them the truth about the low possibility that their symptoms are solely physically based can often be very very helpful to patients (if done the right way). I have had some folks like that who were eventually relieved by the information. Of course we judge patients....but they should be judged fairly and with as little bias as possible.
I am talking about true malingering--if I understand you correctly. (What's the alternative, false malingering?
When a clinician suspects a patient of malingering, the doctor must have an extremely large amount of evidence to back it up. The danger of confronting someone who is not malingering, and calling them one is extremely damaging to that patient. You would be in essence calling them a liar, and if they weren't lying, geez, you called them a liar in their time of need. IMHO, that data must be beyond a reasonable doubt due to the damage that could possibly happen if the doctor is wrong. Even then, you should do what you can to help them within responsible and appropriate practice. E.g. if someone malingered suicidal ideation to get 3 hots and a cot, refer them to the rescue mission a supportive manner (if possible).
The issue that I mentioned bugged me in residency because there were several clinicians I saw who believed their patient was malingering, but did little if anything about it. They just kept seeing the patient, billing that patient as depressive, mood, impulse control, anxiety do NOS (or as one of the nurse managers called it FOS--Full of $hit) Or they played hardball, without being able to demonstrate a formal way to prove the person was malingering that IMHO would stand up in court.
If they had a valid reason that'd be one thing, but in most cases, the clinician seemed to not know what to do because that clinician was not trained to assess malingering or knew who to contact to do an assessment of malingering.
In some cases, it was more than just a suspicion. The clinician was very convinced of malingering, yet did nothing to stop the cycle.
If I never entered forensic fellowship, I knew that as a clinician, the idea of not being able to tell a malingerer to a degree that I felt was strong enough to survive a Daubert standard and my own ethical standard would eat me up inside. Even if I never worked in forensics and did 100% clinical, the ability to detect malingering and evaluate it--along scientific standards that would meet specificities and sensitivities of well over 90% to me would've been worth it.
As Doc Samson alluded (I think, I apologize if I'm wrong), in a hospital situation it is difficult to do the formal testing. A proper evaluation can take several days and several hours of testing by a clinician who can bill for tremendous amounts of money. Assume that the testing overwhelming shows the patient is a malingerer. Great--now you can't bill for this patient because the patient doesn't suffer from a severe mental illness.
