• “Records show an established pattern of seeking inpatient services for ... and delaying discharge during admissions of [include dates].”
• “Review of prior records indicates no evidence of clinical improvement for brief or extended admissions similar to her current presentation.”
• “A second opinion obtained from ... concurs with ...”
• “This case has been reviewed in detail with ...”
• “Formulation and plan have been discussed with patient and other [relevant] providers, including ...”
Dr. Rozel offered this caveat: “I am not a lawyer. The only thing I promise that your lawyer and I will agree on is that they would rather you get your legal advice from them and not from me.”
Reframing the situation
Understanding yourself first will help you understand the patient better, according to Dr. Balfour: “What underlies all this is how you are feeling. Being aware of this is important.”
The range of emotional experiences when dealing with a patient who malingers can run from anger at being lied to, frustration with wasted time and resources, helplessness that nothing seems to make a difference, fear of making the wrong decision, and even hatred borne of constantly experiencing all the other emotions, she said.
Being honest about your own emotions helps keep them out of the way of delivering better care, as does being mindful of the language you use to describe patients. Describing a patient to other staff in words that connote negativity, such as “manipulative,” “attention seeking,” or “high maintenance,” might influence others to see the patient as problematic rather than someone to be helped, said Dr. Balfour, who is with the department of psychiatry at the University of Arizona, Tucson.
Instead of labeling patients, “I find using the techniques of dialectical behavioral training very effective in dealing with [this population],” Dr. Balfour said. A more effective approach includes reframing your view of patients not as liars, but as people who are doing the best they can with what they have in a system that is often set up in ways that prevent, more than augment, care.
In that case, a person who lives in a homeless shelter and who wants help with a drug addiction, for example, will “understandably come to the emergency department to try and get admitted to the inpatient unit where they can get into rehab,” Dr. Balfour said. “Sometimes, our system makes people do things we find annoying in order to get the help they need.”
Instead of making the prevention of unnecessary admissions the goal, find a way to create a rapport with patients to determine their actual problem and see what can be done to solve it. This might take several engagements with the patient, often with more than one staff member. Using the statement, “I don’t feel like I’m getting the whole story” in the patient interview is an effective way to engage patients without accusing them of lying, Dr. Balfour said. “It’s like a magic phrase. Its effectiveness is predicated on the idea that all people, even those who dissemble or embellish, have a wish on some level to reveal sensitive, personal material.”
Remembering not to take malingering personally and that your role is “to be a detective not a bouncer” will help de-escalate untruths, and can lead to a partnership with the patient rather than enmity, Dr. Balfour said.
Dr. Balfour disclosed that she is a consultant for Connections Health Solutions and Otsuka. Dr. Simpson, Dr. Rozel, and Dr. Rodriguez had no relevant disclosures.
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