Why (Some) Patients Never Get Well

Saturday, July 15, 2006 | 4

By Jomar Almeda, M.D. (Faculty, WorkCompSchool)

"Man has to suffer. When he has no real afflictions, he invents some." - Jose Marti

I have always been captivated by the seemingly improbable account of patients, who after a course of medical treatment, astoundingly recover completely from a major injury or illness in less time than expected. Equally remarkable are athletes who bounce back to their usual competitive form following a reconstructive surgical procedure. Still there are some who recover with just the right amount of rest, and needed nothing more to get them up on their feet. Such scenario however does not happen all the time, as patient response to treatment may vary. This is due to a number of factors and also because of the uniqueness of each individual. Nonetheless, properly managed, and absent any serious complication, most injuries and illnesses do still follow a more or less predictable and typical clinical course.

The real frustration in medical practice is failure on the physician's part to satisfactorily deliver the task he was sworn into - to cure or relieve his patient of the suffering brought about by his ailment in spite of having provided him with utmost medical care. For medical conditions that are beyond doubt problematic because of its complexity, the outcome may be understandable. But we also need to accept the fact that a situation exists when sickness can be made to appear worse by an individual's deliberate magnification of his symptoms, upheld by no less than a few medical professionals themselves.

It is not the purpose of this article to discredit anyone, but merely to serve as a reminder for those involved in patient care that feigned sickness do exist&and at times, missed. By his recognition of a fabricated versus a real illness, the health provider would then be able to identify which patient will benefit from further medical treatment, and which patient will not. As in Cicero's words, "The competent physician, before he attempts to give medicine to the patient, makes himself acquainted not only with the disease, but also with the habits and constitution of the sick man."

The term "malingering", originated from the French word "malingre" and was first introduced in the late 17th century. In those days, it was used to refer to people who pretended to be ill to escape military duty. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defines malingering as the "intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives, such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution or obtaining drugs." Two requisite features of malingering are 1). the full awareness of the pretense and 2). the presence of a tangible gain.

It is not always easy to find out who is malingering and who is not, but there are some indicators that physicians use to assist them in evaluating patient credibility. The disparity between the subjective complaints and objective physical and clinical findings may be markedly obvious in malingering. In most cases, the magnitude of the complaint is way out of proportion with the actual pathology. A patient could present with sensory or motor abnormalities that does not follow the expected neurologic distribution. And still there would be patients who present with long-standing pain or psychological symptoms with no established biological abnormality. While every illness may certainly present in an unusual manner, misdiagnosis is not without drawbacks.

Pain behaviors, either verbal or non-verbal, are the patients' means of expressing pain. These include facial grimacing, limping, moving in a protective fashion, and moaning, among others. They may provide the examining physician with valuable clues to arrive at a correct diagnosis, especially when the clinical presentation is consistent with the medical condition being considered. On the other end, a patient may present with exaggerated pain behaviors, without clear objective basis. A physician therefore is tasked, by exercising his expertise and clinical judgment, of accurately interpreting such pain behaviors, and truthfully validating them.

Unfortunately, some physicians are unable or just refuse to comprehend, or recognize discrepancies between subjective symptoms and objective findings. A physician may merely believe every word that a patient says, and attempts to treat every complaint that he makes. Some patients report persistent disabling pain, from a trivial injury sustained several months or years before, unsupported by any objective clinical finding, and present with long-standing symptoms not consistent with their diagnosed condition. For a patient who malingers, and who's condition had gone past the reasonable healing period, it is observable that his symptoms remain unimproved or is even worse with further treatment. Instead of being helped, many of these patients are wrongfully made to undergo never-ending and unnecessary medical interventions which does more harm, as it only exposes them to iatrogenic (physician-induced) complications.

People malinger for personal gain. Thus it becomes even more obvious that when the issue of compensability is involved, the temptation to malinger becomes even greater. These patients continue to demand treatment, but rejects any report of cure nor improvement. The incidence of malingering was noted to have increased subsequent to the creation of the Social Security Disability Act of 1970. The DSM-IV reports that malingering may be considered when the following condition exists: 1) a medico-legal context to the presentation; 2) a marked discrepancy between subjective reports of symptoms and objective findings; 3) when the patient does not cooperate with the diagnostic work-up or prescribed treatment; 4) a diagnosis of antisocial personality disorder.

For anyone involved in patient care, correct diagnosis is the key to success of treatment. As healers, physicians have been trained to diagnose and treat various medical conditions, but they should also be cautious about subjecting his patients to a barrage of tests and treatments for symptoms that are merely made up. In some legal proceedings, malingering patients may be referred to a Psychiatrist. Written tests are then conducted to aid in determining whether the patient's symptoms are real or not. Whatever the intentions are, we should always keep in mind that patients should reasonably be only provided with medical treatment that they need. By keeping up with such practice, no resource, time, and effort is wasted, and complications from unnecessary and excessive treatment can be avoided. For the sick, Hippocrates said, "the least is best ".

Postscript: Birthday greetings to all July celebrants. High school buddies from Colegio de Santa Catalina de Sena, Sid Magbitang, Jovy Tanael, Jessie Revilla, Tony Bautista, and Caca Cabrales. From Integrative Industrial and Family Practice Medical Clinics, Mayra Ramirez, and our office manager, Betty Miyashiro. Cheers and good health to all of you!

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Prior to his involvement with Workers' Compensation, Jomar Almeda, M.D., a graduate of the U.E.R.M. College of Medicine, has over 12 years of active orthopaedic practice in Manila, Philippines. He was Arthroscopy Journal's Traveling Fellow in 2000, and later became an International Member of the Arthroscopy Association of North America in the same year. Jomar also received extensive training at the Nobuhara Orthopaedic Hospital and Institute of Biomechanics in Japan, at the National University Hospital in Singapore, and at Warwick Valley Orthopaedic Surgery, PC in New York.

Jomar is also certified in Occupational and Industrial Medicine and had served as a medical consultant for various multi-national companies in his native country. He is currently with the Workers' Compensation Department of Integrative Industrial and Family Practice Medical Clinics. Jomar can be contacted here.

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