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Raising the Bar in Rehab


Published March 25, 2010 12:06 PM by
So, what do you do when a patient fakes it?

I don't come across a lot of patients who knowingly exaggerate their symptoms or capitalize on their own injuries for other reasons.  Most of my patients are well intentioned and hard working in regaining their function and mobility.

I was working with a patient today who had a history of psychological disorders and was avoiding placement at an inpatient psych facility.  For several reasons, the patient used his "intolerable pain" to maximize his time in the hospital and thereby postpone his discharge.   I have always been in the mindset at work that I am providing great care to patients who need and appreciate my time, so I was caught completely off-guard by the patient's presentation. 

One of my internships in school included a 90% workers-compensation caseload.   There was a higher volume of patients abusing therapy privileges than my current clinical setting, but also more doctors and case managers involved in preventing and stopping therapy services for those individuals.   Since many of the patients diagnoses included low back pain, sprained ankles, carpal tunnel and knee injuries, my instructor taught me to start many of the evaluations by reminding the patient of the usual timeline for recovery.  By setting an expectation early in our patient-therapist relationship, we were able to hold our patients accountable. 

Especially as new health care laws are proposed and signed, it's important for us as providers to prohibit patients from abusing the system.  Easier said than done. 



Like the blog. Stumbled across it today and have enjoyed reading between patients.

I find this post very interesting. I tend to think that there are very few fakers out there.

99% of my case load tends to be spine folks since '93. Early in my career I would tend to find more malingering folks than I do now...matter of fact I don't think I have "found one" in over 4 years.

I really think the better you get at your position the better you can treat the person in front of you. And by all means listen to everything and if you have to assume anything...assume they are telling the truth.



Bill Jones, Momentum Physical Therapy/Sports Enhancement March 30, 2010 1:35 PM
Columbus GA

Janey, thanks for the insight and for telling your personal experience. I will remember this on the days I'm doubting someone's presentation.

Dean Metz March 28, 2010 8:23 AM


Thanks for the comment- I like your perspective.  I especially like the phrase, "He would rather be taken advantage of than miss the opportunity to help someone who could benefit from his expertise."  


Lisa West March 26, 2010 5:58 PM
Waukesha WI


This one hits close to home for two reasons.  

First, I worked for an amazing ortho surgeon who ran a work rehab clinic - before POPTS was a bad thing.  Clients came from out of state to take advantage of our program.  This surgeon's philosophy was to assume the patient was telling the truth - provide treatment as though they were telling the truth - and let them hang themselves.  That said, he didn't use expensive tests to prove the patient was faking.  He operated on the premise that a good clinician didn't need expensive tests to diagnose and treat - the only reason for "diagnostic" tests was to confirm dianosis and level prior to surgery.

He positioned his office so he could observe patient's getting out of their car and walk into the clinic when they thought noone was watching.  That often confirmed his suspicion.  We used a machine to test them that they couldn't fake.  When they took the test they thought they were getting one over on us because we hadn't given them any hint that we thought they were malingering.  Sometimes we were the ones that got the surprise.   He would rather be taken advantage of than miss the opportunity to help someone who could benefit from his expertise.

If they were actually sincere, our pretending we believed them saved us face and allowed them to be confident in their practitioner.  Because we treated everyone as if they were being 100% above board, once they proved themselves as genuine, they never had to know what our initial disposition was.  

We were proved wrong more than once.  Two specific times I a man, one a woman.  Both of them went on to successfully rehabilitate, one of them after a surgery none of us saw coming.  I don't know that they would have recovered to the extent they did if we had let it be known we didn't believe them to begin with.  

The second reason this hits close to home is because I was accused of being a malingerer.  The male ER doc didn't listen to a thing I said.  He heard what he wanted to hear, gave me a shot of some medicine and sent me home.  Less than 24 hours later I was experiencing weakness.  The second day I had complete foot drop and treandelenberg gait.  Day three I had an epidural and was placed on bedrest.  Five days later I was being taken into emergency surgery.  That whole scenario took me out of the clinic.  All because a clinician used his superior intellect to conclude I was faking.  If he had treated me as though I had a genuine complaint, I may have had surgery in a timeframe that would have allowed me to continue practicing.

So before clinicians are too quick to pigoen hole someone into the malingering catergory because of their education and clinical expertise, a good question to ask is, "Am I sure enough to risk changing the entire course of their life if I'm wrong?"  

Are you THAT sure?  

If you aren't, then you need to treat them as if they are genuine and allow time to prove otherwise.  You might be the one proved wrong.  Been there, done that!  And when I was, I was so relieved I'd treated them in a way that they thought I believed them all along.

Another thought - are malingerers abusing the system any worse than patients with genuine complaints who are inconsistent with attendance and fail to follow through on their home programs?  You can set policies in place to objectively deal with those patients - you can outline expectations in the beginning and have established consequences for noncompliance.  That will take care of many of the malingerers without subjectively categorizing.

Also, if your department doesn't already have one, you may talk to someone about establishing a pain management program.  There is some pain that can't be taken away completely, but has to be managed.  This removes the excuse of pain being a reason to stay at the hospital...if you can't take the pain away, they are referred to the pain management program to learn to deal with it.  Some people have the mentality that pain has to be gone for them to be well.  For some, that is not a realistic goal and they need to be told that and learn how to cope.

I've rambled enough.  Hope something in here will be useful to you at some point in your career!



Janey Goude March 25, 2010 3:27 PM

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