These days, many (but not all) health care providers are becoming less and less like scientists and more and more like blind patient advocates. While it is natural for treating providers to advocate for their patients, and in fact, part of their role in many cases, what many appear to have forgotten is that advocacy needs to be based on reliable and valid data. For example, let us say that a patient walks into your office and subjectively reports a plethora of diffuse cognitive and somatic complaints after what appears to have been a relatively mild injury. What is the provider to do? Let us further stipulate that the patient shows up with these same complaints and informs you that he or/she is involved in personal injury litigation or a workers compensation dispute. Should this information be considered in the case formulation and should it potentially alter the plan of care? Or, should these contextual factors all be ignored and shoved aside in the interests of patient advocacy and being nice? Far too often, I see health care providers do the latter and it often causes great harm, despite good intentions by some.
While all ethical health care providers want the best for their patients and do not want to have conflict with them, it is also important to draw boundaries and remember that the patient is not your friend. Trying to become friends with your patient constitutes a multiple relationship that can cloud objectivity, which is so important to the assessment process. Another important factor to remember is that simply because a patient walks through your office doors does not automatically create a situation where you must show 100% allegiance in believing everything the patient says or doing everything they ask of you. While there is nothing wrong with having an allegiance to your patient and being a strong patient advocate, the degree of such advocacy should be modified based on an objective determination of the validity of the patient's clinical presentation.
While many patients present to the clinician's office with an accurate portrayal of their symptoms and problems, there are other patients who exaggerate their presentation for a whole host of reasons. Some exaggerate because they want to convince you that something is wrong, because they want attention for being in the sick role (i.e., factitious disorder), or because they seek some type of external gain such as money in a lawsuit, disability, medications, or avoidance of responsibility. The latter is known as malingering. Patients who exaggerate their clinical presentation may have valid symptoms inter-mixed with exaggerated symptoms. Less common is the patient who has made up a story about a personal injury and is feigning the entire clinical presentation (sometimes referred to as pure malingering).
If the patient's symptoms are purely based on self-report and you have no objective data to support your conclusions, you can potentially fall victim to patient exaggeration. Why is this so important? Improper identification of symptom exaggeration leads to a waste of health care services such as referring patients to needless and endless therapies, tying up access for those patients who legitimately need such services. Furthermore, patients are often granted disability (sometimes for years) or accommodations in school or work that they do not deserve. Many systems that provide disability services or accommodations have quotas on the number of people they will grant such services to. Therefore, granting access of such services to patients who are willfully distorting there clinical presentation is a disservice to those patients presenting in a reliable and valid manner who legitimately need such services.
In my line of work as a board certified clinical neuropsychologist, I frequently encounter situations where symptom validity is not assessed by the health care provider. In many cases, this is because assessment of symptom validity sets the stage for a potential conflict with the patient. In other words, if the provider determines that the symptoms are not valid, this will need to be communicated with the patient in some way, which can upset the patient. The very possibility of conflict with a patient is something that many health care providers do not want to deal with because it can be socially uncomfortable and potentially lay the groundwork for a patient complaint or possible lawsuit. As a result, health care providers tend to give patients the benefit of the doubt and accept self-report at face value. This is a tremendous mistake.
For example, I recently published an article in the journal, Brain Injury, (reference below), showing that 21% of adults who reporting suffering a mild head injury or mild traumatic brain injury failed a very simple test designed to assess the degree of effort they were putting forth on the evaluation. When later asked to rate how difficult this task was, this group of adult patients rated it to be 5.6 out of 10 (with 10 being the most difficult). By contrast, I found that only 5% of children with moderate to severe neurological conditions (e.g., strokes, traumatic brain injuries) failed this same test and that the entire group of children rated the same test as very easy (1.35 out of 10). It is not neurologically possible for a mild traumatic head or brain injury in an adult to cause worse performance on a simple test compared to little children with moderate to severe brain injuries. The only logical conclusion is that the adult group of patients exaggerated their presentation.
Without the use of objective measures such as the one used in my study above, clinicians will find it very difficult to assess for the validity of a patient's presentation -- although they may have suspicions. Objective data helps supplement the confidence one has in those suspicions. Tools are available to assess for validity of cognitive performance as well as the validity of physical, cognitive, and emotional complaints. I will not describe the methods behind these instruments in a public forum, but they are well researched and validated and are very important to utilize.
By not assessing symptom validity, one increases the risk of blind patient advocacy. This can cause one to fall into very bad habits such as not obtaining or reading through the patient's medical records. By not doing so, the clinician misses reviewing important information that may provide an alternate explanation of the patient's presentation or may raise red flags of suspicion. Another bad habit is the willful suppression and omission of information in the clinical note that would show that the patient's problems may be related to factors other than those related to their disability claim. For example, I recall working on a case where a provider omitted that a recent hospitalization concluded that the patient was experiencing pseudo-seizures because this finding highlighted that there was a psychological component to the patient's problems, which conflicted with the claim that all of the problems were neurological. As a result, the tendency is to try to fit a square peg in a round hole and continue to attribute the clinical presentation to a medical cause that does not really exist. Another bad habit is allowing patients to tell you what information goes in their reports, what stays out, and how to write it.
Lastly, it is important to note that the assessment of symptom validity is designed to improve patient care and utilization of the health care system. In many instances, patient exaggeration is related to psychological factors that would be better addressed by referring the patient to psychotherapy rather than tying up medical resources in the community. In this way, patients are better served because the real factors driving their clinical presentation can be addressed, helping them move on to living more productive lives. Of course, not every patient will be happy to learn that there are doubts as to the validity of their performance or symptoms, but I have found that patients are often accepting of such feedback if care is taken to listen to their self-report in a non-judgmental manner during the clinical interview so that a strong rapport is established. This allows the patient to be much more accepting of such feedback because the patient feels that you have listened. Also, the presentation of the feedback is crucial. Rather than calling the patients liars, it is important to emphasize how the information you have gathered can help guide their clinical care. By showing that you listened to the patient, performed a thorough evaluation, and used objective data to make your conclusions, patients tend to be very understanding of such feedback.
With that said, there is no full-proof way to insulate yourself from a patient complaint or conflict. This is most likely to occur with patients who blatantly distort their presentation and have alot to lose by not being able to access the external gains that they seek. However, dealing with these issues is part of the job when evaluating the validity of a patient's presentation, particularly in those with vague medical complaints and controversial medical diagnoses. However, being able to cite objective data to support your conclusions greatly helps in insulating you from a complaint leading anywhere.
In summary, although you may be reducing the chance for any conflict with a patient by not assessing for symptom validity, you can also be making the patient sicker by not doing so. In medicine, this is known as iatrogenic illness -- when the "treatment" makes the patient worse. If you are not assessing for symptom validity, it is important to learn more about the topic and to begin integrating this into your clinical practice.
To learn more about this topic and to schedule Dr. Carone to lecture to your clinical practice, university, or in other settings, contact him at lectures@MedFriendly.com for information on available dates and speaking fees. Dr. Carone is also available for legal consultation (e.g., assessment of case viability, independent opinion of neuropsychological reports) although he does not test patients referred by lawyers or independent medical exam companies at this time. Reference:
Carone, D., (2008). Children with moderate/severe brain damage/dysfunction outperform adults with mild to no brain damage on the Medical Symptom Validity Test. Brain Injury, 22, 960-971.
