A Cry for Help

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Commentary — January 2016

Tex Med. 2016;112(1):17-18. 

By Maggie Ward, MD, and Swati Avashia, MD

The patients in bed 11 has chest pain. I consider my differential diagnosis as I hurry over to the patient. I hesitate in the doorway and wonder if this is the wrong room. I had expected a more distressed patient, but he is smiling. He is breathing comfortably, despite describing an eight out of 10 in terms of chest pain. The pain responds only to "4 milligrams of IV morphine," and his exam is normal. Although he has bipolar disorder, he denies suicidal ideation. 

"Sir, we're going to do some tests, but the good news is that you probably won't stay overnight," I say. His smile fades; he is flabbergasted. "Well, I didn't want to have to mention this, but I actually am feeling suicidal," he says, obviously lying. Although his chest pain evaluation is reassuring, we admit him to psychiatry as a precaution.

The following evening, I again hurry to a patient with chest pain who arrived via ambulance. She informs me she isn't going to stick around to speak with me. The paramedic mentions that the trigger for her chest pain had to do with "the northbound bus stopping at 9 pm" and sarcastically adds that the ambulance served as her "taxi" for the evening. 

We take the complaint of chest pain seriously in the medical profession. Although we learn about malingering in medical school, we aren't taught how to discern malingering from true illness. As a result of my "boy who cried wolf" experiences in the emergency department (ED), I now notice myself adding malingering to my differential diagnosis and often search for what proof I have to validate a patient's medical history.

Malingering presents an ethical dilemma for emergency physicians. For example, what if the first patient had complained of chest pain with deep inspiration? I may have performed a CT scan of the chest to evaluate for pulmonary embolism. Labs and radiographic exams, while necessary to rule out life-threatening disease, are not benign interventions. Venipuncture increases risk for infection, and radiographic exams expose the patient to radiation and the risk of chasing clinically insignificant incidental findings.

A busy ED late at night is not pleasant. Thus, most malingerers go to the ED as a last resort. Furthermore, most of these patients have legitimate needs: housing, access to a free clinic, transportation, and others. Hospitals and taxpayers pick up the tab for the average $1,000 cost of an unfunded ED visit. When added up for multiple patients over months and years, the burden is substantial. 

I recognize that a malingering patient must really be struggling if seeking shelter in the hospital or using an ambulance as a taxi are the only recourses. It's difficult to feel compassion because malingerers may delay care of other patients who genuinely need it, and hospitals, government programs, and taxpayers incur unnecessary costs.

In the moments when I'm frustrated by malingering patients' complete disregard for wasting time, resources, and taxpayer money, I force myself to remember the true reason I went into medicine: to serve and to heal. Although these patients don't have a strictly medical complaint, they do have a social need. 

While no one would argue against the importance of learning medicine to be an effective physician, it is equally important that we are educated on social service resources available to our patients. There are systems in place in the United States to decrease ED visits and hospital admissions in our "frequent flyer" population. 

In the January 2009 issue of the American Medical Association Journal of Ethics, the California Frequent Users of Health Services Initiative published the results of six separate county pilot programs. It demonstrated that connecting homeless patients with housing, income benefits, health insurance, and a primary care home resulted in a 61-percent decrease in ED visits over a two-year period.  

If physicians are aware of the resources available to meet the social needs of patients, we can have a positive impact on our patients and the rising cost of health care. 

Maggie Ward, MD is a second-year resident in family practice at The University of Texas at Austin Dell Medical School. Swati Avashia, MD, is an assistant professor of medicine at UT-Austin Dell Medical School. 

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