Ambiguously ill pose challenge for doctors
■ How should you respond to a patient whose trustworthiness you doubt?
Scenario: A patient appears at the emergency department with chest pain, nausea and profuse sweating. The patient has a long history of medical deception, but is that reason enough to assume that he is not having a heart attack?
The answer to that question is, "Of course not." How, then, should physicians respond when they encounter "ambiguously ill patients?"
Under this rubric, we include patients who might be labeled malingerers, crocks or "difficult," and those who present with psychological disorders, particularly factitious or somatoform disorders. These patients, whose medical complaints physicians suspect of being exaggerated, feigned or at least mistaken, often elicit strongly negative emotions that can cloud clinical decision-making.
Most physicians can agree that they are bound to provide competent medical care for people with physical diseases or injuries, without regard for patients' race, religion or other medically irrelevant characteristics.
Although the AMA Code of Medical Ethics allows physicians to choose their patients as they wish, once a treatment relationship is established, all further decision-making must be based solely on the patients' medical needs. We will focus on how this ethical ideal is frustrated in the care of the ambiguously ill patient.
Physicians often respond to ambiguously ill patients by categorizing them into one of two groups: legitimate patients and illegitimate ones. Legitimate medical patients are persons with evidence of disease or injury whose complaints are commensurate with their apparent physical condition. Assignment to the illegitimate group occurs when complaints are excessive, especially when an obvious explanation for exaggerated complaints (e.g., pending disability claims or psychiatric history) exists.
In extreme cases, this categorizing is done consciously, and an illegitimate patient may be dismissed from the physician's practice. More often, assignment to the illegitimate group affects treatment subtly, e.g., shortened visits, referrals to other physicians. In either case, we believe that this sort of categorizing is logically flawed and ethically dangerous.
Whereas the factors that lead doctors to assign patients to the illegitimate group might explain false or exaggerated complaints, none of them proves that the patient is free of disease or injury.
Consider the patient in the introductory scenario -- the one with the history of medical deception who appears at the ED with heart attack symptoms. Physicians sometimes act as if such patients enjoy immunity from real diseases.
In less extreme cases, the same sort of thinking creeps more insidiously into the evaluation of the patient. For instance, hand and wrist complaints in a patient seeking disability compensation are discounted, or muscle weakness in a depressed patient is interpreted as a symptom of the mental disorder.
In each instance, the presence of a factor that might explain excessive or false complaining is used instead as evidence against the presence of a genuine disease or injury.
In all of the situations described above, judgments about the patients' trustworthiness have been confused with the assessment of their physical condition. But there is no logical or scientific justification for weighing patients' trustworthiness in evaluations of their medical condition. And though the idea might take some getting used to, denying full and competent medical care to untrustworthy patients on the basis of their untrustworthiness is not different in principle from denying care on the basis of race or religion or other medically irrelevant parameters. We believe that doing so is unethical.
There is an apparent paradox here: Untrustworthy people can get sick just like trustworthy people, so the trustworthiness of the patient should be ignored when evaluating a patient's physical condition. On the other hand, a patient who has lied in the past, or who is motivated to lie in the current situations, may be lying about his or her current symptoms, so a patient's trustworthiness cannot be ignored.
The paradox can be resolved by focusing on the issue of reliability -- not the reliability of the patient, but the reliability of the symptom. Symptoms should be used like any other piece of clinical data, such as urinalyses or radiographs. The reliability of each of these sources of information varies for different types of patients, for different diseases and for different test conditions. In circumstances in which the reliability of a given test is questionable, the physician requires more corroborating data before making a diagnosis. The same approach should apply to the use of potentially unreliable symptom reports.
Focusing strictly on the accuracy of a particular symptom can prevent errors of judgment that might occur if focus is misplaced on the trustworthiness of the patient. Consider, for example, two patients who report dizziness and nausea that started around the time new carpeting was installed at their places of employment, suggesting a reaction to an environmental toxin. One of these patients is suing his employer for a work-related injury; the other is not. Imagine that in both cases new data emerge to suggest that the patients' self-reports were inaccurate. Even though the medically relevant facts of these cases are identical, it is hard to avoid the conclusion that the liability plaintiff is less likely to be authentically ill than the non-litigating patient. But this conclusion may be false, and dismissive treatment of the liability plaintiff based on that conclusion would be unethical.
Another way to illustrate the peculiar reactions that physicians have to the ambiguously ill patient is to contrast them with the reactions elicited by other sorts of patients. Consider the treatment of a patient with dementia or a 4-year-old child. Although physicians may solicit symptom information from these patients, that information is often unreliable and is weighted accordingly. Yet no physician would discount the possibility that they are truly ill on the basis of their unreliability or form unfavorable impressions about their moral character on that basis.
Contrasts also can be drawn with patients of unquestionably poor moral character. No physician would argue that untrustworthy people such as convicted tax cheats, bank robbers or even murderers should be denied competent medical care. Why is the untrustworthiness of the malingerer thought of differently than the untrustworthiness of a 4-year-old, and why are physicians so intent on rooting out and dismissing malingerers but not murderers?
One answer is that physicians often react to ambiguously ill patients on a personal level. Physicians invest great concern in these patients and work hard to solve the puzzle of their unexplained complaints. After a while, feelings of self-doubt and frustration begin to build. When evidence emerges to undermine the patient's trustworthiness, the physician latches on to this information as an explanation for the patient's complaints. The physician may feel indignation or a sense of betrayal, and perhaps relief and triumph over the patient when evidence of untrustworthiness is uncovered. Yet after all this, it still may not be clear whether the patient is really sick.
Our suggestion, then, is that dismissive treatment of patients on the basis of untrustworthiness is medically unsupported, logically inconsistent and professionally unethical. Moreover, we believe that these case management errors are largely a product of emotional reactions that cloud clinical decision-making. Accordingly, our suggestions for avoiding these errors focus on managing these emotional reactions.
Our advice for the treatment of the ambiguously ill patient is to adopt a stance of compassion through dispassion -- that is, providing the best possible care for the patient by not getting caught up in the emotional or moral dimensions of a case. This step involves a determined decision that every patient will be treated in exactly the same way, strictly on the basis of the available evidence. Sometimes this requires a physician to disregard a patient's pleas or protests. Although we support patient participation in medical decision-making, physicians who are bullied into giving patients a say in matters for which they have no expertise are at risk for the adverse emotional reactions that we have just described. Just as a pilot flying in low visibility has to ignore her gut feelings and trust her instruments, a physician caught in the fog of an ambiguously ill patient must trust her instruments.
Finally, we respectfully urge physicians to adopt a complementary position of dispassion through compassion. Patients who are relegated to the illegitimate group may include the greedy and the shiftless, and these people may deserve our contempt. But the "illegitimate" group also may include the abused woman seeking refuge in the hospital or the socially anxious adolescent seeking a way to escape from relentless teasing at school.
Although these considerations have no direct bearing on the medical assessment of patients, acknowledging that ambiguously ill patients may have legitimate needs, even if they are not medical needs, may reduce the resentment and adversarial feelings physicians have in response to ambiguously ill patients. Physicians who take this approach can become more effective in making helpful nonmedical referrals for patients whose excessive treatment seeking is influenced by modifiable nonmedical causes.
James C. Hamilton, PhD, associate professor of psychology and affiliate associate professor of internal medicine, University of Alabama; has written widely on factitious disorder and malingering
Marc D. Feldman, MD, clinical professor of psychiatry and behavioral medicine, University of Alabama; author of "Playing Sick?: Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering, and Factitious Disorder"