I was deceived by a patient — and I wasn't the only one

By Kristen Fuller, MD | Fact-checked by MDLinx staff
Published August 26, 2022

Key Takeaways

I was deceived by a patient—and I wasn’t the only doctor who fell for her con.

An eager, smartly dressed middle-aged woman came into my office with pain associated with an underlying chronic condition that wasn’t relieved by over-the-counter, high-dose pain relievers. Based on her physical exam, it was apparent she was in pain that was affecting her daily life.

She wanted something stronger

She politely asked me to prescribe her "something stronger." Before I wrote her a prescription for opioids, I asked her to sign a pain contract that required her to return in 30 days for refills and only receive prescriptions from me in person; she happily did so.

For over a year, she never missed an appointment. She seemed eager to listen to my advice about preventive care such as mammograms, cholesterol testing, and pap smears.

But one night, a colleague called to report that this patient had stumbled into their urgent care clinic extremely intoxicated, requesting an early refill for her pain medications of a different brand that had been prescribed by a fourth doctor who fell for her story.

"My colleague told her enough was enough, and I never saw her as a patient again."

Kristen Fuller, MD

I later found an approach to help prevent such deception: therapeutic discharge.

What is a therapeutic discharge?

Therapeutic discharge refers to discharging a patient from an acute care setting, such as the emergency room or inpatient hospital, because they were found to be deceptive with their clinician.[] It’s an actionable step attending physicians take in the best interests of the patient, physician, and healthcare system.

Patients can be deceptive in many ways, including fabricating or exaggerating their symptoms or medical diseases.

They may fake symptoms with a medical school student, resident, fellow, or young attending, knowing these doctors may not be as savvy as more experienced ones.

We must keep our eyes peeled, and ears open, for warning signs. Deceiving physicians not only wastes our time; admitting a deceptive patient can potentially take up a hospital bed needed by another patient, thereby misusing hospital resources.

Effectively discharging misleading patients can also prevent further harm, iatrogenic or otherwise. In some cases, deceptive patients may intentionally make themselves sick by injecting bacteria, feces, milk, or gasoline into their bodies; they may also attempt harm to the physician and other medical staff.

Malingering behaviors and factitious disorders

Deception comes in many forms; malingering behavior and factitious disorder are the two medical disorders most commonly associated with deception. Malingering is the purposeful fabrication of nonexistent symptoms or exaggeration of real symptoms to achieve a goal. Common warning signs include:

  • Missing school or work

  • Getting out of a legal situation, such as a court date

  • Trying to obtain goods or services, such as disability benefits or hospital accommodations, including medications

The symptoms usually dissipate once the patient receives their desired outcome.

Individuals with factitious disorder are intentionally faking or inducing symptoms, but the goal here is to get the attention and sympathy that is often given to someone who’s sick.[]

According to a study published in 2018 by Psychiatric Services, malingering was suspected among one-third of 405 patients, and 20% were definitely or strongly suspected of malingering.[] Fifty-four percent of subjects used it to gain hospital admission, and 35% sought to stay in the 24/7-staffed comprehensive psychiatric emergency program.

When you suspect a patient is deceptive

As physicians, it’s our job to always show empathy and compassion, even if we believe a patient’s trying to deceive us.

If we feel there’s not a valid medical diagnosis that warrants hospital admission, it’s our duty to refuse their hospital admission.

Take notes

Document your interview and findings, and explain why you think this patient doesn’t warrant admission. These patients need help, but not in the emergency room or hospital. They may be better served by a housing agency, chemical dependency program, or another social or community service.

Ask open-ended questions; then get specific

When interviewing a patient you believe may be deceptive, rely first on open-ended questions.[]

After the patient reports their symptoms, ask specific, detailed questions that may help characterize their symptoms as typical or atypical.

Gather collateral information from other sources

When evaluating a patient you suspect of malingering, gathering collateral information—from family members, friends, nurses, social workers, emergency medicine physicians, and others—becomes essential. You may also discover pertinent information from police reports, EMTs, and a review of the patient’s prior ER visits.

Assess motives, address discrepancies

To assess our patients’ motives, consider asking the following:

  • How have these symptoms affected your daily life?

  • What can I do to help you?

  • What would make your life better?

While exploring their motives, we can gently confront discrepancies in our findings by asking:

  • I’m unsure if I understand what you are saying, as these symptoms don’t typically occur in the way you described. Could you tell me more?

  • Do you think stress is causing you to have these symptoms?

  • Are these symptoms present because you’re trying to avoid work, incarceration, or get a prescription for a specific medication?

  • Is it possible you’re describing these symptoms to convince others that you are having problems?

Each week in our "Real Talk" series, mental health advocate Kristen Fuller, MD, shares straight talk about situations that affect the mental and emotional health of today's healthcare providers. Each column offers key insights to help you navigate these challenging experiences. We invite you to submit a topic you'd like to see covered.

Read Next: Real Talk: When you can't help your patient
Share with emailShare to FacebookShare to LinkedInShare to Twitter