Malingering-by-proxy: need for child protection and guidance for reporting.

The feigning of disabling illness for compensation at the direction or pressure by others, which is called malingering by proxy (MBP), has been the subject of several spirited articles. Chafetz and Prentkowski (2011) suggested that MBP has the potential for real harm to the child. In a poster at the AACN scientific session in 2011, Chafetz and Binder (2011) pursued a case of MBP that showed the child had clearly suffered and failed to progress in the 6 years that had passed since she was first evaluated as an 11 year old. In the present article, we identify three cases that compare and contrast effects of MBP, illustrating that child abuse and/or neglect can be a serious and reportable consequence of MBP behavior. To illustrate how MBP behavior can cause child abuse, we compare MBP behavior with Munchausen Syndrome by Proxy (MSBP), another condition of volitional noncredible behavior produced in a vulnerable person at the direction or pressure by others. Guidance criteria for reporting MBP as child abuse/neglect are introduced in this article.

Importancia y utilidad de las “Guías de simulación clínica” en los procesos de aprendizaje en medicina y ciencias de la salud / Importance and utility of clinical simulation guides in learning processes in health sciences

El uso de guías es una herramienta didáctica tradicionalmente utilizada, no solo en educación médica y ciencias de la salud sino en múltiples profesiones, principalmente por aquellos que fundamentan su quehacer docente en el constructivismo. Su utilidad se ha centrado para la formación en medicina y otras ciencias de la saluden la estandarización de protocolos de manejo, los cuales muchas veces utilizan, por ejemplo, a la denominada medicina basada en la evidencia, como criterio fundamental de calidad con el fin de lograr dicha estandarización conceptual. La utilidad que tienen las guías de simulación clínica difiere un poco de este concepto y, a pesar de requerir obviamente de una fundamentación científica inequívoca, las guías se convierten en un producto intelectual docente, centrado en un proyecto educativo que refleja en la mayoría de los casos una escuela de formación. A diferencia del concepto descrito de manera tradicional, en el cual el objeto de las guías corresponde a la globalización y estandarización de procesos, las guías en simulaciónclínica, si bien estandarizan procesos con el fin de obtener mejores desempeños en la evaluación de los mismos, no pretenden ser globalizados sino centrados en una visión de formación docente acorde con el proyecto educativo institucional; por lotanto, son de carácter institucional y favorecen el desarrollo de la denominada “escuela de formación”. De igual manera, el uso de guías de simulación clínica favorece los conceptos educativos actuales, tales como evaluación formativa, autoevaluación y coevaluación, seguridad psicológica, formación por competencias y seguridad delpaciente...

Guides are frequently used in medical education and other health sciences by teachers who focus on constructivism. In health, their utility has been to obtain standardized protocols that can be accepted globally, using best evidence as a gold standard. The utility that we have found and developed with the guides for clinical simulation is different than the utility of clinical guides. Simulation guides are products of an intellectual exercise of educators focused on an educational project andare the reflection of a school of formation. Unlike clinical guides aimed at the standardization and globalization of concepts, simulationguides are not intended to be global but they must correspond to the educational project as a reflection of institutional objectives and it shouldencourage the development of a school of formation. Likewise, simulation guides encourage the developmentof current educational concepts suchas: formative evaluation, auto and co-evaluation, psychological safety, curriculum by competences and patient safety...

Executive dysfunction in traumatic brain injury: the effects of injury severity and effort on the Wisconsin Card Sorting Test.

This study examined the persistent effects of traumatic brain injury (TBI) on Wisconsin Card Sorting Test (WCST) performance. Since poor effort can contaminate results in populations with incentive to perform poorly, performance validity was explicitly assessed and controlled for using multiple well-validated cognitive malingering indicators. Participants were 109 patients with mild TBI and 67 patients with moderate-to-severe TBI seen for neuropsychological evaluation at least one year post injury. Patients with diffuse neurological impairment and healthy controls were included for comparison. Results suggested a dose-response effect of TBI severity on WCST performance in patients providing good effort; the mild TBI group did not differ from controls while increased levels of impairment were observed in the moderate-to-severe TBI group. Effort during testing had a larger impact on WCST performance than mild or moderate-to-severe TBI. Clinical implications of these findings are discussed.

Emergency management of chronic pain and drug-seeking behavior: an alternate perspective.

Pain is one of the most prevalent conditions treated by Emergency Physicians, although it remains contested how to interpret, measure, and treat this condition. In particular, there is controversy over how to identify and treat patients with chronic under-treated pain and those who are potentially malingering (drug-seeking). This article discusses currently accepted paradigms for treating potentially malingering patients, difficulties some communities may have when these paradigms are applied, and the results of implementing pain treatment guidelines that limit opioid use. Systematically limiting opioids via these guidelines was not associated with a decrease in overall patient satisfaction, patient satisfaction with pain management, overall volume, or volume of patients with potential drug-seeking diagnoses. Emergency Physicians' perception of quality of care delivered, as well as job satisfaction, increased after implementation of the guidelines.

Physicians being deceived.

OBJECTIVE: In several high profile prosecutions of physicians for prescribing opioids, prosecutors claimed that the doctors should have known the individuals were feigning pain solely to obtain the prescriptions. This study was to determine how readily physicians can tell that patients lie. METHODS: A literature search was done for studies of standardized patients used to evaluate physicians' practices. Standardized patients are actors taught to mimic a patient with a specific illness. The papers were then reviewed for the frequency with which the physician correctly identified which office visits were by the standardized (lying) patients. RESULTS: Six studies of practicing physicians using standardized patients reported the frequency with which these actors were identified as the standardized patients. This occurred around 10% of the time. Some real patients were erroneously identified as the actors. CONCLUSION: Deception is difficult to detect. In the current legal climate surrounding prescribing opioids, accepting patients' reports of pain at face value can have significant legal consequences for the doctor. While doctors must make every reasonable effort to confirm the diagnosis and need for opioid therapy, allowance must be made for the fact that conscientious doctors can be deceived.

Information/Orientation subtest of the Wechsler Memory Scale-Revised as an indicator of suspicion of insufficient effort.

The utility of the Information/Orientation (IO) subtest of the Wechsler Memory Scale-Revised in identifying insufficient effort was examined. Performances of 50 benefit-seeking patients were compared to previously generated norms based on a clinical sample. Of the 50 benefit-seeking patients, 6 (12%) had IO scores that were outside the performance ranges of the entire clinical sample. An additional 6 of 50 (24%) had performances that were comparable to less than 2% of the normative sample. These results are consistent with previously published estimates of insufficient effort base rates in benefit-seeking populations and demonstrate the utility of IO as an indicator of suspicion of insufficient effort.

Compensation seeking status and psychometric assessment of combat veterans seeking treatment for PTSD.

Examined differences between compensation seeking (CS) veterans and noncompensation seeking (NCS) veterans on the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and other psychological measures in 142 combat veterans evaluated for posttraumatic stress disorder (PTSD) at an outpatient Veterans Affairs (VA) hospital PTSD clinic. Patients were grouped on the basis of their compensation seeking status, with 69% classified as CS for PTSD. The CS veterans achieved significantly more pathological scores across a wide range of psychological inventories and MMPI-2 validity indices, although they did not differ in frequency of PTSD diagnoses from NCS veterans. Implications of these findings are discussed, and clinicians are advised to be aware of the compensation seeking status of combat-veterans being evaluated for PTSD.

Factors complicating cost containment in the treatment of suicidal patients.

OBJECTIVE: The treatment of suicidal patients contributes to escalating mental health expenditures. Fiscal realities necessitate that cost-containment measures be implemented wherever possible. The authors reviewed the literature to delineate factors that impede cost containment for the treatment of suicidal patients and to outline strategies for controlling costs while improving the quality of care. METHODS: Psychological Abstracts and MEDLINE databases were reviewed. Retrieval and analysis focused on literature published between 1982 and 1992. RESULTS AND CONCLUSIONS: Five factors unique to the treatment of suicidal patients that impede cost containment were identified: the lack of a specific and cost-effective screening method to determine true risk of suicide, the high number of parasuicidal and malingering patients, revolving-door admissions of involuntary patients who become noncompliant with treatment after discharge, the adverse clinical consequences of further increases in existing discriminatory mental health benefits, and the medicolegal liability incurred in treating suicidal patients. The low frequency of completed suicides in relation to attempts and reported ideation indicates that most inpatients labeled suicidal are hospitalized unnecessarily. Thus inpatient treatment should be reserved for patients who make attempts of high lethality and patients with suicidal ideation who are at high risk because of other factors. Ideally, suicidal patients should be committed not to an inpatient facility but to a treatment network in which they can move appropriately between inpatient, day hospital, and outpatient care.

Malingering behavior in private medical practice.

Malingering behavior presents a tremendous and unfair burden on our nation's health care system. Physicians must be prepared to identify and diplomatically discourage such abuse whenever possible. Failure to do so could jeopardize the economy of the entire health care system and will prevent good care from reaching those in most need of it at affordable rates.