Guest guest Posted July 28, 2004 Report Share Posted July 28, 2004 If a patient claims to be suffering, but you believe the patient may be malingering and/or even possibly inducing symptoms, how is that best handled? For context, consider that the patient is living off of state and federal plus private disability insurance from a past employer. She worked for a company that gave her a lucrative disability policy. Something equivalent to her last year's salary, which was close to six figures. In this case, the patients presents as having chronic fatigue syndrome with an energy level of 3. However she has normal sleep of 7 hours and has no desire to sleep during the day. Her days are filled with activity for which she claims she does not have enough time to do everything she wants. She has no other symptoms and her tongue suggests some dampheat, but no major vacuity (little greasy yellow coat, normal size, shape, little dusky. Her pulse was wiry. A pretty straightforward minor wood/earth disharmony when the whole s/s complex was considered. Not much different from most of my healthy, young patients. At 39, from appearance, she clearly spends a large amount of time exercising. She was well tanned and had a perfect complexion. She was well dressed in the style of a fashion valley shopper (this would refer to someone who also has ample to shop). She easily looked 10 years younger than her age. So she is energetic, active, tanned, fit, sleeps well, no GI problems. She lives well and does not have to work. Usually to live this life you have to be independently wealthy (she came from a poor north dakota family) or have married rich (she has always been single). So where's the fatigue? It seems as long as she gets to do as she pleases, there is no fatigue. She gets fatigued when she has to expend that same amount of energy working under someone else rules and constraints, etc. Yes, we all sympathize. I think its the same for everyone who has ever lived. But chronic fatigue patients usually remain severely fatigued despite their circumstances. Merely quitting one's job doesn't solve the problem in true cases, IMO. Her CFS dx came from an MD so she could get disability and she claims to have had a litany of tests over the years confirming various things such as heavy metal toxicity and candida. However she also regularly takes long course of antibiotics for vague, idiopathic symptoms. It appears that she wanders from doctor to doctor till she gets someone to prescribe for her. She then gets a flareup of candida, which she documents and treats with another doctor, thus piling up documentation of her continuing disability. She is clearly ill, but I am not sure if CFS is the right dx. Some kind of personality disorder seems possible. On one hand, I have heard the perspective that any claim of suffering should be taken at face value. Since we treat body and mind as a single unit in our dx and rx of herbs, we can still identify an imbalance in such a patient. Agreed. Even if we cannot verify the chief complaint, the fact that the patient exhibits this behavior tells us something is amuck. Or is it. Just because someone has figured out a way to work the system and avoid work, does mean they are ill. Or are they just clever (and criminal). I am being hyperbolic here to make a point. Just because someone is immoral (or amoral) by societal standards does not mean they are ill, or does it? In ancient chinese culture in confucian circles, not following cultural mores was often determined to be the main etiology of what we would today call a psych disorder. Though I won't digress here, there could be lots of arguments made as to why it is reasonable and moral to rip off corrupt corporations and governments in order to hasten their demise. It did not strike me that this patient had such a well thought out political agenda, though. OTOH, if a person believes they are ill when they are not, this may speak to something more than not just following the rules. Some type of zang-fu disharmony that largely plays out on the psych level. Perhaps something that could smack of delusions such as phlegm misting the mind. The question is where do one's responsibilities lie here: 1. insurance fraud of this type (if that is the case here) is one of the major drains on society and a major factor in rising health insurance costs. It is paid for by employers, insurers and tax dollars. Doctors as well as patients milk this system. 2. the patient in all likelihood has some type of disorder that can be treated, but will this lead to rectification of her behavior or just enable her to continue working the system. In other words, is it correct to enable someone to live this lifestyle. I guess it depends if you perceive her as sick or just slick. If she is sick, then she should be treated. However, do you operate under the pretense that you are treating CFS when you actually believe it to be more of personality disorder. Or do you refer to someone who can tackle that head on. Personality disorders are not good ways to receive medical disability and they carry a lot of stigma. No one likes to see their complaints as rooted in emotions rather than tangibles like viruses or toxins. But even though TCM is a bodymind medicine, the causes of an illness can still be largely emotional. These are the sole internal causes of illness, after all. Unless one uncovers etiology, there will be no cure. This patient has had endless drugs, chelation, every holistic CFS and candida tx imaginable and yet she continues to wear the label despite having none of the symptoms. As we all know, depression may mimic CFS in at least some cases. This patient has never gone the psychotherapy route for her ailments nor ever taken psych drugs. So this hypothesis has never been tested, though I bet anything I am not the first of her docs to feel this way. While mulling this over, I had the idea of an energy level image disorder come to mind. Like anorexia, this type of patient perceives themselves as having low energy when by all objective measures, they have normal or even above average energy levels. I think the standard for normal energy in our society, especially in certain fields (this patient was in entertainment in LA), is insane. You look around at people who are succeeding and they are burning the candles at both ends, all hopped on caffeine or worse, driving around madly, constantly on the cellphone. then women go home and take care of the family, too. Those who appear to succeed in this lifestyle are actually aging themselves rapidly in the process. Yet all that is perceived is the short term successes and the logical conclusion that ones own success depends on a similar lifestyle. However, if one is unwilling to take drugs or stimulants, it is impossible to sustain this lifestyle and one will always come up short. This is a depressing scenario and definitely accounts for some % of the much overdiagnosed CFS. But I think it really comes down to several key issues. First, making a choice NOT to live a life of meaningless taxation, even if that means making a bit less money. But there are options short of living off the dole for most people and that should not be enabled without careful consideration. I actually think the best cure would come from doing satisfying, but not overly taxing work. Second, to work on issues of coping and stress management, not keep looking for invisible causes like viruses. Whenever I hear someone tell me they are on disability for EBV induced CFS, I know I am dealing with a questionable cases as this viral etiology of CFS was dismissed as valid over a decade ago. Finally, what is the truly compassionate action here. Enabling, confrontation, surreptitious psychotherapy, referral, more lab tests. Chinese Herbs FAX: Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 28, 2004 Report Share Posted July 28, 2004 , wrote: > If a patient claims to be suffering, but you believe the patient may be > malingering and/or even possibly inducing symptoms, how is that best > handled? For context, consider that the patient is living off of state > and federal plus private disability insurance from a past employer. > She worked for a company that gave her a lucrative disability policy. > Something equivalent to her last year's salary, which was close to six > figures. > > In this case, the patients presents as having chronic fatigue syndrome > with an energy level of 3. However she has normal sleep of 7 hours and > has no desire to sleep during the day. Her days are filled with > activity for which she claims she does not have enough time to do > everything she wants. She has no other symptoms and her tongue > suggests some dampheat, but no major vacuity (little greasy yellow > coat, normal size, shape, little dusky. Her pulse was wiry. A pretty > straightforward minor wood/earth disharmony when the whole s/s complex > was considered. Not much different from most of my healthy, young > patients. > > At 39, from appearance, she clearly spends a large amount of time > exercising. She was well tanned and had a perfect complexion. She was > well dressed in the style of a fashion valley shopper (this would refer > to someone who also has ample to shop). She easily looked 10 years > younger than her age. So she is energetic, active, tanned, fit, sleeps > well, no GI problems. She lives well and does not have to work. > Usually to live this life you have to be independently wealthy (she > came from a poor north dakota family) or have married rich (she has > always been single). So where's the fatigue? It seems as long as she > gets to do as she pleases, there is no fatigue. She gets fatigued when > she has to expend that same amount of energy working under someone else > rules and constraints, etc. Yes, we all sympathize. I think its the > same for everyone who has ever lived. But chronic fatigue patients > usually remain severely fatigued despite their circumstances. Merely > quitting one's job doesn't solve the problem in true cases, IMO. > > Her CFS dx came from an MD so she could get disability and she claims > to have had a litany of tests over the years confirming various things > such as heavy metal toxicity and candida. However she also regularly > takes long course of antibiotics for vague, idiopathic symptoms. It > appears that she wanders from doctor to doctor till she gets someone to > prescribe for her. She then gets a flareup of candida, which she > documents and treats with another doctor, thus piling up documentation > of her continuing disability. She is clearly ill, but I am not sure if > CFS is the right dx. Some kind of personality disorder seems possible. > > On one hand, I have heard the perspective that any claim of suffering > should be taken at face value. Since we treat body and mind as a > single unit in our dx and rx of herbs, we can still identify an > imbalance in such a patient. Agreed. Even if we cannot verify the > chief complaint, the fact that the patient exhibits this behavior tells > us something is amuck. Or is it. Just because someone has figured out > a way to work the system and avoid work, does mean they are ill. Or > are they just clever (and criminal). I am being hyperbolic here to > make a point. Just because someone is immoral (or amoral) by societal > standards does not mean they are ill, or does it? In ancient chinese > culture in confucian circles, not following cultural mores was often > determined to be the main etiology of what we would today call a psych > disorder. Though I won't digress here, there could be lots of > arguments made as to why it is reasonable and moral to rip off corrupt > corporations and governments in order to hasten their demise. It did > not strike me that this patient had such a well thought out political > agenda, though. > > OTOH, if a person believes they are ill when they are not, this may > speak to something more than not just following the rules. Some type > of zang-fu disharmony that largely plays out on the psych level. > Perhaps something that could smack of delusions such as phlegm misting > the mind. The question is where do one's responsibilities lie here: > > 1. insurance fraud of this type (if that is the case here) is one of > the major drains on society and a major factor in rising health > insurance costs. It is paid for by employers, insurers and tax > dollars. Doctors as well as patients milk this system. > > 2. the patient in all likelihood has some type of disorder that can be > treated, but will this lead to rectification of her behavior or just > enable her to continue working the system. In other words, is it > correct to enable someone to live this lifestyle. I guess it depends > if you perceive her as sick or just slick. If she is sick, then she > should be treated. However, do you operate under the pretense that you > are treating CFS when you actually believe it to be more of personality > disorder. Or do you refer to someone who can tackle that head on. > Personality disorders are not good ways to receive medical disability > and they carry a lot of stigma. No one likes to see their complaints > as rooted in emotions rather than tangibles like viruses or toxins. > But even though TCM is a bodymind medicine, the causes of an illness > can still be largely emotional. These are the sole internal causes of > illness, after all. Unless one uncovers etiology, there will be no > cure. This patient has had endless drugs, chelation, every holistic > CFS and candida tx imaginable and yet she continues to wear the label > despite having none of the symptoms. > > As we all know, depression may mimic CFS in at least some cases. This > patient has never gone the psychotherapy route for her ailments nor > ever taken psych drugs. So this hypothesis has never been tested, > though I bet anything I am not the first of her docs to feel this way. > While mulling this over, I had the idea of an energy level image > disorder come to mind. Like anorexia, this type of patient perceives > themselves as having low energy when by all objective measures, they > have normal or even above average energy levels. I think the standard > for normal energy in our society, especially in certain fields (this > patient was in entertainment in LA), is insane. You look around at > people who are succeeding and they are burning the candles at both > ends, all hopped on caffeine or worse, driving around madly, constantly > on the cellphone. then women go home and take care of the family, too. > Those who appear to succeed in this lifestyle are actually aging > themselves rapidly in the process. Yet all that is perceived is the > short term successes and the logical conclusion that ones own success > depends on a similar lifestyle. However, if one is unwilling to take > drugs or stimulants, it is impossible to sustain this lifestyle and one > will always come up short. This is a depressing scenario and > definitely accounts for some % of the much overdiagnosed CFS. > > But I think it really comes down to several key issues. First, making > a choice NOT to live a life of meaningless taxation, even if that means > making a bit less money. But there are options short of living off the > dole for most people and that should not be enabled without careful > consideration. I actually think the best cure would come from doing > satisfying, but not overly taxing work. Second, to work on issues of > coping and stress management, not keep looking for invisible causes > like viruses. Whenever I hear someone tell me they are on disability > for EBV induced CFS, I know I am dealing with a questionable cases as > this viral etiology of CFS was dismissed as valid over a decade ago. > Finally, what is the truly compassionate action here. Enabling, > confrontation, surreptitious psychotherapy, referral, more lab tests. > > > > Chinese Herbs > > > FAX: > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 28, 2004 Report Share Posted July 28, 2004 (sorry, if that last one posted) What is the question? Seems you have made up your mind as to the diagnosis. If its a matter of you taking insurance money then with your diagnosis I would not treat. That would compromise your integrity for money. Not good. You could lay out how you feel to the patient. This may be the most honest if uncomfortable for you. ( " Truth without love is attack " -Selby) Would she take it to heart (so to speak)? She would probably get angry and leave. It might leave some resentments for both parties. I think most reasonably you could treat her fatigue as depression and tell her that is what you are treating her for. She gets to keep her image as ill and you get a diagnosis to work with. If she resents that then you can confirm you have a selfish person working the system. I had a patient who came to me every week for 4 years. He came in with vague pains, obsessive compulsive and stuttering. Physically he was very healthy and often worked out for hours for his job. He was also successful in his job. One day, after years of treatment, no mental complaints, no stuttering, I just said, listen, you are a healthy guy. He's come back once or twice since in the last 3 years. He says instead of going to acupuncture he sits in his backyard and watches his garden.... Now that is a healthy guy and one dumb business move. :-) doug , wrote: > If a patient claims to be suffering, but you believe the patient may be > malingering and/or even possibly inducing symptoms, how is that best > handled? For context, consider that the patient is living off of state > and federal plus private disability insurance from a past employer. > She worked for a company that gave her a lucrative disability policy. > Something equivalent to her last year's salary, which was close to six > figures. > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 28, 2004 Report Share Posted July 28, 2004 Dear Group, What's wrong with treating healthy people (as long as you are not billing insurance)? I know people who come every week for years and they never get sick, they feel great, and they know they are coming for preventive treatments. Julie - " " Wednesday, July 28, 2004 4:22 PM Re: ethical issue > (sorry, if that last one posted) > What is the question? Seems you have made up your mind as to the diagnosis. If its a > matter of you taking insurance money then with your diagnosis I would not treat. That > would compromise your integrity for money. Not good. > > I had a patient who came to me every week for 4 years. He came in with vague pains, > obsessive compulsive and stuttering. Physically he was very healthy and often worked out > for hours for his job. He was also successful in his job. One day, after years of treatment, > no mental complaints, no stuttering, I just said, listen, you are a healthy guy. He's come > back once or twice since in the last 3 years. He says instead of going to acupuncture he > sits in his backyard and watches his garden.... Now that is a healthy guy and one dumb > business move. :-) > doug Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 29, 2004 Report Share Posted July 29, 2004 I think that is great as long as everybody knows that is what is going on. I felt like a shrink telling a patient " you need to come in every week for years to understand your obsession with seeing me. " :-) doug , JulieJ8 <Juliej8@b...> wrote: > Dear Group, > > What's wrong with treating healthy people (as long as you are not billing > insurance)? I know people who come every week for years and they never get > sick, they feel great, and they know they are coming for preventive > treatments. > > Julie Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 31, 2004 Report Share Posted July 31, 2004 Whenever I hear someone tell me they are on disability for EBV induced CFS, I know I am dealing with a questionable cases as this viral etiology of CFS was dismissed as valid over a decade ago. Finally, what is the truly compassionate action here. Enabling, confrontation, surreptitious psychotherapy, referral, more lab tests. Chinese Herbs >>>>Put in your report if you are writing one, include all the objective evidence for good level of energy Alon Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 1, 2004 Report Share Posted August 1, 2004 Hi Todd and Alon Seems like my CFS/fibromyalgia patients always look " ok " to me in many ways and it's always been hard to believe they are ill. However, the proof seems to be in the pudding. If after trying many different protocols nothing seems to work or make them feel any better at all, this is when I would get suspicious. Once I got my patients " figured out " , they seemed to respond beautifully and gratefully to treatment--though they needed a lot of it for a long time. They did, however, careen at times from blood stasis to Lv/Sp disharmony to damp heat for example. I've never seen anyone, however, who was a strictly CFS patient without fibro concurent in their dx. This is not to say they don't exist; just haven't shown up in my limited experience yet. Thanks, Shanna , " Alon Marcus " <alonmarcus@w...> wrote: > Whenever I hear someone tell me they are on disability > for EBV induced CFS, I know I am dealing with a questionable cases as > this viral etiology of CFS was dismissed as valid over a decade ago. > Finally, what is the truly compassionate action here. Enabling, > confrontation, surreptitious psychotherapy, referral, more lab tests. > > > > Chinese Herbs > >>>>Put in your report if you are writing one, include all the objective evidence for good level of energy > Alon > > Quote Link to comment Share on other sites More sharing options...
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