Physicians being deceived

PAIN MEDICINE

Volume 8

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Number 5

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2007

© American Academy of Pain Medicine 1526-2375/07/$15.00/433 433–437 doi:10.1111/j.1526-4637.2007.00315.x

Blackwell Publishing IncMalden, USAPMEPain Medicine1526-2375American Academy of Pain Medicine? 200785433437Original Articles

Physicians Being DeceivedJung and Reidenberg

Reprint requests to:

Marcus M. Reidenberg, MD, Depart-ment of Pharmacology, Box 70, Weill Medical Collegeof Cornell University, 1300 York Avenue, New York,NY 10021, USA. Tel: 212-746-6227; Fax: 212-746-8835;E-mail: [email protected].

FORENSIC PAIN MEDICINE SECTION

Physicians Being Deceived

Beth Jung, EdD, MD, MPH,* and Marcus M. Reidenberg, MD

†

*Department of Pharmacology, Joan and Sanford I. Weill Medical College of Cornell University, New York, New York; Schering-Plough, Springfield, New Jersey;

†

Departments of Pharmacology, Medicine, and Public Health, Joan and Sanford

A B S T R A C T

I. Weill Medical College of Cornell University, New York, New York, USA

ABSTRACT

Objective.

In several high profile prosecutions of physicians for prescribing opioids, prosecutorsclaimed that the doctors should have known the individuals were feigning pain solely to obtain theprescriptions. 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 physi-cians’ 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 identifiedwhich office visits were by the standardized (lying) patients.

Results.

Six studies of practicing physicians using standardized patients reported the frequency withwhich these actors were identified as the standardized patients. This occurred around 10% of thetime. Some real patients were erroneously identified as the actors.

Conclusion.

Deception is difficult to detect. In the current legal climate surrounding prescribingopioids, accepting patients’ reports of pain at face value can have significant legal consequences forthe doctor. While doctors must make every reasonable effort to confirm the diagnosis and need foropioid therapy, allowance must be made for the fact that conscientious doctors can be deceived.

Key Words.

Deception; Prosecution; Opioids; Standardized Patients

Deceiving Physicians

barrier to prescribing opioids for patients inpain is physicians’ fear of being investigated

by a governmental agency and punished for pre-scribing this treatment [1–8]. A survey of prose-cutors in four states found that many wouldrecommend a police investigation when given ascenario of a patient with nonmalignant paintreated with opioids [9]. Our review of DrugEnforcement Administration (DEA) actionsagainst physicians who prescribed opioids foundthat some of these actions were based on prescrip-

A

tions given to undercover agents [10]. In severalhigh-profile prosecutions of physicians for pre-scribing opioids, prosecutors claimed that the doc-tors should have known the individuals werefeigning pain solely to obtain the prescriptions[11–13]. How responsible is a physician for beingdeceived?

The responsibility for being deceived can beviewed in the context of factitious disease, Mun-chausen’s Syndrome, either directly or “by proxy,”and frank malingering. But a physician can onlybe subjected to criminal penalties if the deceptionleads to prescription of a controlled substance.Because of this possibility, some physicians arereluctant to prescribe adequate doses of opioidsfor some patients with pain. Thus, the conse-quences of a doctor’s fear of being deceived affectspatients with pain much more than other kinds of

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patients. For this reason, we focused on the spe-cific problems of being deceived by patients whosay they are in pain.

Physicians operate with what Burgoon et al.[14] call a truth bias. That is, they presume thatpatients’ presentations of themselves are true,complete, and accurate. Their assessment ofpatients’ pain complaints are based both on cur-rent information (obtained in the interview andphysical examination) and on the starting point,or anchoring point [15] for the assessment. Doc-tors assume that patients come to see thembecause they have a problem for which they wanttreatment.

Law enforcement personnel appear to have adifferent assumption when they interview somepeople. Yet, in a study of police, judges, and federallaw enforcement personnel,* only the Secret Ser-vice agents were better than chance at detectinglying [16]. Thus, law enforcement personnel whopresume physicians can discern lies cannot recog-nize lies themselves.

Can physicians tell when patients lie? Studieswith standardized patients can address this ques-tion. Standardized patients are individuals (includ-ing actual patients) who have been trained topresent accurate, reproducible history and physi-cal examination findings of a particular clinicalproblem. They are increasingly used in teaching[17], evaluation [18–22], and research [23,24].They have been used since 1998 to evaluate for-eign medical graduates applying for Americanmedical licenses and, since 2004, as part of the USmedical licensing examination [25,26]. They per-mit assessment of skills and behaviors essential tomedical practice but which are poorly measuredby paper-and-pencil tests.

Standardized patients provide a new way toconsider the question of deceiving doctors bypatients not telling the truth. Standardizedpatients have been used in the community to studyresource utilization [24], risk factor determinationand counseling [22,23], and diagnosis, recognitionand management [18,19,27]. All studies involvedtraining individuals to present an overall scenario(history, physical examination findings, responsesto physicians’ questions, expressing pain) consis-tent with a disease or condition. For these studies,the individuals would then go to the doctor

*Federal law enforcement personnel included CentralIntelligence Agency, Federal Bureau of Investigation,Secret Service, Drug Enforcement Agency, etc.

pretending to be a real patient and right after thevisit, accurately record the physician’s questionsand interventions. The standardized patients weretrained in how to present themselves to office staff,and to handle payment for the visit in order notto be perceived as standardized patients. All phy-sicians tested with standardized patients had vol-unteered to be studied in this way, and were askedto report any patient visit they believed was madeby a standardized patient. Six studies reported onthe rate at which physicians detected standardizedpatients when they appeared for their officeappointment.

The first [18] was a study of how well Austra-lian general practitioners managed depression.Twenty-five physicians were each visited by twostandardized patients. None of these were identi-fied as such by the physicians.

The second study was used to evaluate anddevelop the methodology of standardized patientsfor evaluating primary care [28]. Eight differentstandardized patients visited 11 doctors. The stan-dardized patient was detected seven times (13%)and was suspected of being the standardizedpatient eight times (15%) in the 55 visits in non-painful illness. The actor portraying a patient withvascular headache was detected twice (18%) andsuspected once (9%).

Another study included pain (headache for onecase and back pain for another) as the presentingsymptom in two of 10 scenarios. Twenty-six of 263visits by standardized patients were detected assuch. The frequency of detection of each scenariowas not reported [21].

In a study of 59 doctors visited by an olderwoman for a periodic health exam she wasdetected as the standardized patient by two doc-tors [22]. In another study of 51 other doctorsvisited by a woman in her 50s for a periodic healthexam only two doctors detected her as thestandardized patient [23]. A study to evaluatenonsteroidal anti-inflammatory drug (NSAID)therapeutics by family and internal medicine prac-titioners had standardized patients portray chronichip pain of osteoarthritis and epigastric pain ofNSAID gastropathy. Thirty-six of the 312 visits(12%) were identified as being the standardizedpatients [24,29].

In one study, two real patients were identifiedas fakes [24,29] and another article indicated somereal patients were considered imposters but nonumbers were presented [28]. There was no men-tion of assessing “false positive” identification inany of the other articles.



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When a patient complains of pain, doctorsapply their experience of how people with painappear and respond. Often, different people assessthe same patient’s pain intensity differently [30].The correlation between subjective pain intensityand facial pain expression is not strong and differsbetween men and women [31]. In a study of decep-tion in pain expressions, Poole and Craig [15] per-formed experiments on 104 college students. Thestudents observed videotapes of facial expressionsof people in pain or faking pain. The observersthought the fakers were in more pain than the truesufferers. When the observer was warned aboutpossible deception, the observer estimated lowerpain intensity in subjects with both genuine andfaked pain. Thus, a faked facial expression of paincan easily deceive an observer.

Both deception and fear of deception have con-sequences. Patients can get too much medical carewhen the doctor is deceived (as in Munchausen’ssyndrome) or insufficient medical care when thedoctor fears deception (disbelieving reports ofpain when it exists). These consequences affectboth the individual patient and society.

The experience with standardized patientsshows deception is difficult to detect. In the natu-ralistic setting of an office encounter, genuinepatients can be mistaken for fake patients as wellas fake patients accepted as real ones. In the cur-rent legal climate surrounding prescribing opioids,accepting patients’ reports of pain can have signif-icant legal consequences for the doctor. Theseconsequences must be addressed to improve thetreatment of patients with chronic pain.

What should a conscientious doctor do that isreasonable to avoid being deceived? The ModelPolicy for the Use of Controlled Substances forthe Treatment of Pain by the Federation of StateMedical Boards of the United States says, “physi-cians (should) incorporate safeguards into theirpractices to minimize the potential for abuse anddiversion of controlled substances” [32]. First, “aphysician-patient relationship must exist and theprescribing should be based on a diagnosis anddocumentation of unrelieved pain.” Suggestionsfor documenting in the medical record were pre-sented in [1] and include: history and physicalfindings supporting the diagnosis of a painful con-dition requiring opioid therapy, laboratory and/orimaging studies as needed to confirm the diagno-sis, a treatment plan and consultations for addi-tional evaluations and treatments as indicated.Regular follow-up visits with documentation arealso required [1]. When more than one doctor is

treating a patient, the one prescribing controlledsubstances must keep the other doctors informedabout the regimen and any other medical matterscoming to the prescribing doctor’s attention. Theother doctors certainly should reciprocate so allare on the same team.

Assuming this is present, what additional issuesshould be considered?

One issue is identifying patients with a sub-stance abuse disorder and differentiating themfrom those diverting prescription drugs to theillicit market. Much of the attention in the OpioidGuidelines in the Management of Chronic Non-cancer Pain by the American Society of Interven-tional Pain Physicians is devoted to detectingillicit drug use [33]. The purpose of random drugscreening appears to be the detection of unpre-scribed central nervous system active drugs in theurine of the patients. This can certainly identify apatient as a potential substance abuser but doesnot necessarily identify diverters. The AmericanPain Society, in its the Use of Opioids for Treat-ment of Chronic Pain [34], states that “knownaddicts can benefit from the carefully supervisedjudicious use of opioids for the treatment of painfrom cancer, surgery, or recurrent painful illnessessuch as sickle cell disease.” An estimated 9% of theUS population over age 12 years has used cannab-inoids within the past year [35]. The NationalInstitute of Drug Abuse (N.I.D.A.) has estimatedthat 46% of the US high school seniors had triedmarijuana at some time and that 20% were currentusers [36]. Thus, the clinical significance of 18%or 11% prevalence of marijuana use detected inurine test of 500 chronic pain patients [37,38] isnot completely clear. N.I.D.A. estimated that 19.1million Americans, or 7.9% of the US population,were classified as illicit drug users; 7.1 million ofthese were classified as substance abusers or sub-stance dependant in 2004 [39]. Thus, interpreta-tion of the 16% or 22% detection of illicit drugsin the urine of a group of chronic pain patients intwo different studies [37] is also complex, as all ofthese people are not necessarily dependent orabusers of the detected drugs. Certainly, substanceabuse problems present in chronic pain patientsshould be addressed. This is needed for propermedical care.

In conclusion, we agree with the Model Policythat safeguards to minimize abuse of prescribeddrugs and diversion of them [32] should be part ofmedical practice. Determining if a current or priorsubstance abuse problem exists is an importantpart of the history. It suggests that the patient is



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at risk of recurrence and this should be addressed.Portenoy and Payne [40] have prepared a table ofaberrant drug behaviors that are suggestive of adrug problem, and behaviors of pain patients thatare “less suggestive” of a drug problem. Some sug-gestive patient behaviors are: multiple dose esca-lations, other noncompliance with therapy despitewarnings, multiple episodes of prescription “loss,”seeking prescriptions from multiple sources, anddeterioration in functioning. Patient behaviors lesssuggestive of a drug problem in a chronic painpatient include aggressive complaining about theneed for more drug, drug hoarding during periodsof reduced symptoms, requesting specific drugs,and occasional nonsanctioned dose escalation [40].Obtaining a urine test for illicit drug use is appro-priate for a chronic pain patient with these orother suggestive behaviors. It may indicate a sub-stance abuse or dependence problem that shouldbe confirmed and addressed, as would any otherconfounding medical problem.

Building trust between doctor and patient isan important part of the management of chronicpain patients. Victor and Richeimer point outthe importance of the patient’s demonstratingresponsibility in the relationship by followingthrough on the patient’s part of the managementplan [41] and not trying to conceal deviations fromthe physician.

Patients who are diverters, on the other hand,cannot be treated as other chronic disease patients.Behaviors suggestive of a drug problem can alsoindicate a possible diversion problem. Additionalsuggestive behaviors in the Portenoy and Paynearticle include prescription forgery, stealing or“borrowing” drugs from others, and learning thatthe patient is selling drugs (p. 40). Our review ofprosecutions of doctors for prescribing opioids[42] found that often it was other parties and notthe doctor that discovered the acts of diversion.The doctor had been deceived.

We have presented the data on how easily adoctor can be deceived by a standardized patientinto thinking the standardized patient was a bonafide patient. We have noted that Munchausen syn-drome is another example of the ease with whichdoctors can be deceived. It should not be surpris-ing that undercover agents can also deceive con-scientious doctors. When portions of the medicalpress describe cases of physicians accused ofdiverting controlled substances because they weredeceived, suspicion of patients with chronic paincomplaints increases. Unscrupulous doctors existand they can be clever in masking what they are

actually doing under the guise of practicing med-icine. They should be caught and dealt with. Butour data show that conscientious doctors can bedeceived. Therefore, while doctors must makeevery reasonable effort to confirm the diagnosisand need for opioid therapy, allowance must bemade for the fact that conscientious doctors canbe deceived.

Acknowledgments

Supported in part by a grant from the charitable founda-tion of Marilyn Spinoza Weinberg and Robert F. Wein-berg. Dr. Reidenberg is a member of the Weill CornellCERT.

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