Physicians Being Deceived

Blackwell Publishing IncMalden, USAPMEPain Medicine1526-2375American Academy of Pain Medicine? 200785433437 Original ArticlesPhysicians Being DeceivedJung and Reidenberg PA I N M E D I C I N E Volume 8 • Number 5 • 2007 FORENSIC PAIN MEDICINE SECTION Physicians Being Deceived Beth Jung, EdD, MD, MPH,* and Marcus M. Reidenberg, MD† ABSTRACT ABSTRACT 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. Key Words. Deception; Prosecution; Opioids; Standardized Patients Deceiving Physicians A barrier to prescribing opioids for patients in pain is physicians’ fear of being investigated by a governmental agency and punished for prescribing this treatment [1–8]. A survey of prosecutors in four states found that many would recommend a police investigation when given a scenario of a patient with nonmalignant pain treated with opioids [9]. Our review of Drug Enforcement Administration (DEA) actions against physicians who prescribed opioids found that some of these actions were based on prescripReprint requests to: Marcus M. Reidenberg, MD, Department of Pharmacology, Box 70, Weill Medical College of Cornell University, 1300 York Avenue, New York, NY 10021, USA. Tel: 212-746-6227; Fax: 212-746-8835; E-mail: mmreid@med.cornell.edu. tions given to undercover agents [10]. 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 [11–13]. How responsible is a physician for being deceived? The responsibility for being deceived can be viewed in the context of factitious disease, Munchausen’s Syndrome, either directly or “by proxy,” and frank malingering. But a physician can only be subjected to criminal penalties if the deception leads to prescription of a controlled substance. Because of this possibility, some physicians are reluctant to prescribe adequate doses of opioids for some patients with pain. Thus, the consequences of a doctor’s fear of being deceived affects patients with pain much more than other kinds of © American Academy of Pain Medicine 1526-2375/07/$15.00/433 433–437 doi:10.1111/j.1526-4637.2007.00315.x Downloaded from https://academic.oup.com/painmedicine/article-abstract/8/5/433/1848371 by guest on 27 May 2020 *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 I. Weill Medical College of Cornell University, New York, New York, USA 434 *Federal law enforcement personnel included Central Intelligence Agency, Federal Bureau of Investigation, Secret Service, Drug Enforcement Agency, etc. pretending to be a real patient and right after the visit, accurately record the physician’s questions and interventions. The standardized patients were trained in how to present themselves to office staff, and to handle payment for the visit in order not to be perceived as standardized patients. All physicians tested with standardized patients had volunteered to be studied in this way, and were asked to report any patient visit they believed was made by a standardized patient. Six studies reported on the rate at which physicians detected standardized patients when they appeared for their office appointment. The first [18] was a study of how well Australian general practitioners managed depression. Twenty-five physicians were each visited by two standardized patients. None of these were identified as such by the physicians. The second study was used to evaluate and develop the methodology of standardized patients for evaluating primary care [28]. Eight different standardized patients visited 11 doctors. The standardized patient was detected seven times (13%) and was suspected of being the standardized patient eight times (15%) in the 55 visits in nonpainful illness. The actor portraying a patient with vascular headache was detected twice (18%) and suspected once (9%). Another study included pain (headache for one case and back pain for another) as the presenting symptom in two of 10 scenarios. Twenty-six of 263 visits by standardized patients were detected as such. The frequency of detection of each scenario was not reported [21]. In a study of 59 doctors visited by an older woman for a periodic health exam she was detected as the standardized patient by two doctors [22]. In another study of 51 other doctors visited by a woman in her 50s for a periodic health exam only two doctors detected her as the standardized patient [23]. A study to evaluate nonsteroidal anti-inflammatory drug (NSAID) therapeutics by family and internal medicine practitioners had standardized patients portray chronic hip pain of osteoarthritis and epigastric pain of NSAID gastropathy. Thirty-six of the 312 visits (12%) were identified as being the standardized patients [24,29]. In one study, two real patients were identified as fakes [24,29] and another article indicated some real patients were considered imposters but no numbers were presented [28]. There was no mention of assessing “false positive” identification in any of the other articles. Downloaded from https://academic.oup.com/painmedicine/article-abstract/8/5/433/1848371 by guest on 27 May 2020 patients. For this reason, we focused on the specific problems of being deceived by patients who say they are in pain. Physicians operate with what Burgoon et al. [14] call a truth bias. That is, they presume that patients’ presentations of themselves are true, complete, and accurate. Their assessment of patients’ pain complaints are based both on current information (obtained in the interview and physical examination) and on the starting point, or anchoring point [15] for the assessment. Doctors assume that patients come to see them because they have a problem for which they want treatment. Law enforcement personnel appear to have a different assumption when they interview some people. Yet, in a study of police, judges, and federal law enforcement personnel,* only the Secret Service agents were better than chance at detecting lying [16]. Thus, law enforcement personnel who presume physicians can discern lies cannot recognize lies themselves. Can physicians tell when patients lie? Studies with standardized patients can address this question. Standardized patients are individuals (including actual patients) who have been trained to present accurate, reproducible history and physical examination findings of a particular clinical problem. They are increasingly used in teaching [17], evaluation [18–22], and research [23,24]. They have been used since 1998 to evaluate foreign medical graduates applying for American medical licenses and, since 2004, as part of the US medical licensing examination [25,26]. They permit assessment of skills and behaviors essential to medical practice but which are poorly measured by paper-and-pencil tests. Standardized patients provide a new way to consider the question of deceiving doctors by patients not telling the truth. Standardized patients have been used in the community to study resource utilization [24], risk factor determination and counseling [22,23], and diagnosis, recognition and management [18,19,27]. All studies involved training individuals to present an overall scenario (history, physical examination findings, responses to physicians’ questions, expressing pain) consistent with a disease or condition. For these studies, the individuals would then go to the doctor Jung and Reidenberg Physicians Being Deceived treating a patient, the one prescribing controlled substances must keep the other doctors informed about the regimen and any other medical matters coming to the prescribing doctor’s attention. The other doctors certainly should reciprocate so all are on the same team. Assuming this is present, what additional issues should be considered? One issue is identifying patients with a substance abuse disorder and differentiating them from those diverting prescription drugs to the illicit market. Much of the attention in the Opioid Guidelines in the Management of Chronic Noncancer Pain by the American Society of Interventional Pain Physicians is devoted to detecting illicit drug use [33]. The purpose of random drug screening appears to be the detection of unprescribed central nervous system active drugs in the urine of the patients. This can certainly identify a patient as a potential substance abuser but does not necessarily identify diverters. The American Pain Society, in its the Use of Opioids for Treatment of Chronic Pain [34], states that “known addicts can benefit from the carefully supervised judicious use of opioids for the treatment of pain from cancer, surgery, or recurrent painful illnesses such as sickle cell disease.” An estimated 9% of the US population over age 12 years has used cannabinoids within the past year [35]. The National Institute of Drug Abuse (N.I.D.A.) has estimated that 46% of the US high school seniors had tried marijuana at some time and that 20% were current users [36]. Thus, the clinical significance of 18% or 11% prevalence of marijuana use detected in urine test of 500 chronic pain patients [37,38] is not completely clear. N.I.D.A. estimated that 19.1 million Americans, or 7.9% of the US population, were classified as illicit drug users; 7.1 million of these were classified as substance abusers or substance dependant in 2004 [39]. Thus, interpretation of the 16% or 22% detection of illicit drugs in the urine of a group of chronic pain patients in two different studies [37] is also complex, as all of these people are not necessarily dependent or abusers of the detected drugs. Certainly, substance abuse problems present in chronic pain patients should be addressed. This is needed for proper medical care. In conclusion, we agree with the Model Policy that safeguards to minimize abuse of prescribed drugs and diversion of them [32] should be part of medical practice. Determining if a current or prior substance abuse problem exists is an important part of the history. It suggests that the patient is Downloaded from https://academic.oup.com/painmedicine/article-abstract/8/5/433/1848371 by guest on 27 May 2020 When a patient complains of pain, doctors apply their experience of how people with pain appear and respond. Often, different people assess the same patient’s pain intensity differently [30]. The correlation between subjective pain intensity and facial pain expression is not strong and differs between men and women [31]. In a study of deception in pain expressions, Poole and Craig [15] performed experiments on 104 college students. The students observed videotapes of facial expressions of people in pain or faking pain. The observers thought the fakers were in more pain than the true sufferers. When the observer was warned about possible deception, the observer estimated lower pain intensity in subjects with both genuine and faked pain. Thus, a faked facial expression of pain can easily deceive an observer. Both deception and fear of deception have consequences. Patients can get too much medical care when the doctor is deceived (as in Munchausen’s syndrome) or insufficient medical care when the doctor fears deception (disbelieving reports of pain when it exists). These consequences affect both the individual patient and society. The experience with standardized patients shows deception is difficult to detect. In the naturalistic setting of an office encounter, genuine patients can be mistaken for fake patients as well as fake patients accepted as real ones. In the current legal climate surrounding prescribing opioids, accepting patients’ reports of pain can have significant legal consequences for the doctor. These consequences must be addressed to improve the treatment of patients with chronic pain. What should a conscientious doctor do that is reasonable to avoid being deceived? The Model Policy for the Use of Controlled Substances for the Treatment of Pain by the Federation of State Medical Boards of the United States says, “physicians (should) incorporate safeguards into their practices to minimize the potential for abuse and diversion of controlled substances” [32]. First, “a physician-patient relationship must exist and the prescribing should be based on a diagnosis and documentation of unrelieved pain.” Suggestions for documenting in the medical record were presented in [1] and include: history and physical findings supporting the diagnosis of a painful condition requiring opioid therapy, laboratory and/or imaging studies as needed to confirm the diagnosis, a treatment plan and consultations for additional evaluations and treatments as indicated. Regular follow-up visits with documentation are also required [1]. When more than one doctor is 435 436 actually doing under the guise of practicing medicine. They should be caught and dealt with. But our data show that conscientious doctors can be deceived. Therefore, 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. Acknowledgments Supported in part by a grant from the charitable foundation of Marilyn Spinoza Weinberg and Robert F. Weinberg. Dr. Reidenberg is a member of the Weill Cornell CERT. References 1 Richard J, Reidenberg MM. The risk of disciplinary action by state medical boards against physicians prescribing opioids. J Pain Symptom Manage 2005; 29:206–12. 2 Cleeland CS. Undertreatment of cancer pain in elderly patients. JAMA 1998;279:1914–5. 3 Pantel ES. Breaking Down the Barriers to Effective Pain Management. Report to the Commissioner of Health, Barbara A. De Buono, MD, MPH, from the New York State Public Health Council. January, 1998, Appendix E. 4 Sox HC Jr. In Opposition to S. 2151, The Lethal Drug Abuse Prevention. October 1998. Available at: http://www.acponlime.org/hpp/soxtesti.htm (accessed June 6, 2006). 5 Weissman DE, Joranson DE, Hopwood MB. Wisconsin physicians’ knowledge and attitudes about opioid analgesic regulations. 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Doctor, 2 Pharmacists Held in Shasta Drug Sting; Investigators Link Ring to 3 Over- Downloaded from https://academic.oup.com/painmedicine/article-abstract/8/5/433/1848371 by guest on 27 May 2020 at risk of recurrence and this should be addressed. Portenoy and Payne [40] have prepared a table of aberrant drug behaviors that are suggestive of a drug problem, and behaviors of pain patients that are “less suggestive” of a drug problem. Some suggestive patient behaviors are: multiple dose escalations, other noncompliance with therapy despite warnings, multiple episodes of prescription “loss,” seeking prescriptions from multiple sources, and deterioration in functioning. Patient behaviors less suggestive of a drug problem in a chronic pain patient include aggressive complaining about the need for more drug, drug hoarding during periods of reduced symptoms, requesting specific drugs, and occasional nonsanctioned dose escalation [40]. Obtaining a urine test for illicit drug use is appropriate for a chronic pain patient with these or other suggestive behaviors. It may indicate a substance abuse or dependence problem that should be confirmed and addressed, as would any other confounding medical problem. Building trust between doctor and patient is an important part of the management of chronic pain patients. Victor and Richeimer point out the importance of the patient’s demonstrating responsibility in the relationship by following through on the patient’s part of the management plan [41] and not trying to conceal deviations from the physician. Patients who are diverters, on the other hand, cannot be treated as other chronic disease patients. Behaviors suggestive of a drug problem can also indicate a possible diversion problem. Additional suggestive behaviors in the Portenoy and Payne article include prescription forgery, stealing or “borrowing” drugs from others, and learning that the patient is selling drugs (p. 40). Our review of prosecutions of doctors for prescribing opioids [42] found that often it was other parties and not the doctor that discovered the acts of diversion. The doctor had been deceived. We have presented the data on how easily a doctor can be deceived by a standardized patient into thinking the standardized patient was a bona fide patient. We have noted that Munchausen syndrome is another example of the ease with which doctors can be deceived. It should not be surprising that undercover agents can also deceive conscientious doctors. When portions of the medical press describe cases of physicians accused of diverting controlled substances because they were deceived, suspicion of patients with chronic pain complaints increases. 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