MALINGERING patients or those feigning illness remain a challenge to many physicians. Malingerers generally have psychological or personality problems, but some do it for personal gain.

What these malingerers don?t realize is that making their minds believe they are sick?because of their constant internalization of their morbid condition?will eventually really make them sick of whatever illness they are feigning. Call it karma or perhaps, the power of the subconscious mind?what we think and act we have, we?ll soon have. We really have to be careful of what we tell our minds to make-believe.

A 40-something male ?patient? comes to mind who became a victim of his own scheming mind. He came to the emergency room more than 10 years ago feigning signs and symptoms of heart failure. He must have done his assignment in reading about the clinical presentation of heart failure, and his acting was superb. He was breathing fast and in a labored manner as if he was in distress. He was anxious and restless, with a morbid look of someone who has a sense of doom.

He fooled everyone and he was promptly admitted to the intensive care unit. All sorts of laboratory workup was done on him, and the results were all normal. It turned out that he was just after a medical claim, for which he needed a medical certification that he was admitted for a life-threatening medical condition. He didn?t get that certification, of course.

Severe heart failure

The man never followed up in the clinic but a year or so later he was rushed anew to the emergency room, again complaining of the very same symptoms he was feigning a few years back. And indeed, he had actual severe heart failure. His heart was markedly flabby on 2-D echocardiogram.

Reviewing his history, he was a heavy drinker, gulping bottles of beer with every meal as if it was water. After another extensive workup, he was diagnosed to have alcoholic cardiomyopathy, a heart condition caused by the toxic condition of excessive alcohol intake on the heart leading to heart failure. He was discharged with some improvement but still weak. He was advised he needed a heart transplant, which we don?t do here. He followed up a few times, but was not heard of again.

The poor malingerer got what he was initially pretending to have. Too bad for him, but it was perhaps poetic justice inflicted by his own self.

When to suspect malingering

As a general rule, malingering may be suspected in the following instances:

? When a lawyer accompanies a patient for examination;

? When an incentive or motive is evident;

? When objective medical tests do not jibe with the patient?s complaints;

? When the patient is uncooperative with the prescribed treatment; and

? When the patient has antisocial behavior.

Malingering is not really a modern-day problem. It has been recorded as early as Roman times by the physician Galen, who reported two cases: a patient who simulated severe abdominal colic to avoid a public meeting, and another one who feigned an injured knee to avoid accompanying his master on a long journey.

While others may be psychologically or mentally challenged making them imagine they are sick, some may do it for a reason, or even for personal gain. Malingering patients waste a lot of resources, including the time of medical personnel who could have attended to other patients with true medical problems.

Although a doctor can already suspect when a patient is malingering, he still has to give him or her the benefit of a doubt. These malingerers are still entitled to the same safeguards and attention as other patients.

Even if malingerers are found to be so, it is not considered ethical to ?blacklist? these patients or warn other hospitals or healthcare personnel about them. It is probably just fair that in some countries, proven malingerers are unfavorably regarded by the country?s criminal justice system. It may lead to a harsher sentence, and is considered an intentional ?obstruction of justice.?

That would indeed be poetic justice for malingerers.