Being surveilled: ”We run quite a diagnostic risk when we take molecular examples of behavior and postulate that we have a significant finding. To wit, we have found the patient engaging in activities which we are certain demonstrates that they are not, in fact, that severely injured. Someone is at the mall, and, therefore, s/he is not ill and should be at work. Someone requests a day off from work in order to complete tasks at home. We then find s/he has left town, and we are certain that s/he never planned to complete any work assignment.
Some of the examples from my practice:
Patient is a 43 yo white male who fell from height while working as a roofer. The man is ~72 inches in height and weighs ~185 pounds with blonde hair and beard. He states that he cannot stand or sit for extended periods, has pain radiating from lower back to buttocks and down both legs to his calves. The insurer forwards a surveillance tape they were sold that claims to show the man working landscaping. Indeed, the individual shown on the tape appears to be moving plants and turning over soil without observable limitations. I wondered why the person filming the patient was not concerned that the man on the film was ~66 inches and 220 pounds…and was Hispanic.
Patient is a 60 year old executive who fell from his desk chair and injured his dominant (right) shoulder, clavicle, elbow and wrist. Someone called his employer, surveilled the patient and stated that the man was in his yard gardening. When the patient was asked if this were true, he acknowledged that he had repeatedly done so. I asked how this was possible. He said that he uses his non-dominant arm, uses a crawler that he has for his car, lays on his stomach, and then noted: “I would go stir crazy if I did not attempt to do something…anything.”
In the quest to find malingering patients, we make truly untenable connections between what we believe they should do and what they feel they must do. If recovery from injury spans many months, or even years, from where would the quality of life be found? A patient can be indicted for inactivity since this is not full participation in rehabilitation. In turn, they can be indicted for attempting surveilled activities that will normalize their lives.
In effect, we cannot draw clinical conclusions from a random sampling of a patient’s behavior.