Quotes of the Day

Dr. Scott Haig is an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons. He has a private practice in the New York City area. Some patient names have been changed to protect privacy.

When you go in for a routine check up, "I can't find anything wrong" is a great thing to hear the doctor say. It's not so great when something really hurts. Orthopedic medicine is largely about treating pain; arthritis, pinched nerves, torn tissues and broken bones are our business. Patients who complain of pain but have no hard evidence of anything wrong when we examine them can make this business very tricky, and unfortunately, there are plenty of people like this.

You might think the answer in those thorny situations would be to "just give them pain medicine". You'd be wrong. Sure, narcotics like codeine, morphine and all their addicting cousins will temporarily lessen most pains, even undiagnosed ones; the problem is they work less well with every passing week and as you "get used to them," the pain — whose source has not been in any way removed by these drugs — will actually increase. Trust me: If there is anything worse than an undiagnosed pain patient, it's an addicted, undiagnosed pain patient.

Of course, it's hard for doctors to be certain that nothing is medically wrong, and that kind of diagnosis will invariably be challenged. We have to be as sure as possible that we aren't missing a true physical (the medical word is "organic") problem. I find the patient's medical history is most likely to turn up the valuable clue, but there's also the "gut check". We all love this mysterious genius that springs up in us once in a while; it's the thing that tells us little Johnnie is getting sick, Mary seems pregnant or Billy is lying. Alternative medicine practitioners claim they use these indescribable diagnostic methods a lot. M.D.'s use "gut feeling" as well, but we won't do an operation or give a dangerous medication based on it alone.

The truth is psychological or social need is a common source of undiagnosed pain. There are people for whom "being sick" is the only way (they think) they can get love and attention. As most orthopedists are still human beings, these patients are not that hard to identify, and they are easily treated with a few drops of the milk of human kindness.

And there's always the money angle, which — no surprise — is very common. People can get out of work and still get paid with a "doctor's note", and many expect to be paid-off in a lawsuit if a doctor validates their claim. Are these people lying? How can you prove it? In 2006, with all the modern medical technology we have, pain still remains completely subjective; it exists only in the mind of the person feeling it.

But even if we can't prove it, we can usually "tell", and quite easily. Just like parents, pastors and policemen, physicians get pretty good at detecting lies. What's not so easy is then letting your patient know that you think he is lying. Not only is he paying you to be his advocate, but being caught in a lie is still embarrassing for most people. And remember, if they're looking for money in the first place, they can sue you too. It tests your integrity. it's often easier, often safer to "go along with it".

But is it right, or even that simple? Pain and disability have a pernicious way of becoming true even if they start out false. My patient Eddy was in a car accident in the last several years. When he saw me soon after the accident, my examination showed he had a mild finger and knee sprain, but no bruising or swelling. All of his x-rays and MRI's were essentially normal. Eddy walked with a ridiculously fake limp and a cane, when he remembered to.

I told Eddy he should get over the sprains within a few weeks and recommended anti-inflammatory medication like Advil or Aleve, some rest and then gradual resumption of work. He really didn't want to hear this and insisted he could never work with so much pain. I never actually said "I think you're acting", but he didn't come back after two more visits (with reports of worse pain at each).

After years of physical therapy and other doctors, Eddy returned to my office. He now has a real limp and his knee is truly stiff. His "bad" hand is weak and uncoordinated. He has gotten good at using the cane, and now he really needs it. Eddy did not want any treatment. He just came "for documentation" of his pain and inability to work. This time I had to agree with him — Eddy is now physically disabled.

Eddy exaggerated the pain of minor injuries in order to get out of a job he didn't like. He probably didn't think he would really become disabled by being a good plaintiff. It's the evil twin of rehabilitation — act sick-get sick — and it happens a lot. "Accentuate the negative" may be sound legal counsel, but it's the worst possible medical advice anyone could ever give. It's a pain for the doctor, and often ultimately, an even bigger pain for the patient.

• DR. SCOTT HAIG
• Sometimes a physician's greatest challenge can be dealing with patients who insist they're sick but exhibit no clear signs of anything wrong