By Cheong Pak Yean
Patients with Munchausen syndrome* feign disease or psychological trauma, to draw attention, sympathy, or reassurance to themselves. If there is external gain for doing it, it is called malingering. Neither term is often encountered in the medical records of family practice. Instead, the term used by many doctors in Singapore to describe such patients is Chao Geng, which is Singlish for stinking imposter. It is a term that is never written in the records.
*Munchausen syndrome is a mental health condition where a person acts as if he has an illness when in fact he does not.
I Came by MRT!
My resident doctor. K, and I saw the patient together. The health care assistant provided an ominous introduction: She is very unsteady. She fainted and fell in the reception area.
The patient appeared distant, giving short answers with no elaboration. We decided to quickly do a neurological examination. As we helped her from the wheelchair to the couch, she slumped, almost destabilizing us. Was this a serious condition? If so, a normal examination would not exclude that. Should we refer her to the emergency department? Do we get an ambulance? If we refer to a neurologist urgently, how is she traveling there?
As K engaged the patient’s attention in the physical examination, I casually asked the patient how she had come to the clinic. By MRT, she reflexively responded. I turned to K to ask where the MRT was. While still examining the patient, K replied easily, a ten-minute walk from here, first down the stairs after the station, then the escalator, then walking along the shops…..
The woman’s composure did not change but when K finished with the examination, she got off the couch unaided and walked by herself to the consultation chair.
Commentary
The medical students observed that a number of physical diagnoses are commonly assigned to the Chao Geng patient. Doctors tend to give the benefit of the doubt to such patients and may not be able to fully investigate the veracity of the complaints. Their priority is to ensure that serious biomedical issues have been excluded.
The situation becomes distressing to the doctor when such a patient presents with a history that may portend serious illnesses, which is not readily excluded by careful questioning or examination. The patient described in the vignette presented with an acute onset of unsteady gait and giddiness. The absence of positive neurological signs does not mean the absence of a serious neurological problem.
The situation was clarified by the use of the Columbo technique* of distraction to catch the patient off-guard. With the patient’s subterfuge exposed, the doctors distanced themselves in stages. This, rather than direct confrontation, lessened the risk of the patient accusing the doctor of maligning her!
——— A/Prof Cheong Pak Yean
*This technique is named after the detective in a television series popular in the USA in the 1970s. Colombo liked to get his suspects comfortable and relaxed, and then he would uncover the truth by asking an unexpected question that caught them by surprise.
Cheong Pak Yean is an internal family physician and psychotherapist. He is an SMA honorary member, past president SMA, College and adjunct associate professor of NUS. His current interest is in medical communication and humanities.
The commentary and vignette were reproduced with permission from the book “Being Human, Stories from Family Medicine” edited by Cheong Pak Yean and Ong Chooi Peng and published in 2021 by the College of Family Physicians Singapore.
Pictures of illness experiences were drawn by NUS medical students in workshops conducted from 2012-2017 by A/Prof Cheong Pak Yean. Senior family physicians subsequently shared vignettes and commentaries based on the pictures.
