“Well then, if you won’t prescribe the Xanax for me, I guess I’ll just have to get it off the street.”

“If you send me home, I promise you’ll be reading about me in the obituaries tomorrow.”

“I’m in terrible pain. You have to treat me. You have to give me narcotics. If you don’t, I’ll call the state medical board and report you.”

I hate to be manipulated.

Hate. It.

There is a certain subset of patients, many of whom have primary personality disorder problems or abuse substances, who come to the ED with nothing more in mind that getting exactly what they want. They will say anything, do anything, act any way, pull any stunt to get their way.

These are the folks who will hit themselves to cause bruises to make it look like they are being abused. The man who will prick his finger and squeeze drops of blood into his urine sample to create hematuria, bolster his story about having kidney stones, and get that morphine that he craves. The woman who will inject small amounts of feces into her  young child to cause the temperature spike that will get the child admitted to the hospital for a fever workup. (Not to do anything for the child, but to satisfy the mother’s own need for attention via the hospital admission. You may have heard of this one: Munchausen syndrome by proxy.)

These folks often know that they have you over a barrel, and they enjoy getting and maintaining the upper hand. Coming to the hospital ED is not a traumatic experience for them. It’s a challenge, an adventure, and a game to be played and won. They want to see you squirm, make you sweat and make it difficult for you just because they can.

Oddly enough, you might think that once one of these folks is discovered, it would be easy to dispatch them and move on to the next case. Not so. It actually takes more time  with this kind of presentation that with other, more straightforward cases.

Why? The person may actually have an illness that needs to be diagnosed and treated, and this is just the way they respond to the stress. They might actually go out and accidentally kill themselves, not really meaning to, after your call their bluff and release them. They may be going into a serious narcotic withdrawal, or delirium tremens (DTs) and you miss it because you were so focused on their demands for painkillers that you neglected the fact that they also drink a case of beer a day.

If you come into the ED and tell me a story, a reasonable story of pain and suffering and need for psychological treatment and comfort, I will do all in my power to help you. I will give you the proverbial shirt off my back. I will willingly spend emotional, physical and financial capital to find out what’s wrong with you and help you.

If you come in and try to scam me, lie to me, manipulate me and make me bend to your will just for kicks or your own secondary gain, I will go cold as ice. Now the caveat here is that I will work up your complaint and figure out what is going on and why. I will figure out that this is a personality thing, a need for attention, an unconscious need to be sick, or some such. I’ll figure that out, as that is what I’m trained to do.

I’ll treat you professionally and the same way I would treat anyone else. But keep in mind that you have changed the game for us. You have set this up as us against them, protagonist against antagonist, cop versus robber.

The doctor-patient relationship should be one that consists of mutual respect, achieving a common goal, honesty and teamwork.

Where there is true pain and suffering, physical or emotional, there is no place for manipulation.

Greg Smith is a psychiatrist who blogs at gregsmithmd.