Background: The term “secondary gain” is rarely heard outside of a medicolegal context, and is a disparaging term used to describe a patient with a compensable injury in whom symptom exaggeration or fabrication is suspected. The allegation of secondary gain is difficult to confirm, and may arise from a lack of an appropriate diagnostic evaluation and proper attribution of symptoms to pathology. Additionally, clinicians who allege secondary gain or malingering in a patient in the absence of clear evidence may be motivated by economic incentives to make such determinations.
Case Report: We present a tragic case study in which a 32-year-old man with obvious signs of acute posttraumatic cervical myelopathy was subjected to multiple evaluations by more than 10 various clinicians over an 8 month period before he was referred for a cervical spine MRI. Although the patient underwent surgery to decompress the lesion, ultimately he died from an overdose of narcotic pain medication associated with a residual central cord pain syndrome.
Conclusions: There were a variety of systematic or “secondary gain” pressures acting on the clinicians in this case that may have led to the lack of a definitive diagnosis and the resulting improper care. This included a business model that emphasized repeated treatment in the case of the treating chiropractors and the desire for future employment in the case of the physician performing the insurer-mandated evaluation. It is reasonable to examine the motivation of clinicians who allege secondary gain in a patient in a third party evaluation setting.

Keywords: secondary gain, Malingering, cervical myelopathy