Does Secondary Gain Exist?

In this and two subsequent columns, I will discuss the concept of secondary gain as it applies to disability. My goal is to revise a view I long embraced and, indeed, promulgated enthusiastically to students, house officers, and fellows. On many occasions in my teaching clinic, I stated that the concept of secondary gain in disability is misleading if not erroneous because what can be labeled as gain in reality represents loss. Sometimes I was even more dogmatic and said that secondary gain does not exist.

I have been off target in my views, misguided by an effort to develop a more fair-minded and compassionate approach to disability. In what I think will be a constructive effort at revisionism, I will advance another concept of secondary gain that, while nuanced, is hopefully more illuminating. I did not get the inspiration for another look at secondary gain from reading an article in a high-impact journal or hearing a lecture from a touted thought leader. Rather, I rethought my views during a piano concert by Leon Fleisher, a virtuoso with a troubled right hand.

Subjective Pain and Secondary Gain

Like virtually every rheumatologist I know, I have evaluated patients who seek disability despite minimal signs of arthritis or musculoskeletal disease. Some of these patients lack any objective findings by physical exam, X-ray, or laboratory tests. Nevertheless, they believe that their symptoms preclude employment. The origin of these ailments is mysterious. Patients with fibromyalgia, chronic fatigue syndrome, and whiplash injury are among this group, and deciding whether these patients should be considered for disability is both controversial and vexing. Lacking better explanation for the desire of these patients not to work, the term “secondary gain” is often used.

What is secondary gain? In common parlance, it refers to the benefits or advantages that can accrue from not working. These may include money, freedom from a demanding or boring job, and leisure time for enjoyable activities. All of these benefits are supposedly made better by knowing that a generous check will arrive in the mail every month to pay the bills.

For some patients, the situation is more complicated because secondary gain may represent a desire for control and leverage to pressure family for attention and care. This dynamic can even extend to the physician as pressure to recommend disability. Suffice it to say, physicians do not like this. Applying the term “secondary gain” to a patient can convey a negative sentiment, often accompanied by annoyance and condescension from the provider. It can also lead to a blame game, in which patients are blamed for their symptoms and desire for disability.

Not Everyone Gains

Clearly, there are patients with arthritis who want to work but have trouble on the job. Even if the jobs are tough and pay little, these people want to keep at it. There is little secondary gain in disability for these people. I can remember a man with a back stiffened with ankylosing spondylitis whose work involved climbing a ladder to stock merchandise in a hardware store. My patient loved his job and took pride in knowing the locations of wire brads and cotter pins on high-up shelves.