Intern by Sandeep Jauhar Page A

I stroked a little harder. Still nothing. The sensation in her right arm was normal, but her left arm, even when I scratched it with my nails, was completely numb.
    But this didn’t make sense. Though her sensory deficit was profound, she had walked in clutching her handbag. And her muscle strength and reflexes were normal and equal in both arms. When I noticed that her closed eyelids fluttered gently whenever I touched her left arm, I could draw only one conclusion: she was lying.
    The following week, I attended a lunchtime conference where a bespectacled forensic psychiatrist spoke to us about malingering. “Deception by patients is common,” he said, and doctors, because of fear of confrontation or a desire to give patients the benefit of the doubt, often don’t pick up on it. Sometimes it is obvious, as when a patient with a back injury cannot go to work but can keep up with his bowling league. Other times the deception is so complete that the lying patient can outfox even the most astute clinician.
    Years later, I learned that the lying can assume different guises. One is called
malingering
: the intentional production of false or grossly exaggerated physical or psychiatric symptoms motivated by the desire to avoid work, evade prosecution, obtain drugs, and so on. Another, spurred by the need to play the role of a sick person, is termed
factitious disorder
. When patients lie to themselves, convincing themselves that they are sick when they are not, the condition is called
somatization disorder
.
    Whatever the cause, deception by patients is rarely straightforward or simple. Patients may omit details, deliberately or not, or they may fabricate them. They may feign symptoms that do not exist (
simulation
), or intentionally hide symptoms that do (
dissimulation
). They may even tamper with data or laboratory substances.
    Malingering patients signal their deception in a variety of ways, the speaker told us that afternoon. They may give hesitant answers or make vague or irrelevant statements. They may express exaggeratedconfidence in their doctor’s ability. Like my patient, they may feel compelled to perform suspiciously poorly on testing.
    The most valuable tools for detecting deception are being aware that one might be lied to, asking open-ended questions, and prolonging the medical interview. But, he added, doctors must also know their medicine—for example, that deficits like inability to feel pain or judge temperature often occur together because these sensations are carried by the same nerves.
    Very little guidance is provided to doctors for handling malingering patients. Some advocate confronting them. Others feel that this strategy can alienate patients and instead prefer a more sympathetic approach, treating the deception as a symptom. But in the end, the psychiatrist said, the problem was generally confusing and the management of it unsatisfying.
    FOR MUCH OF THE OUTPATIENT ROTATION , my classmate Ali had been saying that all of us should get together for drinks, so early one evening toward the end of the month, we met at an alehouse near the hospital. It was a typical Irish pub, with low wooden ceilings, murky lighting, and dartboards. Except for Emily, our entire outpatient group showed up: Cynthia, a pretty, troubled brunette with an asthenic build and pale complexion who was as ambivalent about medicine as I; Vijay, who had accompanied me on the night I met Sonia; Ali, a stocky Persian with a broad face, big brown eyes, and a ski-jump nose—he was all head; Alphonse, a quiet, unassuming man from the Caribbean; and Rachel, a knockout blonde with a Mary Tyler Moore hairdo who always seemed to be wearing a scowl on her face. (She bugged me; something about her smelled of money and high society.) We pulled two tables together and ordered pitchers of beer. At first we were formal with each other, but after a drink or two, everybody started to loosen up.
    â€œIsn’t it weird not to