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  But all was not well. Her neck and shoulder, only mildly bothersome previously, now ached as if in a vise. Her left arm was almost entirely numb, except for shooting pains when she flexed her neck. Though a recent MRI had been normal, I was pretty sure she had pinched a nerve in her neck, probably from a herniated disc.

  I asked her to close her eyes and gently stroked her left arm. She felt nothing. 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 exaggerated confidence 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.

  “Isn’t it weird not to be graded after so many years?” someone said as we munched on popcorn. There were murmurs of agreement. We had all become so reward-dependent.

  We laughed about our mishaps over the month. Cynthia said she still hadn’t figured out how to work the computer system. Just last week she had ordered blood tests for a patient that somehow never got transmitted to the lab, so for forty-five minutes the lab kept sending the patient back to her office, asking her to reorder the tests. Ali emitted a loud, uninhibited cackle not unlike the laugh of a hyena.

  Rachel said the clinic experience had convinced her to subspecialize. She recounted how one morning she had seen a patient whose voice was hoarse. She had no idea what was wrong with him, but her preceptor, on a routine flyby, immediately diagnosed goiter, an enlargement of the thyroid gland. “You have to know too much to do primary care,” she said. “I just want to focus on something I can be good at.”

  “It’s strange,” Ali said. “Sometimes it feels like I’m wearing someone else’s clothes and I can’t wait to get home to put mine back on.” We all nodded. We all felt the same way.

  “Does anyone here think we’re really helping patients?” Cynthia asked skeptically. “I mean, I can’t convince myself that what we’re doing is making that much of a difference.”

  “I don’t know,” I answered, surprised to find myself defending the profession. “Look at lawyers. What do they contribute?”

  Afterward, around eight o’clock in the evening, I walked alone to Central Park. Someone had once told me that when he was a kid visiting New York, he thought the avenues were like tunnels. When I crossed Park Avenue, I saw what he meant. In the distance the apartment houses, rising majestically, seemed to reach out to each other, as if collapsing under the weight of their own grandeur.

  I sat down by a tree near the park entrance. A stooped man wearing a blue overcoat and a bowler was feeding nuts to squirrels, beckoning them with, “Come, come, come, little boy.” A tiny mouse was chasing its own tail in the grass, going round and round, tirelessly, ceaselessly; a crowd had gathered to watch it. I looked up at the magnificent buildings on Fifth Avenue with their balustraded terraces and molded façades, each a small world in itself, reaching up to the sky.

  In the grass I perused a handbook on critical care cardiology Rajiv had loaned me. In internship your next hurdle is always the biggest, and yet this evening, that really seemed to be the case. The cardiac care unit at New York Hospital was the epitome of pressurized, high-intensity medicine. For all intents and purposes, my residency was going to begin on Monday: overnight call, emergencies, all the craziness and hullabaloo of inpatient medicine. Residents in the CCU wore cotton scrubs like a badge of honor. The very term told me that I was finally going to get my hands dirty.

  I thought back to my one and only experience in the CCU, in my first clinical clerkship in internal medicine at the beginning of my third year in medical school. I was working with a star resident of the internal medicine program at St. Louis. David was confident, competent, quick. He thrived under pressure.

  One afternoon, my team was called to the CCU. A patient, James Abbott, had just been admitted with excruciating chest pain that had started a few hours earlier. He was in his early fifties, extensively tattooed, just the sort of tough I wouldn’t want to meet alone in a parking lot at night—but right then he was whimpering. He kept stroking his sternum up and down, as if trying to rub the pain away. It was obvious that he was having a heart attack. He had all the classic risk factors: hypertension, high cholesterol, a history of cigarette smoking. His electrocardiogram and blood tests showed characteristic signs of low blood flow to the heart muscle. I don’t recall our examining him, but for this most common type of cardiac emergency, there is little diagnostic role for the physical exam.

  A few hours later, we were paged back to the CCU. Abbott was now writhing in pain, and his blood pressure was dropping. David had a nurse get an electrocardiogram
. He ordered an intern to prepare to insert a catheter into Abbott’s radial artery. Then he asked for an intubation tray. “Check his blood pressure,” he told me.

  I had measured blood pressure only a few times, mostly in my classmates. I carefully wrapped the cuff around Abbott’s left arm and inflated it. Then I let the pressure out slowly, listening with my stethoscope at the bend of his arm. “One hundred over sixty,” I called out.

  “Check the other arm,” David said. By then he was scrubbing Abbott’s arm with iodine soap. More people arrived, attracted by the commotion. I wrapped the cuff around the right arm and quickly inflated it, but when I let out the pressure, I heard nothing. Must be doing something wrong, I thought. I tried again while people jostled me, with the same result. Must be the noise, I shrugged, and I let it go. For a moment I thought to ask David to check the pressure himself, but he was busy doing more important things.

  The next morning David caught me before rounds. His face was pale. “That guy had an aortic dissection,” he said. A CAT scan had revealed a corkscrew-like tear from the abdominal aorta all the way back to the heart. “The night resident picked it up,” he said. “He noticed there was a pulse deficit between the arms. No pressure on the right.”

  I listened in silence. A pulse deficit is a classic sign of aortic dissection, but in the hubbub of the previous afternoon, I had somehow ignored it. I thought about telling David about the blood pressure measurement I had taken, but I didn’t. Abbott’s dissection was by now far advanced, and surgeons who had been consulted said he would not survive an operation. He died eight hours later.

  For weeks I couldn’t get over the idea that I was somehow responsible for Abbott’s death. If we had caught the dissection the previous day, was there a chance he could have been saved? I eventually managed to convince myself that the death wasn’t entirely my fault. But that didn’t make me any less afraid of cardiac patients.

  I closed the cardiology book and got up. A leaf fluttered to the ground, its shadow flitting to meet it. The memory of Mr. Abbott had left me feeling nervous, blunting the good feeling I had had when I entered the park. I sprinted home to get in some more reading.

  CHAPTER FIVE

  on call

  “When I die,” said dear and whimsical old Doctor Pycroft, “I shall have a bell hung on my head-stone, with an inscription asking the compassionate passer-by to ring it long and loud. And I shan’t get up.”

  —REGINALD L. HINE, CONFESSIONS OF AN UNCOMMON ATTORNEY, 1946

  Mrs. Piniella is dead.” The words came to me in a dream, resonating in my head like a Gregorian chant. “Mrs. Piniella is dead.” Those words again; what did they mean? Who was Mrs. Piniella? Why was she dead?

  My eyes opened to find a ghastly face peering at me. I recoiled, as if from a jolt, emitting a short, muted howl. The gargoyle moved in closer, too fast for my eyes to accommodate.

  “Wake up, Doctor,” the nurse said. “Mrs. Piniella is dead.” Her face, silhouetted eerily by the corridor light, was now just inches from mine. I stared at it, uncomprehending.

  “That means you have to pronounce her,” came a gentle voice from across the call room. It was Steve Coles, the resident who was supervising me in the CCU. The exchange must have woken him, too. “Just go and examine her and write a quick note,” he said.

  I closed my eyes, trying to return to my dream.

  “Doctor, wake up,” the nurse pleaded, shaking me gently the way my mother used to on middle-school mornings. She was short and stocky, with a broad Filipino mug and a mop of ink black hair. Her stale breath warmed my face.

  “Okay, I’m coming,” I said. I turned over onto my stomach. The thudding in my chest reverberated across the tiny mattress. This was a different kind of fatigue than I had ever experienced, a tiredness mixed with unnatural excitation that went straight into the bones. I heard the door close.

  A few minutes later I was drifting back to sleep when Steve’s voice jarred me awake. “Just write a quick note,” he called out. “And make sure you call the family.”

  I pulled myself out of the cot and stumbled in the dark to the bathroom. Leaning over the sink, I splashed cold water into my eyes. Though I had been asleep for only half an hour, my mouth felt dirty, so I rinsed it with some hospital mouthwash. Then I turned off the light and tiptoed back through the call room. Slinging on my white coat, I opened the door. Light flooded in from the hallway; I exited and shut the door quickly.

  I passed through the conference room, which was littered with printouts, X-rays, and the detritus of the previous evening’s meal. Faded scrubs and stained white coats were draped over the backs of chairs. Candy wrappers and empty potato chip bags had accumulated in the space between the computers. I plodded to the nursing station. Five in the morning is a strange time to be awake, the nexus between night and day, when everything moves slower and trying to speed it up seems almost obscene. Suddenly I stopped, fumbling through my coat pockets. I was carrying laminated cards for Normal Lab Values, Cholesterol Guidelines, Framingham Risk Assessment, Pediatric Growth Charts—everything, it seemed, but the one thing I needed most: Death Pronouncement. How was I going to do this? I had never declared someone dead before. It wasn’t taught in medical school, and they hadn’t gone over it during orientation. Steve undoubtedly knew what to do, but he was sleeping, and I didn’t want to wake him up. All day I had hovered around him like a shy toddler around a parent on his first day of preschool. I didn’t want him to think that I could do nothing on my own.

  The nurse who had woken me looked up from her beauty magazine and pointed her head in the direction of the room. “How’d she die?” I asked. The nurse shrugged her shoulders. “She just died,” she answered flatly.

  Without alarms, the room was eerily quiet. Taking a deep breath, I went in. Nancy, a fellow intern, had signed out that Mrs. Piniella was probably going to pass away tonight. For most of the day she had displayed “agonal” breathing—loud gulps of air followed by prolonged periods of apnea, or no breathing—a pattern that frequently heralds death. I inched up to her body. “Mrs. Piniella,” I whispered. I removed the bedsheet. Corpses had always made me feel queasy. In anatomy lab I had mostly watched as others dissected. Her eyes were closed, her mouth slightly open, her nostrils flaring a bit, a snakelike plastic tube hanging out of one of them. Her arms were grossly swollen and had a pale bluish tinge. I gently pushed on her chest. “Mrs. Piniella.” She did not move, but then I had never seen her move. I pinched her hand. I rubbed my knuckles on her breastbone, trying to elicit some response. There was none.

  I racked my brain, trying to remember what to do to verify a patient’s death. I vaguely recalled that you had to establish the demise of three major organ systems: the brain, the heart, and the lungs. I shined a penlight at her pupils. They were fixed and dilated. I shook her and called out her name. No response. I applied my stethoscope to her chest. It was deathly quiet. I put two fingertips on her carotid artery, and for a moment I thought I felt a pulse—could she have a pulse without a heartbeat?—until I realized that it was probably just my own, transmitted through my fingertips.

  I draped the sheet back over her face. “Yes, she’s dead,” I told the nurse outside, as if the whole exercise had been some sort of test.

  “You have to write a note, Doctor, and put an order in the computer.”

  “Order for what?”

  “The order that she is dead.”

  The order that she is dead?? My lips curled up into a grin, inviting the nurse to laugh with me at the absurdity of her request, but she just continued to stare at me blank-faced.

  “All right,” I finally said.

  I sat down and jotted a brief note. “Called by nurse to pronounce death at 5:10 a.m. Patient had no spontaneous respirations. On exam: no breath sounds, no heartbeat, no pulse. Assessment: Death. Plan: No resuscitation, as patient was DNR.”

  I entered an order into the computer. Unlike most orders, this one was just one simple click. I filled out the dea
th certificate. Under “cause of death,” I wrote “cardiac arrest.” Under “due to or as a consequence of,” I wrote “heart failure.” “Was an autopsy performed?” I checked “no.” I wasn’t about to call the family at this hour to ask for one. The nurse looked over my shoulder.

  “You have to change the time of death, Doctor.”

  I looked up. “Why?”

  “Because I put four o’clock in my note, and there cannot be a discrepancy.” Sure enough, she had written “4 a.m.” on the previous page.

  “But when did she die?” I asked, puzzled.

  “About an hour ago, Doctor,” the nurse declared, a bit flustered. “I did not want to wake you. You looked tired.”

  It was too early to argue, so I wrote another note. The computer wouldn’t let me backdate the order, so I left it the way it was.

  Back in the call room, Steve was lying awake. “Did you pronounce her?” he asked.

  “Yes,” I replied.

  “Everything okay?”

  “Yes, no problems.”

  “Did you call the family?”

  “Uh, no.”

  “And the attending?”

  I knew I had forgotten something. I went back outside and made the calls. Mrs. Piniella’s niece seemed relieved when I delivered the news that her aunt had died. The attending physician sounded annoyed for being woken.

  It was too late to go back to bed—I didn’t think I’d be able to wake up again—so I took a seat in the conference room and looked over the whiteboard. It was divided into a grid, with each square representing a patient’s room. Within each square were tiny unfilled boxes denoting tasks that still had to be completed: “CBC Q4,” “blood cultures x2,” “wean vent.” In my mind, I went over the past twenty-four hours, my first day in the CCU. When I arrived yesterday morning at six-thirty, I was met by Amanda and Nancy, my fellow interns in the CCU. Amanda was a soft-spoken woman with large, quiet brown eyes who had gone to Yale as an undergraduate and then to medical school in the South, which left her with a winsome mix of southern drawl and clipped New England patois. As I would soon discover, she always came in early to preround and finish her daily progress notes before the attending physician arrived. Her unassuming, intelligent manner was very appealing. Nancy was a good-looking blonde with a rather severe visage and matching personality who reminded me of the nurse Hot Lips Houlihan from the television show M*A*S*H. She had gone to medical school here at Cornell with Vijay, who had warned me that she was competitive, even a bit cutthroat.