malingering

Another guest post from a friend. Doctor in retirement, but still plugged in. 

Malingering

If you are not already familiar with this term, you may have heard it recently in the news regarding the Abraham Lincoln carrier serviceman who jumped overboard in what, to all intents and purposes, appears to be a suicide attempt. The Navy, at the direction of Pete Smegbreath, no doubt, has filed charges against the seaman accusing him of "malingering" - faking an illness, injury, or disability in order to avoid his duties.

I first encountered this word as a first-year medical student attending a required lecture in Physical Medicine and Rehabilitation (PM&R) - a medical discipline born of war. PM&R evolved from the management of injuries and consequent disabilities sustained in the theaters of combat. So did much of surgery, for that matter. The amputation of injured and/or infected limbs, management of chest wounds, and so on emerged from war. PM&R dealt with the aftermath. That discipline involves the assessment of physical impairments, the design and fitting of prosthetics and devices that ameliorate disabilites, and so forth. Much of the VA's work is PM&R.

So, back to "malingering." Our lecturer, a Houston VA PM&R physician, wanted to give us some insight into how people deal with impairments - resourcefulness, resilience, and the lack thereof. Half in jest, he said, "If I ask a determined individual who has no arms to open a door, he will do it using his mouth." You have probably seen images of people with thalidomide-related birth defects who eat dinner with their feet, dress themselves without hands, and invest all of their abilities to eke out as normal a life as any of us do. So, there was more than a pearl of truth in our lecturer's words.

"Others, will simply look at the closed door and accept defeat," he added. That's not malingering. Malingering is faking illness or disability - not merely refusing to attempt a task.

Malingering is "bone spurs."

I practiced Internal Medicine for three decades and change. I never diagnosed a patient with "malingering." It's really hard to fake sepsis, heart failure, a stroke, end-stage renal or liver disease, diabetes, hypertension, cancer, etc. If a patient is going to fake something, it is going to be something easier like seizures, intractable headaches, bowel or bladder incontinence, or perhaps bone spurs. Fakers don't often come to the attention of Internists.

I am brooding about malingering this evening because I know that a 19yr old brain, especially a male 19yr old brain, is not fully developed. In particular, the frontal lobes where problem solving, planning, and execution are done, have not matured and will not be mature for another six years. I think this young serviceman was overwhelmed by circumstances beyond his control and even further beyond his ability to endure.

You see, endurance requires very advanced cognitive abilities. It requires the ability to formulate and evaluate alternatives. It requires the ability to mentally "see" beyond tomorrow, next week, next month, and to peer into an uncertain future where the misery of the "present" fades into a distant "past."

You do it all the time. So do I. Most 19yr olds cannot do it. It isn't malingering, it is biological immaturity. It isn't bone spurs.

Alas.