Jon S. Berlin, MD

"There must be some way out of here," said the joker to the thief."There's too much confusion, I can't get no relief. . . .""No reason to get excited," the thief, he kindly spoke,"There are many here among us who feel that life is but a joke.But you and I, we've been through that, and this is not our fate,So let us not talk falsely now, the hour is getting late."From "All Along the Watchtower," Bob Dylan

The following cases highlight some of the challenges clinicians face when treating patients in whom malingerling is suspected. One key aspect of these evaluations is not overlooking signs or symptoms that point to serious illness.

Working in the emergency care setting takes choice out of the equation when dealing with cross-cultural issues for both clinicians and patients. As clinicians, we need not have had any prior scientific interest in a patient's particular culture, and the patient has not cautiously selected us to trust. We are thrown together.

The use of restraint and seclusion remains a controversial issue, and emergency care providers must remain absolutely current on it. We can come under criticism both for using too much coercion and for not using enough. Restraint and seclusion exist at an intersection of science, government policy, and public perception. These seemingly straightforward forms of medical coercion are still, in actuality, far from straightforward.