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What You Should Know: Lies in the Patient-Doctor Relationship

What You Should Know is an ongoing series covering a range of informational topics relevant to current and future healthcare professionals.
It happens to every medical student sooner or later – the realization that their patient has lied to them. Especially for students, who are just beginning to gain clinical experience, this realization can come as a shock. A sense of betrayal, anger or even the desire for retribution can set in, all of which can be damaging to the doctor-patient relationship.
These emotions aside, it might help student doctors dealing with the nature of this reality to understand where deception enters into the therapeutic relationship – as well as how and why people lie in a clinical setting and what the doctor can do about it.
The Necessity of Honesty
In their brilliant work on Lies in the Doctor-Patient Relationship, Drs. Palmieri and Stern point out that one of the most damaging aspects of lies is that it compromises the need for honesty in the clinical relationship. In the final analysis, a physician must rely on the facts from a patient and/or their families (as well, of course, on the knowledge he/she has gained from clinical investigations such as a physical exam or blood work) to make an accurate diagnosis. If information the physician is receiving is false, this can put make diagnosis difficult or impossible – and can waste the doctor’s time with excessive or unnecessary tests and procedures.
Despite the fact, however, that honesty is in the best interest of both the physician and the patient, lies appear to be part of that relationship as well, and have been since the beginning.
For student doctors just beginning to come to terms with this, it might be helpful to consider the nature of lies and lying (in a clinical context), how and why lies happen, and how doctors-in-training can deal with the situation.
The Nature of Lies and Lying in the Clinical Setting
Palmieri contends that “lying is the act of one person intending to mislead another, deliberately, without prior notification and without having been asked by the target” and notes that lies can take many forms, including omitting, distorting, evading, denying facts or fabricating “facts” that do not actually exist. He notes that this definition excludes patients that give false information to a doctor which they themselves believe to be true or cases of confabulation, where a patient with gaps of memory will spontaneously make up facts to fill this void.
And it is well for new doctors to keep in mind that physicians themselves are not entirely innocent of dishonesty! As a matter of fact, even Hippocrates, the Father of Western Medicine, considered that it was part of a doctor’s etiquette to hide things from his patient, noting this etiquette involved “concealing most things from the patient while you are attending him” and “revealing nothing of the patient’s future or present condition for many patients through this have come to take a turn for the worse.” Hippocrates, however, was well aware of the fact that patients, too, keep things from their doctors and warned his interns to “keep watch also on the fault of the patient which often makes him lie about the taking of things prescribed.”
That particular aspect of medicine has apparently not changed since ancient times!
Ancient history, however, does play a role in what happens between doctor and patient even today. It is important to remember that, for most of Western medicine’s 5000-year-old history that the doctor-patient relationship was one described as “beneficent paternalism.” The role of the doctor was to take care of a patient the way a parent would take care of a child. The role of the patient was to follow “doctor’s orders.” This only began to change significantly around the time of World War II and this intensified in the 1990s with an increased emphasis on “shared decision-making.” It is this perceived balance – or imbalance – of power which can fuel patient deception or evasion.
How and Why Lies Happen
Patients and doctors deceive one another in different ways. Doctors can deceive through over- or under-stating certain facts about the patient’s condition, failing to tell the patient the entire truth or oversimplifying complex matters. Patients may exaggerate or downplay symptoms or consciously fake an illness (as is the case with malingering).
Patients will frequently give false information about the way they live their lives. The Roswell Park Cancer Institute quoted a recent patient survey which found that, overall, around 38% of patients lie to their doctor about some aspect of their lifestyle. Of those who do lie:
● 32% lied about their diet or the amount of exercise they get
● 22% lied about smoking habits
● 17% lied about sexual habits or practices
● 16% lied about alcohol consumption
● 12% lied about use of recreational drugs.
When asked why they lied, the top five answers were:
● The patient did not want to be judged (50%).
● The patient was too embarrassed to tell the truth (31%).
● The patient did not think their doctor would understand (21%).
● The patient though it was one of the doctor’s business (9%)
● The patient wanted to obtain a certain drug or treatment (6%).
How to Deal with Lies in the Clinical Relationship
Thus, it is wise for a student doctor, just at the beginning of a medical career, to recognize that lying in some form or another is an almost inherent part of the doctor-patient relationship. Palmieri has helpful suggestions on trying to minimize this issue once it has been faced. These include:
● Normalizing the tendency for patients to be reluctant to share embarrassing information. It is good to start the conversation with something like, “Look, I know it is hard to talk about some of these issues – and it’s tempting to just lie – but I can only give you the care that you need if you are honest with me.”
● Recognizing the limits of medical knowledge. Rather than be evasive, it is better to be up front and let a patient know that there are limits to medical knowledge, such as, “We know how Down’s Syndrome happens, but we don’t know why.”
● Negotiating with the patient ahead of time as to what information will be disclosed. This can be especially important for the delivery of bad news. Palmieri suggests it is helpful for the doctor to say frankly, “I want you to understand your situation fully, but I am struggling with how best to tell you.” This can let the patient decide how much news they want to hear.
● Looking at the truth as a “process” rather than an “occasion.” Understanding that lies will occur in a patient-doctor relationship is important – but not to the exclusion of the honest communication when takes place between doctor and patient as well.
The Roswell Park site also offers pertinent advice on how doctors can deal with a patient who is deceptive. This includes:
● Explaining the serious, and even potentially fatal, consequences of lying.
● Remembering that body cues such as failing to make eye contact or fidgeting can be unreliable and do not necessarily indicate guilt.
● Considering the patient’s motivation for what they say – especially if it is a matter, for instance, of obtaining analgesics or applying for benefits. Doctors must avoid becoming cynical, but at the same time aim for a sort of “healthy skepticism”.
● Taking into account the fact that many patients with dementia may be “lying” due to memory lapses or other cognitive dysfunctions.
● Doing homework. For example, requesting that new patients bring records from previous clinics or hospitals with them for the physician to review.
● Having a patient receiving controlled substances sign a contract stating he or she will take the drugs only as prescribed and not sell or give them away.
● Doing lab tests to verify compliance with a given drug regimen.
While none of these methods are fool-proof, they can certainly help a doctor to determine if there is any serious dishonesty in the patient relationship.
What should be stressed here though, is that the best way to minimize deception in the doctor-patient relationship is to build trust. The patient must trust that their doctor will not judge them for their behavior and strive to give them the care that they need. If a doctor can win this trust, much of the perceived need for lying will be eliminated.
This is a good reminder for student doctors that this trust is the best basis for a therapeutic relationship – and that building that trust and rapport with the patient is more than just a nicety – is a necessity.
References
Kennedy, R. The Doctor-Patient Relationship: When Patients do not Tell the Truth.
NeuroscienceCME Website. 2015.
Palmieri, J. and Stern, T. Lies in the Patient-Doctor Relationship. Primary Care Companions
Journal of Clinical Psychiatry. 2009. 11(4) 163-168
Schwartz, S. When Patients Lie to You. Roswell Park Cancer Institute. 2014.

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Brian Wu graduated from the University of Maryland with a Bachelor’s of Science in Physiology and Neurobiology, and graduated from the Keck School of Medicine (University of Southern California) with an MD with a focus on holistic care and treatment. He currently holds a PhD in integrative biolog... Brian Wu graduated from the University of Maryland with a Bachelor’s of Science in Physiology and Neurobiology, and graduated from the Keck School o...