Honesty between doctors and patients goes both ways

Yesterday, someone asked me, “Can I be perfectly honest with you?”  I wanted to reply, “No, just be dishonest, I like it better that way!”  “Can I be” implies that, in past conversations, my patient has been dishonest.  Dishonesty is a relationship breaker.  Dishonesty leads to distrust and if I cannot trust what a patient is telling me, I cannot be effective; the doctor-patient relationship is terminated.

Am I being too harsh?  Are there degrees of dishonesty that are acceptable?  While there may be a place in the real world for partial truths and degrees of honesty, there is no room for dishonesty in the exam room.  In June of this year, I published “Three Things” an article about the importance of being honest with your doctor and being honest with yourself.  When surveyed about the three most important things a doctor can tell his/her patients, the most common theme was to be honest.  Don’t lie.

Today was one of those days.  A second patient admitted that, when he saw me on Friday, he was not honest with me.  His condition had worsened dramatically, the pain making him regret not haven’t been “perfectly honest”.  Both patients had their own reasons for hiding the truth.  There are many reasons patients exercise various degrees of honesty.  Some patients feel their actions make them look foolish; some fear the doctor’s scorn, some fear the answer to their problem will be too much for them, others are simply embarrassed.  No matter what the reason, the doctor-patient relationship should be a partnership based on mutual trust and respect.  In a relationship of trust and respect, there is no place for dishonesty.

Unfortunately, it’s a two way street.  There are times when I want to be less than totally honest.  There are times when I want to “soft sell” the truth, knowing that the truth is going to hurt.  After all, my job is to heal, not to hurt.  Nonetheless, if I shelter my patient from the truth or mislead him, I break the relationship of trust and respect.

There are other times when family members ask me to spare their loved one the horrors of a bad truth.  They want to lessen their loved one’s (my patient’s) pain and suffering.  Telling the truth, the whole truth, can be a real problem.

So, what to do?  Risk the relationship of mutual trust and respect to spare someone pain?  Then what happens when your patient needs honesty and discovers your deceit?  It’s not an easy choice.

We are all humans, striving for the impossible goal of being perfect.  The doctor-patient relationship is as imperfect as the two people who make up that relationship.  Each has to recognize the other’s imperfection.  Each has to strive to be “perfectly honest”.  Each person has to realize how difficult it is to be “perfectly honest”, and that honesty can save a life, can take a life, and can hurt!

I have chosen the path of seemingly brutal honesty, pulling no punches, for the vast majority of my career.  I think people deserve the truth and that my job is to preserve the trust in the doctor patient relationship.  There have been times when I have regretted that choice.

I hope my patients will choose the honest approach, no matter how difficult that choice.  I hope they will understand how important knowing what is truly happening to them is and how the truth will ultimately impact their diagnosis and the success of treatments.   I hope they recognize that the life they save may be their own.

I also hope that they will forgive me when I tell them what they didn’t want to hear, what hurts.

Stewart Segal is a family physician who blogs at Livewellthy.org.

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  • http://reclaimingchris.blogspot.com/ Christie Critters

    Glad you are not MY doctor.  Sometimes patients are not ready for “brutal honesty”  and when it gets too uncomfortable, sever the relationship.  Then the good that you could have done by leading them to the truth by stages is lost…
    Most of us get  to the “brutal truth” eventually.

    • Doug Capra

      Your basic point is well-argued and makes sense. But doctor-patient relationships
      are based upon complex contexts and the life experiences. I believe a significant
      number of patients have tried to be truthful to their doctors, some perhaps in round-
      about ways because they were testing the waters. Some of these patients feelings
      were dismissed and they learned a lesson. When you’re asked a question, does the
      questioner really want an answer, or is the question just rhetorical? 
       Medical professionals also need to accept a
      basic truth — a significant number of patients are afraid to express their true feelings
      and concerns because they believe, if rejected, that will affect their medical care in
      a negative way. I’m not suggesting their perception is true. I don’t believe it is true as
      a general rule. But that’s what they believe. Perhaps a good initial discussion, led by
      the doctor, would help. “I really want you to tell me the truth about everything, esp.
      your feelings and your emotional health. I accept that these are your feelings, that they’
      belong to you, and I won’t reject them. You don’t need to worry about me being angry
      with you because you’re honest with me. I won’t judge you. At the same time, I’ll be
      honest with you about my assessment of your health, and my expectation is that, 
      though you may not agree with me, you’ll accept that it’s my educated opinion as your
      doctor. We need to talk with each other honestly.”
          Something like that. To some, that sounds just too basic. But I sometimes think,
      in the time crunch, we forget the basics and assume too much about each other.

  • Anonymous

    I’m not always completely honest with my doctors because my doctors have, generally speaking, never taken me seriously. So when something is bad, and they start to allude that it’s not as bad as i think it is, i end up backing down and minimizing the severity of my symptoms or the seriousness of its impact on my life.

    It gets REALLY REALLY OLD being told over and over again that if I’d just lose weight and exercise more, all my problems would disappear. (It turns out I have celiac disease, a severe form of the skin manifestation of it, so it was LITERALLY staring them in the face every time, but their own biases prevented my diagnosis.) I’d be happy to be honest with doctors, if they’d be happy to check their biases at the door and treat me (and other people of size) like a human being.

    I agree patients need to be honest, but when doctors are dismissive, rushed, biased, and convinced everyone’s trying to pull a fast one over on them (rather than everyone is just trying to get some medical care with their dignity in tact), the onus is really on the doctors to step up to the plate and take patients a little more seriously and treat them with a little more dignity. doctors are the ones in the position of power in this situation, and they’ve got an obligation not to abuse that power.

  • Anonymous

    I was honest with my former Dr. I got yelled at, for telling him I was terrified of my ex-husband!!  I was told I was a little touched in the head by this Dr.    My ex-husband had beat me up and had to go to the hospital for care.  You tell me who is touched in the head???????  Joke is I am a nurse.. So should i be dishonest???

  • http://www.practitionersolutions.com Niamh van Meines

    Thank you for this thoughtful piece. I can’t help but wonder that I might understand your perspective better if you gave us examples of when honesty was damaging to your relationship with the patient & what the impact was. I’d also like to hear examples of when it was very helpful & how it saved lives. I think it’s a very gray area. People don’t often know that they are not being completely honest & I always have forgiveness for people who are not ready for the whole truth, but over time can come to terms with “coping” in their own unique way, with a life changing illness. I’m thinking that there are significant factors (personality traits, attention seeking behaviors, behavior patterns, personality / mood disorders, coping mechanisms) that impact honesty in the relationship. For example: certain cultures / personalities feel that they must endure pain, so they are not inclined to accept pain management to a degree that will completely alleviate the pain. As a result, they may not be completely honest about their experience of pain or the severity. I’m not inclined to hold it against them that they are not honest with me but hope over time, that I can convince them that they don’t have to suffer this way. I would be concerned that an “all or nothing”attitude would interfere with this little dance between clinician and patient that is an integral part of the relationship. I’m grateful that you have brought this subject up. It helps us all understand the dynamics of our relationships with patients.

  • heartsurgeryguide.net/

    establishing an honest, open two way conversation between patients and medical staff is critical for optimal outcomes after cardiac surgery. patients should not assume medical staff has all answers, they can address only problems that are made known to them, and many issues not evident on lab and radiology reports.  patients are their own best advocates so ask questions, demand answers until satisfied.  hide nothing