The lies in the doctor-patient relationship

People lie. Patients lie.  Patients tell blank untruths, patients misunderstand truth, patients confabulate with the damage of a thousand fifths of vodka of yesteryear.

A core conceit of medicine posits that health care providers expect pure honesty from patients from first handshake on.  Violating every social norm around encounters with strangers, we expect that patients with no grounds for trust reveal all.

Providing primary care to patients on the furthest margins of the bell curve of human behavior — drug seekers, addicts, pathological personalities — means accepting that truth can be a squirrelly beast.  These patients constitute substantial portions of the highest resource-utilizing groups, rotating through ERs and inpatient wards, wandering from one primary care office to another, frequenting urgent care clinics searching for some esoteric palliation for their personal, medical, or financial woes.  Controlling medical costs means finding effective approaches to tellers of untruths.

Lack of truth-telling need not harm one’s ability to cope effectively with patients — but the adamant need that providers have to obtain the truth can impair patient care.  Firing vulnerable patients because of lies, letting one’s own emotional offense to mistruths take precedence over patient care, rousing a sense of shame where help is needed: these are ways that clinicians serve difficult patients poorly and contribute to the vagrant nature of care for trouble people. Not only do patients lie, but health care providers are likely equally poor at sussing out veracity versus lies. We judge truth at our own peril, as evidence suggests we are not very good at it.

How can providers cope with lies?  Explore rather than confront. (“It seems that you have cocaine in your system today. Do you want to talk about what is going on?”)  Use clear and consistent clinical policies that remove judgement from the interaction. (“Your drug screen today shows that you took benzos. I hear you saying that you did not take these drugs. In situations like this, I do not make any judgment, but our clinic policy requires that I see you weekly until this issue has cleared up.”) Presume a neutral approach, and gut-check the emotional kick around being lied to — understand it is not personal, but a part of the therapeutic process that can be handled with the same emotion one might put into a high potassium level … a problem to explore cause for, treat in the moment, and ultimately try to effectively solve.

Of course it can be a relief at times to find blatant truth-telling among otherwise complex layers of perception. (Refreshing is the patient that simply says, “I’m hooked on heroin and selling my prescription meds to pay for it. Can you help me?”)  But at the end of the day, these are less interesting cases than those beset by a truth that must be unknotted — like an eminently satisfying mystery novel whose villain you cannot guess until the final page, and whose motive is as much a twist as his weapon of choice and locus of crime.

The truth is that the truth is only a very small piece of the portrait.  The thrill of medicine is the narrative that patients formulate about themselves to inform their pathologies and shape their desires for self.  The nuances of the untrue patient narrative — like the literary foil of the unreliable narrator — can tell a story as effectively as a verbatim recounting of a recorded crime.  But unlike dry verbatim confessional (“Hi, my name is Jenny and I’m an alcoholic”), the unreliable narrator brings flawed, human flesh to his own history, paints her own Faulknerian tale before the clinician’s eyes.

Embrace the narrative.  Withhold judgment. Explore the story in all its complexities, contradictions, and outrageousness.  Because therein lies the humanity.

Julie Craig is a family physician who blogs at America, Love It or Heal It.

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