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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  • DoubtfulGuest

    And when the doctor lies?

    • EmilyAnon

      When doctors lie, it’s called elision, which Dr. Atul Gawande, in his book “Complications”, defines as ‘withholding of the truth’. He said it’s a necessary deceit to get the patient to trust them, especially useful to the newby doctor when asked questions about their experience.

      • DoubtfulGuest

        Yes, seems like they have a justification for everything…I’m talking about after a major mistake. I already trusted the doctor. I’d trust an inexperienced, honest doctor, too. I wouldn’t care if I’m their first patient, as long as they’re honest. In my situation, there was probably some ‘beneficience’ justification invoked, some question about my competence (even though I figured out part of the correct diagnosis myself). Of course, no explanation of any of this has ever been forthcoming…I’ve been left to speculate on my own. I’ve asked many times for the whole truth. Probably the idea was to keep me from becoming ‘anxious’ (*facepalm*) but it backfired. Conveniently it serves the doctor’s risk management interests not to tell me any facts that would help me understand anything.

        Thank you, Emily. I should read this book sometime that I’m in a better frame of mind. I just have a pit in my stomach from reading this post.

      • Lisa

        There is no such thing as necessary deceit, for what ever reason.

        • DoubtfulGuest

          Supposedly some patients don’t want to hear the truth. I have yet to meet any, though. Because some folks don’t want to hear they’re overweight or whatever, doctors have these elaborate justifications for any kind of lie. Pre-tty slick…

          Sorry, Dr. Craig, this is really a nice post in many ways. It’s just that 1) half the story is missing and 2) this statement is a little too…something: “The thrill of medicine is the narrative that patients formulate about themselves to inform their pathologies and shape their desires for self.”

          If I ever get to talk with this doctor who messed up and then deceived me about it, I’m totally going to try your compassionate, non-judgy approach. Should be interesting.

          • Lisa

            There is a difference between not giving the patient information, after ascertaining how much information the patient wants, and withholding information. My experience is similar to yours; I think people want information about their medical opinion.

          • DoubtfulGuest

            That’s right…good point. I read that the recommendation is to ASK the patient how much information and decision-making power they want. I think for docs sometimes it’s all the same, like they do a quick, very subjective assessment: “She looks like the type who’d rather be lied to”.

            Oh no, wait. They’d never be that direct in their minds. It’s probably more like “Blah blah anxious, blah blah doesn’t want to take responsibility for herself, blah blah expects me to take charge, so…”

        • EmilyAnon

          I agree. I think the author justified elision as a way of keeping the patient in the dark to hide a doctor’s lack of experience. He said trainees sometimes have to “steal” (his word) their learning from patients, and they do so through deceit. Another way being behind the closed doors of the operating room. It’s an eye-opening book.

          • Lisa

            I always read my surgical reports as I learn a lot.

          • Patient Kit

            I just put “Complications” on my to-read book list. Sounds…interesting. 8-(

          • EmilyAnon

            I read it some years ago when I was really “green” and before I started doing my own research. It’s a personal biography when the author was in training, and he writes beautifully. Publishes many medically related articles in the New Yorker. I have a feeling you will be a fan as well. I’m sure all libraries have copies, mine did.

      • SteveCaley

        Naw. Elision’s a great concept, pretty clear, when you’re talking about pronunciation; less so when writing, and hardly anywhere in patient conversation.
        To refresh a term that’s been beaten into nonsense – the patient/doctor conversation is a place where a special thing goes on, in my opinion – that is a DIALECTICAL conversation. Hardly anyone gets anything out of that word, dialectic. The encounter truly is dialectic, not oratory – the patient is not to be persuaded by a speech, nor is it a didactic – the patient is not to be taught something.
        It is the rational discovery of a common truth, or truths – when the discussion is at its best. That’s the patient visit in a nutshell, in medicine.
        To be honest, I don’t give a damn whether a new patient trusts me or not – that’s a prejudice on the part of the patient. What I need to do is engage the patient on a dialectical path, and see what they think after. If they don’t trust me then, or don’t like me, or think my wife dresses me funny – that’s their opinion.
        In the medical dialectic, I start with the simplest and clearest elements, and then the discussion develops to the extent that the patient needs, wishes and expects. If there are critical things that must be told, I will tell them. Beyond that, it’s the PATIENT’S prerogative to elide, not the doctors.
        That is the fundamental principle of the medical dialectic.

        • EmilyAnon

          show off ;-)

          • DoubtfulGuest

            He’s quite the intellectual, isn’t he? Provided he also walks the walk, this is pretty good stuff…

    • Suzi Q 38

      You took the words right out of my mouth.
      I have had TWO doctors lie to me. Thank goodness when the CEO asked me for proof, I could submit it.
      I told one of them that I was firing him because I no longer could trust him.

  • ninguem

    I lie all the time.

    “You were right, dear”.

    • DoubtfulGuest

      Excuse me…Sir? I’m trying to cast an Eeyore-shaped cloud over the whole post and you wrecked it.

      • ninguem

        I’m sorry dear.

        I was wrong.

        (full husband mode)

        • DoubtfulGuest

          Your nose is growing, Sir.

        • EmilyAnon

          A good wife always forgives her husband when she’s wrong.

          • Suzi Q 38

            I will have to remember that.

          • ninguem

            So if a man is alone in the woods, he says something but no one hears, is he still wrong?

          • DoubtfulGuest

            Are we talking with or without a donut?

          • EmilyAnon

            I know it’s a riddle, but I don’t get it. Mine was just a play on words.

    • Suzi Q 38

      Smart man.
      My husband adds a kiss on the forehead.

    • buzzkillerjsmith

      ” Honey, I’d love to hear every little thing about the annoying interpersonal interaction you had with someone you had never met before and will never meet again. Please don’t spare the details.”

  • SteveCaley

    Humans lie. We do so because we are uncomfortable. It takes hard work learning how to tell the truth tactfully. Lying is a part of our culture.
    I have taken care of incarcerated felons. I figure that about half that comes out of their mouth is complete and utter fabrication; the other is the truth. That puts them a leg up on the politicians – you have a 50% chance of hearing the truth.
    Caring for the patient is KNOWING that they will not tell the truth. It is not from their being people of poor character. It is rumored that Freud responded to a query about the lengthiness of psychoanalysis something along these lines – “All one needs to do is lie down and tell the unvarnished truth for 60 minutes, just one time. Then you are done. But look at how many PREVIOUS sessions are needed to get there – years!”
    Medical care is the ability to read through and attentively listen. I know doctors that care only for honest patients – they are called veterinarians.

    • DoubtfulGuest

      And when the doctor lies? :)

      “Caring for the patient is KNOWING that they will not tell the truth.” Why do we answer all those personal questions then? What’s the point? Especially with a challenging diagnosis, the patient is doing some work, too. We’re not sitting there quietly, sipping umbrella drinks while the doctor figures everything out. We have to try to explain our symptoms in a way that will make sense to you and, (this may not apply to you personally) won’t make the doctor angry.

      So here was my big deception: my muscle weakness had been going on for quite a bit longer than I first reported to a neurologist BECAUSE a previous PCP had told me my earlier estimate was not possible: “You can’t have had it that long and still not have a diagnosis”. So, I reported what I thought would be a more acceptable number of years (6-8), the first time I saw a neurologist. The weakness had gotten substantially worse right around that time, so it was still an important benchmark. I kept looking for an opportunity to tell him the real story…waiting for questions from him about sports, exercise, early childhood illnesses. Those questions never came.

      This is the same doctor who lied to me after he made a mistake. I suppose he justifies it because of a small amount of “fake good” on my part, which I kept looking for an opportunity to fix. (I was accused of “faking bad” by him and other doctors at the time). I really appreciate your comments, Dr. Caley, it’s just we need to look at both sides in order to solve these communication problems. It’s not just patients and their Faulknerian pathologies. Any thoughts about doctors’ lies?

      • SteveCaley

        Thanks for your question.
        I still stand with “Humans lie. We do so because we are uncomfortable. It takes hard work learning how to tell the truth tactfully.”

        It is unprofessional for a physician to lie, and always ethically wrong. The ethics of the profession demand that we tell the truth, and apologize if we have not done so.

        It is not a detriment, though, if a patient lies. They are under a completely different situation. When patients restate things, I do not think they are bad people. They do what humans do under pressure. Patients do not have to “perform” for the doctor – or at least they should not.

        It is unprofessional for a physician to lie, and always ethically wrong. I just ran across Tim Mazur’s paper
        (see https://www.scu.edu/ethics/publications/iie/v6n1/lying.html

        and I parsed it quickly. I am a virtuist; I could agree with Kant; I am not a utilitarian. Anyone who can support lying by physicians, have at it. Not me.

        • DoubtfulGuest

          Wow, great answer, thank you, Dr. Caley. I actually think we should tell the truth, too. I’m no fan of double standards. I expect your response will get much positive notice from readers.

          • Suzi Q 38

            I have thought about this.
            Speaking of patients…..
            If I have or in the past have a drug addiction problem, it is safe to say that a physician might expect me to lie about how many Vicodin I use a day. Maybe when I ask for more, you would know that I was a drug addict, so you would prescribe the Vicodin in smaller numbers or lower amounts.
            Patients lie about gaining weight….”it must be my medication (probable).” Or it could be the licorice and gumdrops I ate last week. Going out to eat, or eating way too much food with each meal could also be the problem.

            Doctors want to be held to a higher standard, but some will lie to cover their errors at times. After this happens with a patient, the patient has to decide if h/she wants a doctor who easily lies.

            I say “No.”
            I don’t need a doctor who lies because I can’t trust that doctor.

            I still say that when it happens to you (the patient), it shocks and” hits” you as if you were slapped.

            You just were not expecting your doctor to lie.
            After all, they are the “pillars” of society. We put them on a “pedestal.”

            I don’t anymore.

        • an observer

          “It is not a detriment, though, if a patient lies.”

          I’ve seen horrible complications and, even, death as a result of a patient lying or withholding information. Sorry, I don’t care what philosophy books you read, but regardless of who lies, it can mean the difference between life and death.

          Find me a doctor who’s okay with patients lying to them and you’ll find a poor doctor.

          • DoubtfulGuest

            “Find me a doctor who’s okay with patients lying to them and you’ll find a poor doctor.”

            Uncalled for, I think. His statement is about the doctor’s ethical obligation to patients. Patients are unfortunately in an inferior position. The things you all tell us affect what we think it’s okay to tell other doctors. Dr. Caley is referring to a relationship that develops over time. You make a good point about emergencies, I hadn’t thought about that.

            In my situation the PCP who told me “You can’t have had the muscle weakness for that many years” pretty much convinced me for a time. “Well, she’s the doctor, so what I felt wasn’t weakness per se, it was something else, maybe anxiety like she says”. Off and on, I went back to my original thoughts about what I’d experienced.

            I made the mistake of not giving the first neurologist a fresh start. Everyone we meet deserves a fresh start, and in medicine the stakes can be high. But later, I did correct that information with him and his response was to become very angry. This was after he’d made his own mistake and just wanted to get rid of me. What are your standards for doctors’ honesty with patients?

          • SteveCaley

            Perhaps that poor doctor’s me. Patients that lie gamble with their own lives. If I had a magic wand, I would make patients NEVER lie to me. I’m sorry if I implied in any way that I can help a patient in spite of their deliberate withholding or distortion of fact. That being said, humans often do and will; if I do not consider the possibility, I am being naïve. Does that work for you? Anybody who’s done shifts in the ER, as I have, has a much lower expectation for human behavior. Doctors and cops – they’ve seen it all. I really don’t care how the soap got up there. I really don’t. I DO know it happens. I CAN get it out. That’s all I care about, capisce?

          • DoubtfulGuest

            S/he’s new here, that’s all. Hopefully if an observer sticks around s/he’ll see how unbecoming it is to swoop down and engage in mud-slinging. An observer might have something to add to the discussion if only s/he could go about it differently.

          • SteveCaley

            Naw – I’ve been through residency! That wasn’t even a tap on the shoulder. It’s a subtle point, and I haven’t found myself explaining anything perfectly. Anyone who expects perfection from moi, better wait, it ain’t here yet. Thanks for the cheer-up, though.

          • DeceasedMD1

            Just be glad it’s soap and not a gerbel.

          • Suzi Q 38

            it depends on what the lie is.

        • rbthe4th2

          Then I know a lot of unprofessional and unethical docs because they have lied.

          • SteveCaley

            What causes them to lie?

          • rbthe4th2

            Fear that people are going to see they made a mistake, that it will be reported to management, that someone is going to get sued, that they’ll get bad marks on reviews, inability to deal with mistakes personally, don’t like to admit they’re wrong, simply missed something & don’t know how to respond to the patient …

          • SteveCaley

            It’s terrible – patients don’t tend to sue doctors on honest errors, but for appearing not to care about mistakes. Luckily, I haven’t had an error cause harm, but I have missed things. I have apologized to patients.

          • rbthe4th2

            You are better than the one I have now. I’ll die due to no care in the area and they’re just hounding me. I’m quite vocal about it, in terms of ‘here are my records’ if people want to see them. Well, fix your problems, if you don’t fix them, don’t complain when people say hey here was my experience under this doctor.

          • SteveCaley

            This stuff makes me frantic. ALL THERE IS to
            healthcare is delivering services to PATIENTS. Everybody gets it – except the people in charge. The doctors have very little say in the
            matter – produce, or you’re fired.

          • rbthe4th2

            The doctors, in this case, are the ones who don’t want my story known. They followed me on public property, take photos of me sitting or standing on public property, send cops after me for doing so, & when that doesn’t work, send security guards out to record my every movement.

            Seriously, when a doctor does wrong and then doesn’t fix it and acts like this when the person says here are my experiences, here’s the facts, doesn’t scream or yell at people, do you think this reflects well on the profession and on that particular group allowing said behavior?

            Would you believe they’re looking for patient healthcare delivery under those circumstances?

          • SteveCaley

            Fear, helplessness and suspicion are the public health problems today, like cholera and tuberculosis were a hundred years ago. We should try to get them out of our civilization.

          • Suzi Q 38

            Good for you!
            We need to hear the apology.
            I need to know that h/she is sorry,
            so I can move on from it.

    • Karen Ronk

      I guess I am the oddball but I as I have gotten older, I am very uncomfortable even contemplating lying. I feel like a nag with friends who are constantly telling little “white” lies or “fudging the truth” (or still “stealing” cable) and I question why it is part of our culture.

      As a child, I was probably more like your incarcerated felons, but I would attribute that more to my overly dramatic personality (still working on that). Telling the truth is not widely accepted anymore. There have been countless incidents when people have had to come back to me and say that I was right or truthful about a situation. And those who know me well, realize now that I may misread a situation or get bad information, but I do not deliberately lie. Frankly, that has not served me particularly well so maybe I need to start.

      • DoubtfulGuest

        No good deed goes unpunished, as they say. Good points, Karen. I also feel a lot of stress about lying, even thinking about it.

  • ninguem

    What is truth?

    You never can find a philosopher when you need one.

    They’re all goofing off at the philosopher donut shop.

  • DoubtfulGuest

    Hello john doe, Sorry for the delayed response…I just now saw this. My records were changed, too, although there was probably no deliberate deception involved. Seems like the doctor ought to look me in the eye and tell me that, though, and the fact that he hasn’t is concerning. I was dismissed as a patient as well, probably due to the doctor’s risk management concerns. I’m very sorry for your terrible experience and I, too, would be interested to hear back from the author of this post. Sometimes they check back and sometimes we’re just responding to a re-post from their own blog, so no interaction takes place.

    My feeling is that even minor purposeful deception is unacceptable. Even if your response was out of proportion to the offense — did you decide that or did someone else? Patients are in a vulnerable position, we’re expected to trust complete strangers. When that trust is broken, it can be devastating. I also had my own emotional status deteriorate when it was implied that I wasn’t competent to hear the truth of what went wrong with my care. It can feel like gas-lighting. If the doctor had just been honest with me about his mistake, he would have gotten a compassionate, reasonable response.

    I don’t know the right answer for your situation, but I wonder how much suffering could be prevented by doctors explaining honestly and respectfully. I think access to mental health care is becoming more limited, but if someone had been available it seems like they should have tried to help. It’s odd how we can be competent adults to be held responsible when it serves the doctor’s interests (e.g. paying our medical bills, taking medications as prescribed, getting to and from appointments) but not when it might be uncomfortable for the doctor. I’m still trying to resolve my own situation, and again, I’m very sorry you went through this.

  • DoubtfulGuest

    Hey PH, good points. I think this sentence, which I found almost as giggle-inducing as the other one I quoted, is supposed to be a nudge-nudge wink-wink to other doctors about somatization disorder and that kind of thing. (*eyeroll*)

    I really appreciate this doctor’s sense of responsibility toward her patients, I’m just not sure I’d want her observing or judging me. Wow, look at the human train wreck blossoming before my eyes (I needed a mixed metaphor here). When doctors are willing to honestly talk about themselves that way, then maybe we could get somewhere.

    I’m sure I’ve *misinterpreted* something, though, PH. My little patient brain just can’t handle…

  • DoubtfulGuest

    It would be nice if a doctor would reply to you, too. Maybe if we cut out our childish, off-topic humor they’ll deign to participate. ;)

  • Gibbon1

    I think I have something to add from my own profession (though not medical) experience. I think I picked this up from my mother, who essentially as far as I can tell never lied about anything period. And my dad also an engineer who seemed supremely comfortable with admitting ignorance.

    That said, I don’t lie to my customers, coworkers or my boss. And I try impart some idea how confident I am about a subject.

    The too long didn’t read. People are so conditioned to people lying to them, either outright or by displaying excessive confidence that they simply do not know what to make of someone who is honest. In my case it takes probably _six months_ for people to get that my ‘hemming and hawing’ is another engineers ‘oh absolutely totally’

    Worse I think people are conditioned to believe their own lies.

  • DoubtfulGuest

    Does he assume any individual patient is lying, or only that lying is common and he still does his best to help?

    I’d actually rather have a doctor tell me my story sounds fishy and give me the opportunity to prove it or explain better, than the alternative. In which a doctor gives me a rope to hang myself with while they watch with jadedness and Schadenfreude. Because it’s really easy for patients to hang themselves even when they’re telling the truth. Physicians can ensure that happens with their leading questions, constant interruptions, and rapid-fire interrogation style.

    I’d agree with you to a point, until you use the ‘m’ word in relation to a particular doctor without knowing the whole story.

  • DoubtfulGuest

    What’s the multiplier doctors use for drinks per week, sexual partners and so on? For those who want their doctor to know the truth, should we give fractions then? :)

    I sometimes wonder if Dr. Kevin messes with the titles on purpose so we have something to disagree on. Lies in a relationship, right? But then the post is only about patients’ lies? I think lots of people here have made valuable points and we do try to have some fun here…

  • Lisa

    The discussion may have veered from the topic of the essay, but when I read it, I was irritated as it implied the lies in a doctor-patient relationship are only on the part of a patient.

    • DoubtfulGuest

      Next up: Patients cause world wars, famine, and climate change. Doctors stand by in helpless horror…

  • Suzi Q 38

    They probably honestly were giving you the benefit of the doubt.

    Not every patient who makes a medical records request and then evaluates the records and finds errors has a mental illness.

    Kudos to them.

    I was complaining about a real condition and they didn’t believe me until they saw my cervical MRI a year and a half later.
    By then, my condition escalated to the point that I could barely walk.
    The neurology teaching hospital could not believe that the first doctors at the first hospital didn’t evaluate, treat or refer me sooner. They apologized that my walking ability and pain was permanent and if they had gotten me in their hospital sooner, it would have been better.

    I was not dismissed as a patient, but should have been…only because they did not know what was wrong with me….Why not send me to the right specialists?

  • buzzkillerjsmith

    Wandering from one office to another. That’s sounds like me. And I work there.

  • DoubtfulGuest

    Whoops, you were addressing the author of this post, not Dr. Caley…one of these days my brain will work better.

  • Suzi Q 38

    We don’t sue over such in the state of California.

    We have tort law, and a judge would throw out such a lawsuit.
    Furthermore, a patient may have difficulty finding a lawyer who would take h/her malpractice case on a contingency basis.

    All bets are off if the patient is wealthy….and some are.

    My brother, for instance, was so angry at his physician that he sued him for malpractice and did not care how much it cost him.
    He was THAT angry. I think he spent about $50K, and later dropped the case once he made the physician miserable.
    He makes in the high 6 figures a year, so $50K was OK by him.
    I could think of better things to do with $50K.

    Some doctors are smug in California, feeling secure about tort law, etc. That is O.K. except if you call someone who has a huge ego and temper like my brother a “liar,” then you are asking to get sued, IMHO.
    I would not sue as I am not wealthy. I would just do everything in my power short of suing to report the physicians actions.

    I would prove that I wasn’t a liar and then call the patient advocate. I would also do the patient-physician “break-up.”

    At least get h/her a reprimand.
    Post it on YELP, and on other sites that evaluate physicians.

    Post: “This doctor had the audacity and arrogance to call me a “liar.”” I do not recommend h/her.”

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