When patients aren’t truthful, misled doctors may give a wrong diagnosis or treatment.
Bill Moore of Pacific Grove was barely in his 20s when he found out he had cholesterol trouble.
This was bad news for Moore because his father had died of a heart
attack at 45 and because, as he told his doctor, Moore was eating all
the right stuff.
The doctor prescribed cholesterol-lowering medication, and a subsequent test showed the drug was working very well. Too well.
His doctor was very surprised, Moore says. "I told him I must be
unique. I must have a unique body composition." But the truth was Moore
had fed his doctor a false written record of his eating habits before
beginning the drug — reporting vegetables and salads that had never
been on his menu, and not reporting all the hamburgers and pizzas that
had.
Only when he started on the cholesterol drug did he finally begin
eating the way he’d been claiming to eat all along. It was that change combined with the drug that made his cholesterol levels plunge.
Inaccurate information can do more than confuse a doctor. It can lead
to misinterpreted symptoms, overlooked warning signs, flawed diagnoses
and treatments — potentially endangering a patient’s health, even life.
Still, doctors know that at least some of the time, at least some of
their patients overstate, understate, embellish, omit, or otherwise
stray from a straight and thorough reporting.
"Everybody lies at some point," says Dr. Sharon Parish, a professor of
clinical medicine at Albert Einstein College of Medicine in New York
City who practices at Montefiore Medical Center. They do it out of
embarrassment, to please the doctor, to avoid a lecture.
But doctors and patient advocates agree that in most cases, when
patients lie, they’re pretty much asking for trouble. Even when telling
the truth is unappealing, "getting into a lying relationship with your
physician is really far more perilous," says Peter Clarke, director of
the Center for Health and Medical Communication at USC and co-author of
the 1998 book "Surviving Modern Medicine."
An early lesson
That patients lie is one of the basics doctors learn in medical school.
Of 1,500 responders to a 2004 online survey by WebMD, 45% admitted they
hadn’t always told it exactly like it was — with 13% saying they had
"lied," and 32% saying they had "stretched the truth."
Not included in those figures would be patients who "lie" without
knowing they do so by withholding information because it slips their
mind or they have no idea it could be useful. (Maybe Aunt Agnes would
gladly tell about the time she snored so loud she woke the neighbors if
she knew that a diagnosis of sleep apnea could depend on it.)
In the WebMD survey, 38% of respondents said they lied about following
doctors’ orders and 32% about diet or exercise. Doctor reports bear
this out.
"Patients are strongly motivated to have their doctors think they’re
good patients," says Dr. Steven Hahn, professor of clinical medicine at
Albert Einstein College and an internist at Jacobi Medical Center in
New York City.
It’s hard to make a good impression when you’re on an examining table
in a flimsy, open-backed gown — a fact that might make lying that much
more tempting. But even fully clothed, talking face to face across a
desk, a patient cedes authority to the doctor. And people generally
like to please those in authority, says Emanuel Maidenberg, clinical
professor of psychiatry at UCLA.
Patients also are prone to lying about the fact that they engage in
social taboos, things their doctor might not approve of. In the WebMD
survey, 22% lied about smoking, 17% about sex, 16% about drinking and
12% about recreational drug use.
"When you’re studying psychiatry, you’re taught that if a patient says,
‘I use cocaine once a month,’ you figure it’s twice a month," says Dr.
Robert Klitzman, professor of clinical psychiatry at Columbia
University. "We were taught to double."
Patients lie because they don’t want to be judged, embarrassed or
misunderstood. They lie about pursuing alternative health remedies
because they disagree with their doctor or because they think an item
is none of their doctor’s business.
Doctors, of course, make the case that even deeply personal matters
such as sexual orientation or having an extramarital affair can affect
the care doctors give (how to interpret symptoms, what tests to order,
exams that might be important). Patients may see only unpleasant
invasions of their privacy — and a risk that somehow their co-workers,
parents or spouses will find out too.
"We live in complex social webs," Klitzman says. "Someone will see the forms… People talk."
But co-workers, parents and spouses aren’t the only threats
hanging over a patient’s head. Health insurance is another. And so —
not surprisingly — sometimes people lie in order to keep something out
of their medical records or out of the hands of their insurance
companies.
That can be of genuine concern, say doctors and patient advocates. What
happens in the doctor’s office doesn’t always stay in the doctor’s
office.
Anything and everything health-related that patients tell their doctors
is supposed to go into their medical records. That information is
confidential, protected under the federal Health Insurance Portability
and Accountability Act.
But in fact, it’s only confidential until it isn’t.
Whenever patients apply to buy individual insurance policies, and
whenever they file claims under policies they own, the insurance
company can request their medical records.
Patients can refuse to release the records, but if they do, the company
can refuse to sell them a policy or refuse to pay claims. This is part
of the deal patients agree to by signing on to the insurance contract.
And it doesn’t take much in a patient’s records to nix the sale of a
policy. "A case of acne can do it," says Jerry Flanagan, an advocate
with Consumer Watchdog.
And there are other insurance complications. If, when processing a
claim, the insurance company finds something in a patient’s records
that contradicts something the patient said when purchasing the policy,
the company can retroactively cancel the policy, Flanagan says. Then it
can demand reimbursement for any claims it has already paid — even if
those claims had nothing to do with the reason for canceling the policy.
"I would never advocate lying to your doctor," Flanagan says, "but I can definitely understand why someone might."
Dr. Ken Duckworth, medical director of the National Alliance on Mental
Illness, suggests one scenario in which it might be tempting to lie.
Say someone learns from a gene testing company that she is carrying a
gene that puts her at risk for a disease for which there is no
treatment or prevention. Then, he says, "it could be in a patient’s
interest to conceal that information."
Arthur Caplan, director of the Center for Bioethics at the
University of Pennsylvania in Philadelphia, cites yet another
hypothetical: Say a patient feels deserving of coverage for a certain
condition or treatment, but his symptoms don’t quite fit the insurance
company’s requirements. The patient might adapt the description of his
symptoms to qualify for coverage, "and that might arguably be
defensible or excusable."
Accuracy is vital
Sometimes, a doctor may be willing to help by overstating a patient’s case.
In 1997, Dr. Victor Freeman, then a primary care research fellow at
Georgetown University Medical Center, asked 167 internists across the
country what doctors should do if one of their patients was at first
turned down for coverage of a treatment that was medically indicated.
Almost half — 45% — said it was ethical to lie in order to get
coverage for the patient. The more serious the condition, the more
doctors said lying was appropriate: 57% when bypass surgery was at
stake for a patient with severe angina or chronic atherosclerosis; 47%
when the issue was comfort care for a patient with terminal ovarian
cancer causing abdominal pain and extreme nausea; 32% when a patient
with severe depression was seeking a psychiatric referral.
At other times, a doctor may be willing to help by leaving things out of a patient’s record.
Dr. Howard Brody, director of the Institute for the Medical
Humanities at the University of Texas Medical Branch in Galveston,
Texas, suggests patients talk to their doctors if they have symptoms or
conditions they fear could disqualify them for insurance coverage.
"There may be times when a doctor will agree to not put it on [record]," he says.
"But that’s very iffy. It’s not good medical practice as a rule."
Clarke suggests patients have two sets of medical records, a
private one between patient and doctor and another for sharing with
others.
"The solution is not to lie to your physician but to establish
private records that won’t be released to third parties," he says. "If
your physician won’t do that, it’s reason enough to leave the
physician."
Short of changing to a healthcare system where insurance companies
can’t refuse to sell anyone a policy because of a health condition —
which he favors — Flanagan says there’s no ideal solution for some
patients.
Even so, most doctors, ethicists and patient advocates think it’s a bad
idea to lie to a doctor, although they all see reasons why patients
might want to — and even scenarios where a lie might be justified.
Some ethicists consider it a moral obligation for patients to tell the
truth to their doctors, Brody says. In establishing a patient-doctor
relationship, the first step is to take a thorough medical history.
"None of the rest makes any sense without an accurate history to guide you," he says.
Lying about what you eat, how much exercise you get or whether you’re
taking your medication as prescribed may seem benign but can be
hazardous. If it seems you’ve been doing everything right, and your
condition still isn’t improving, the doctor could change your current
treatment plan to something more serious and invasive — and
unnecessary.
As for embarrassment, perhaps patients worry too much about what their doctors think of them.
"Doctors have heard it all," Klitzman says. "They’ve seen it all."
In other words: Get over yourself.
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