Why Thoughtful Patients Lie to Their Doctors

Posted on January 27, 2009
Filed Under General Rationing Issues |

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In a recent article in Newsweek, reporter Joan Raymond points out that 13% of American patients admitted to lying to their doctors, and another 32% admitted to “stretching the truth.”  Favorite topics about which patients routinely prevaricate to their trusted medical servants include whether they are: following the doctor’s treatment plan, following a healthy diet, continuing to smoke, limiting alcohol consumption, avoiding substances and supplements not approved by the doctor, and practicing safe sex.

Several prominent physicians made themselves available to Ms. Raymond, in order to supply quotes for her article expressing their utter dismay at this revelation, and to offer numerous very good reasons for patients to always tell their doctors the truth about everything.  DrRich will not recite these reasons, as you all know what they are, but will for the record state that he believes they are very good reasons indeed, and encourages patients to come clean with their doctors whenever it is practicable to do so.

But on the other hand, unlike the suitably scandalized physicians whom Ms. Raymond dug up for her article, DrRich is neither particularly surprised nor particularly upset by the fact that patients lie to their doctors. (By the way, DrRich must remember to get his name on one of those media resource lists, to give the reporters some quotes that are a little different for a change.)

DrRich is not surprised because he is a student of human nature, and also because he was paying attention in medical school all those decades ago, when the wizened, world-weary professor (not unlike, perhaps, DrRich today), told us idealistic, snot-nosed, callow youths that in order to get a reasonable estimate of how often a patient engages in some unfortunate behavior (such as smoking, drinking, or excessive exercise, which was known, back then, to jar the organs loose), that one must multiply whatever answer the patient gave by 2.5, unless the answer was “zero,” in which case one must take the correct answer as, “a lot.”

Accordingly DrRich applied this rule during his entire practice, and to the best of his knowledge things generally worked out all right. (Knowing about this rule also causes DrRich, when he reports on his own bad habits to his own doctor, to divide by 2.5 so the numbers will come out right. DrRich supposes this places him in the 32% of patients who stretch the truth, though he would prefer to think of it as calibrating.)

In gauging the scandalized reaction of the prominent doctors interviewed by Ms. Raymond to the news that patients lie, DrRich surmises that either medical professors have long since stopped teaching their students about the “2.5 rule,” or the medical eminences in question simply exaggerated their expressions of dismay by a similar factor, in order to give a proper-sounding response.

In any case, if DrRich is at all surprised by the results of the survey reported in Newsweek, it is because so few patients apparently lie to their doctors.

In the old days, patients who lied generally did so because of human nature, that is, to avoid embarrassment, or so their doctors would not think them weak for their lack of success in curtailing unhealthful habits. Today, for patients who stop and think about it, there are additional reasons to consider lying.

For one thing, their doctors are not being truthful to them. A survey published in Health Affairs in 2003 revealed that one-third of American physicians admitted to routinely withholding from their patients pertinent information about optimal medical treatments.  They do so, according to the survey, because the patient’s health plan might not cover those optimal treatments (at least, not without a hassle).  And in 2000, the American Medical Association filed an amicus brief with the Illinois Supreme Court asserting that doctors have no duty to inform their patients when insurers have given them financial incentives for withholding medical care.

The doctor-patient relationship is supposed to go both ways, and if the doctors are lying, then patients understandably might not feel compelled to always be truthful.

For another thing, it has been amply demonstrated that doctors are not above ratting their patients out to insurance companies, if they have information that might allow the insurer to retrospectively cancel health coverage. DrRich has written about this earlier, here.   Patients could thus perhaps be forgiven for being somewhat circumspect about revealing to their doctors prior medical conditions or personal habits that might jeopardize their insurance coverage if discovered.

Finally, as the poet said, it does not require a weatherman to tell which way the wind blows. Take obesity. Obesity is the latest scourge on healthcare costs, according to most authorities, and there is talk (and more than talk, in Great Britain, for instance) about withholding certain medical services from patients who insist on remaining obese. Take smoking. Those who refuse to quit, if they wish to beat back their withdrawal symptoms for a few hours, are made to go out of doors even in the dead of winter, weakened lungs and all, far away from even a building entrance that might offer at least a little shelter. They’re smokers; it they die, they die.

In an era of universal healthcare, where your bad habits so clearly affect my pocketbook, then it is not beyond the pale to speculate that anyone who chooses to lead a less than perfectly exemplary life could (like the smokers and the fat) be made to pay an extra price in compensation, perhaps up to and including forfeiting one’s access to healthcare.

Now, it is difficult to hide the fact that one is obese, and it is difficult to hide the need for a smoke at 10 AM if you are employed in an office building. But if one engages in, say, frequent meat-eating, or butter-spreading, or habitually fails to exercise 90 minutes per day, or occasionally forgets to use a condom, well, who’s to know unless one tells?

It is for precisely this reason that DrRich has always avoided using those supermarket “frequent shopper cards,” which tabulate all one’s purchases and offer attractive awards in proportion to the money one spends on groceries. When he needs his angioplasty, DrRich does not wish his insurance company to deny him coverage because the supermarket’s database (which the insurance company will have paid to access) reveals that in 1995 he purchased over 10 gallons of chocolate marshmallow ice cream, which he cannot definitively prove did not directly contribute to his arterial disease.

Similarly, DrRich will not castigate patients who choose not to reveal all their unfortunate lifestyle choices to their physicians - at least, not as long as their physicians remain as compromised as they are today.

If the traditional doctor-patient relationship should ever become fully restored, then DrRich will read the admonitions of Ms. Raymond’s Rolodex medical experts and exclaim, “Right on! Stop lying to your doctors.” Until then, he finds himself sympathizing with thoughtful patients whose reluctance to tell the whole truth, he supposes, is likely underestimated in the Newsweek survey by a factor of, say, 2.5.

Comments

9 Responses to “Why Thoughtful Patients Lie to Their Doctors”

  1. Annie on January 28th, 2009 7:17 am

    Cannot a case be made (by physicians represented able by a team of cutthroat - er - highly competent legal beagles that insurers are practicing medicine without a license?

    While I understand about legal mandatory reporting in the cases of child abuse, domestic abuse and the like - because the underlying principle is to protect vulnerable people who cannot protect themselves - the idea that physicians “rat out” their patients seems to me to be the antithesis of the professional’s responsibility to patients. A patient, contrary to a consumer, has some degree of assumed vulnerability and dependence on the physician. Otherwise, why the need for a physician in the first place?

    Are you aware of an “rogue” type physicians who keep two sets of medical records - one for the third parties and one for their eyes only? Or physicians who refuse to deal with third parties? I’m aware that psychiatrists often encourage their patients to pa in cash and to not generate medical records which can become hydras and disseminate stigmatizing information which ma be used against patients. Certainly as patients find themselves dealing with arbitrarily applied pre-existing conditions and exclusions, this would be an incentive to bypass the third part system, as well.

    The medical record is no longer that at all, is it?

  2. DrRich on January 28th, 2009 8:54 am

    Annie,

    You are correct in pointing out that doctors have a moral and professional obligation to honor the privileged information they receive from their patients. That so many of us docs admit (to pollsters, at least) that we can no long honor those commitments reveals the depths to which our once honorable, once ethical profession has sunk.

    I am not aware of rogue physicians, but I have written about the growing need for (what I call) “off-the grid” healthcare, which essentially is what you are suggesting - where the medical records for the bureaucrats and the “real” medical records (which contain actual, useful medical information about the patient) are separate documents - the second of which would be entirely illegal, of course, on a federal level. This latter option, unfortunately, has its own negative implications, such as needing some sort of organizational force, like a “Medical Mafia,” to arrange for communication links between black-market practitioners, protection from authorities and from rival gangs of black-market doctors, bribes, threats, extortion, knee-breaking, etc. So it’s not all a bed of roses, but still and all, considering where we are today, it’s something to consider.

    Rich

  3. Annie on January 28th, 2009 12:26 pm

    Oops - apparently, I didn’t pay the “y” key bill. I apologize for the typos.

    The Robert Wood Johnson Foundation just announced a fairly large grant toward more robust public health initiatives that would appear to fit within your schema. link at my name

  4. John Bohlen on January 30th, 2009 1:07 pm

    It may be of interest that Jancis Robinson, a wine writer, once calculated out what surveys/polls said was the “average” alcohol consumption reported by British citizens. When compared to what the government really collected in alcohol tax - it was about half.

  5. DrRich on January 30th, 2009 1:56 pm

    John,

    It is gratifying to know that not everything I learned in medical school all those years ago has become completely obsolete.

    Rich

  6. Donna B. on February 4th, 2009 2:31 am

    Geez. I have been telling my doctor the truth, but I’m going to stop now!

    She’s thinking I smoke 2.5 packs a day and drink a bottle of wine 4 times a week.

    Or… maybe I’m lying above :-)

    The ‘underground’ records should be kept by the patient for use when actually needed. Maybe. Maybe not.

    Crap, I’m going to see if I have any wine left and have another cigarette.

  7. DrRich on February 4th, 2009 5:46 am

    Donna,

    DrRich sees no reason you would lie to him. I have you down for a pack a day and only 1.6 bottles per week.

    Still too many cigs, though.

    Rich

  8. Marilyn Mann on March 1st, 2009 9:00 am

    This is so true.

    I would add other ways doctor lie:

    1. Prescribing treatments that they know to be placebos.

    2. Misstating the science, or omitting key facts that their patients would have liked to know. Sometimes this is because the doctor hasn’t done the necessary work to know what science is out there. Othertimes, doctors are blinded by financial incentives, unwillingness to give up long-held opinions in the face of new evidence, or fears that their patients will be “confused” if they tell them the truth.

  9. Trusted.MD Network on March 12th, 2009 9:40 am

    What’s really wrong with the cardiology guidelines?…

    I understand that Dr. Rich has written a couple of great posts on this subject. Before I read and comment on them I want to make a few independent observations on the JAMA article in question and the accompanying editorial, the latter co-authored by o…

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