When patients aren't truthful, misled doctors may give a wrong diagnosis or treatment.
By Karen Ravn of the LA Times
June 8, 2009
June 8, 2009Bill 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.
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.
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."
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.
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.
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 the Foundation for Taxpayer and Consumer Rights.
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.
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 the Foundation for Taxpayer and Consumer Rights.
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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