Body of lies: Patients aren't 100% honest with doctors

When patients aren't truthful, misled doctors may give a wrong diagnosis or treatment.

By Karen Ravn of the LA TimesJune 8, 2009

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 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.

Obama addresses the AMA

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The Yin/Yang of Health and the Environment

Introduction to the June issue of Virtual Mentor on the theme of medicine and the environment.

You see that pale, blue dot? That’s us. Everything that has ever happened in all of human history has happened on that pixel. All the triumphs and all the tragedies. All the wars, all the famines, all the major advances. It’s our only home. And that is what is at stake: our ability to live on planet Earth, to have a future as a civilization. I believe this is a moral issue. It is your time to seize this issue.

—Al Gore, An Inconvenient Truth

In 2006, director David Guggenheim made the Academy Award-winning documentary An Inconvenient Truth about former Vice President Al Gore’s quest to raise public awareness on global warming and climate change, framed not as just a political issue, but a moral one, requiring immediate attention. Gore rekindled interest among citizens, business owners, politicians, and legislators to “go green”—to examine the choices we make with the environment in mind. As in the 1960s when Americans started grassroots campaigns to protect the environment; save the rainforest, save the whales, save the chimpanzees, save the polar ice caps, save the ozone layer, reduce, reuse, and recycle—it suddenly became trendy to love the planet again. People started bringing reusable tote bags to the grocery store, buying more energy-efficient light bulbs and appliances, considering more fuel-efficient or hybrid cars, and switching to power companies that use renewable resources like wind or solar energy. Businesses took cues from the consumers and started making greener products, greener buildings, and greener commercial models. The government also responded to growing public advocacy, implementing policies at local and national levels to improve our air quality, incentives to consume less-polluting and more-renewable forms of energy production, and initiatives to reduce society’s carbon footprint. With Gore receiving the Nobel Peace Prize for his efforts, and all the public hoopla and media attention about the environment, we could only expect that health care would eventually be swept into the green revolution and experience an environmental awakening.

Unlike businesses, consumers, and even the government, however, health care must not whimsically follow tides of social opinion nor yield even to the force of scientifically proven facts without first considering its mandate to safeguard the health of the people and communities it serves. This timely June issue of VM looks at medicine and the environment: the interplay of physicians, hospitals, medical organizations, and health care professionals with our planet and its resources. We explore how our actions and policies relate to the patient-physician relationship, to our well-being as a species, and our obligation to, as Gore put it, “seize this issue” and catalyze change.

Examined closely, the topic is as vast and complex as the pale, blue dot we live on, and this issue highlights only a few of the many intricate facets of the discussion we hope to elicit. The authors who accepted the challenge to write about medicine and the environment approached the topic in terms of two broad categories, entwined in an ecological yin and yang—how the human health enterprise contributes to waste and destruction of the environment, and then how environmental toxins and exposures in turn affect human health.

Do we have special responsibilities as doctors to be advocates for environmental change? Does considering the environment mean a compromise in quality of care? Is the trend of hospitals going green by recycling and reducing toxic wastes just a fad or must it become a fundamental, conscious, lasting effort in how we practice medicine? As physicians, while we cannot steward the planet, we can be watchful over the smaller communities that we serve. We can identify environmental factors that affect the health of our patients and their families and help them seek justice within the legal system for harmful environmental exposures. Although readers may notice a well-intentioned overall bias toward “an inconvenient truth” in this issue, I hope each section incites us to explore an aspect of this relatively uncharted terrain of medical ethics: our duty as physicians “to do no harm” to the communities we serve, to our descendants, and, ultimately, to the planet Earth.

By Ceci Connolly

Washington Post Staff Writer
Thursday, June 11, 2009

When President Obama touches down today in Green Bay, Wis., he will be landing in one of the highest-value health communities in the nation, a city that by numerous measures has managed to control medical spending while steadily improving health outcomes.

"If we could make the rest of the nation practice medicine the way that Green Bay does, we would have higher quality and significantly lower costs," said Peter Orszag, the Obama administration budget chief who has emerged as a key player on health-care reform.

In his drive to rein in skyrocketing health-care costs, Obama is increasingly focused on wasteful medical care that does not extend life and may actually be harmful. Today's town-hall-style meeting, his first as president to promote health reform, is intended to spotlight one city's strategy for squeezing out waste without hurting quality.

The event, coupled with a speech to the American Medical Association on Monday, represents a fresh push by the White House to sell the public on legislation that could dramatically alter how care is given and paid for in this country.

"In the coming days and weeks as Congress moves to the issue, the president will be more active in making the public case for the urgent need to reform our health-care system," said White House spokesman Dan Pfeiffer.

What Obama is likely to hear in Green Bay is testimony to the value of digital records, physician collaboration, preventive care and transparency, say those most involved in Wisconsin's innovative approach.

"There's been a fairly steady progression of quality" in areas such as diabetes care and cancer screening, said Chris Queram, executive director of the Wisconsin Collaborative for Healthcare Quality, which publishes statewide performance measures. "Every physician believes he is doing the very best for their patients, but when they see data that their group is not practicing at the same level as across the state, it's a real positive motivator to improve."

The federal Agency for Healthcare Research and Quality gives Wisconsin high scores on 100 measures, ranging from the treatment of heart disease to childhood asthma.

But it is the findings of the Dartmouth Institute for Health Policy and Clinical Practice that have generated the most excitement in the Obama administration, all the way up to the Oval Office. For more than a decade, the New Hampshire researchers have documented and mapped wide variations in the cost and types of care given to American seniors through the Medicare program, concluding that spending more on health care has not resulted in better health.

In the final two years of a patient's life, for example, they found that Medicare spent an average of $46,412 per beneficiary nationwide, with the typical patient spending 19.6 days in the hospital, including 5.1 in the intensive-care unit. Green Bay patients cost $33,334 with 14.1 days in the hospital and just 2.1 days in the ICU, while in Miami and Los Angeles, the average cost of care exceeded $71,000, and total hospitalization was about 28 days with 12 in the ICU.

Some differences can be explained by big-city prices, acknowledged Elliott Fisher, principal investigator for the Dartmouth Atlas Project, "but the differences that are really important are due to the differences in utilization rates."

Much of the evidence suggests that the more doctors, more drugs, more tests and more therapies given to patients, the worse they fare -- and the unhappier they become, said Donald Berwick, president of the independent research group Institute of Quality Improvement.

That has been the case at Gundersen Lutheran Health System in La Crosse, Wis., which has spending patterns comparable to Green Bay's. Persuading patients to sign medical directives and using electronic medical records to alert doctors and nurses, for example, the health system has dramatically reduced the intrusive, expensive end-of-life procedures that often drive up costs but rarely stave off death for long, said chief executive Jeffrey E. Thompson.

"At the end of life, what most people want is for their wishes to be respected," not to undergo an aggressive battery of tests and treatments, he said.

Richard Cooper, professor of medicine at the University of Pennsylvania, says he thinks the variations identified by the Dartmouth researchers -- due primarily to enormous hospital expenses -- are often related to patients' socioeconomic status. States such as Wisconsin have lower medical costs because they are predominantly white and middle class, he said. The notable exception is Milwaukee, with its "poverty corridor," he said. "Nobody wants to talk about the fact that if you want to deal with health care you have to deal with poverty."

In Green Bay, health providers are partnering with employers to attack the root causes of high health-care costs, said George Kerwin, chief executive of Bellin Health System. Investments in primary care and free health assessments are beginning to pay dividends -- even for the health system's own 3,000 employees, he said. After years of double-digit insurance premium hikes, Bellin has brought the increases down to less than 3 percent a year.

In La Crosse, Thompson is using similar strategies.

"In our country we've chosen to spend a ton of money on the health-care delivery part and not much" promoting healthier lifestyles, he said. As the single largest purchaser of care, the government "could use that leverage to focus on keeping people healthy rather than lots of technology-based treatment of disease," he said.

President Obama to Speak on Health Reform at AMA Meeting

WASHINGTON, D.C. – President Barack Obama will speak at the American Medical Association’s (AMA) 158th annual meeting in Chicago next Monday, June 15, on the need for health care reform.

“President Obama has made health reform a top domestic priority, as has the AMA,” said AMA President Nancy H. Nielsen, MD. “President Obama’s speech to AMA physicians shows that he values the input of those who dedicate their lives to caring for patients. We have a historic opportunity for health-care reform this year, and the AMA is committed to improving the system so that it works better for patients and physicians. We are honored to welcome President Obama to our annual meeting, where physicians develop the policies that guide the AMA’s advocacy.”

“The AMA is actively working for health reform that covers the uninsured, makes private insurance more affordable, increases the value our nation receives from its health-care spending and enhances prevention and wellness for patients,” said Dr. Nielsen.

“To achieve the vision of health care for all, the nation must reduce the rate of growth in health care spending,” said Dr. Nielsen. “The AMA pledged to President Obama that the medical profession would reduce unnecessary costs by focusing on quality improvements, such as developing best practices for care and improving medication reconciliation.”

“In order for physicians to focus on patient care, health reform that covers the uninsured must also include permanent Medicare payment reform, antitrust relief and medical liability protections,” said Dr. Nielsen.

“President Obama’s appearance at our meeting is a wonderful opportunity for physicians to hear first-hand from him about reform efforts, and we are delighted that he will join us,” said Dr. Nielsen.

Doctors’ Group Opposes Public Insurance Plan

WASHINGTON — As the health care debate heats up, the American Medical Association is letting Congress know that it will oppose creation of a government-sponsored insurance plan, which President Obama and many other Democrats see as an essential element of legislation to remake the health care system.

The opposition, which comes as Mr. Obama prepares to address the powerful doctors’ group on Monday in Chicago, could be a major hurdle for advocates of a public insurance plan. The A.M.A., with about 250,000 members, is America’s largest physician organization.

While committed to the goal of affordable health insurance for all, the association had said in a general statement of principles that health services should be “provided through private markets, as they are currently.” It is now reacting, for the first time, to specific legislative proposals being drafted by Congress.

In the presidential campaign last year and in a letter to Congress last week, Mr. Obama called for a new “public health insurance option,” which he said would compete with private insurers and keep them honest.

Speaker Nancy Pelosi of California said Wednesday that she supported that goal. “A bill will not come out of the House without a public option,” she said Wednesday on MSNBC.

But in comments submitted to the Senate Finance Committee, the American Medical Association said: “The A.M.A. does not believe that creating a public health insurance option for non-disabled individuals under age 65 is the best way to expand health insurance coverage and lower costs. The introduction of a new public plan threatens to restrict patient choice by driving out private insurers, which currently provide coverage for nearly 70 percent of Americans.”

If private insurers are pushed out of the market, the group said, “the corresponding surge in public plan participation would likely lead to an explosion of costs that would need to be absorbed by taxpayers.”

While not the political behemoth it once was, the association probably has more influence than any other group in the health care industry. Lawmakers seek its opinion and support whenever possible. It has repeatedly persuaded Congress to cancel or postpone cuts in Medicare payments to doctors, though it has not secured a “permanent fix.”

If the doctors are too aggressive in fighting the public plan, they risk alienating Democrats whose support they need for legislation to increase their Medicare fees.

The group has historically had a strong lobbying operation, supplemented by generous campaign donations. Since the 2000 election cycle, its political action committee has contributed $9.8 million to Congressional candidates, according to data from the Federal Election Commission and the Center for Responsive Politics. Republicans got more than Democrats in the four election cycles before 2008, when 56 percent went to Democrats.

Robert Gibbs, the White House press secretary, said that in his address to the group next week, Mr. Obama would “outline the case for health care reform and make clear why we can’t afford to wait another year, or another administration, to bring down costs that are crushing families, businesses and government.”

Mr. Gibbs did not say whether Mr. Obama would discuss a public insurance plan, the most contentious issue in the debate.

The A.M.A., an umbrella group for 180 medical societies, does not speak for all doctors. One group, Physicians for a National Health Program, supports a single-payer system of insurance, in which a single public agency would pay for health services, but most care would still be delivered by private doctors and hospitals. In recent years, some doctors have become so fed up with the administrative hassles of private insurance that they are looking for alternatives.

Until now, stakeholders in the health care industry have generally muted their criticism of Democratic proposals. But as details of the legislation have emerged, the criticism has become more pointed.

America’s Health Insurance Plans, a lobby for insurers, said Tuesday that the government plan proposed by some Senate Democrats could “dismantle employer-based coverage and significantly increase costs for those who remain in private coverage.”

Under a proposal favored by many Democrats, doctors who take Medicare patients would also have to participate in the new public plan. Democrats say that requirement is needed to make sure the public plan can go into business right away with a large network of doctors.

The medical association said it “cannot support any plan design that mandates physician participation.” For one thing, it said, “many physicians and providers may not have the capability to accept the influx of new patients that could result from such a mandate.”

“In addition,” the A.M.A. said, “federal programs traditionally have never required physician or other provider participation, but rather such participation has been on a voluntary basis.”

In an interview, Dr. Nancy H. Nielsen, president of the American Medical Association, said she was delighted by Mr. Obama’s plan to address the doctors.

“Health care reform is as important to us as it is to him,” Dr. Nielsen said. “We will be engaged in discussions in a constructive way. But we absolutely oppose government control of health care decisions or mandatory physician participation in any insurance plan.”

Mr. Obama’s trip recalls a speech to the A.M.A. in Chicago on June 13, 1993, by Hillary Rodham Clinton. She proposed “a new bargain” in which the White House would limit malpractice lawsuits and free doctors from onerous rules if doctors supported her effort to overhaul the health care system.

The association agrees with Mr. Obama on some points. It says that individuals and families who can afford coverage should be required to obtain it.

Like Mr. Obama, the association wants Congress to cut payments to private Medicare Advantage plans. The White House says Medicare pays the private plans 14 percent more than it would cost the government to care for the same people in traditional Medicare.