How to identify patient dishonesty that compromises care, encourage full disclosure, and build trust
When patients get sick, they expect their doctor to make them well. They demand the best care, the latest drugs and the most advanced diagnostics available — and they seek nothing less than a total recovery. Oddly, though, it’s often the patients themselves who sabotage their own medical outcomes.
Indeed, a surprising number of patients withhold information or outright lie to their doctors for fear of being judged, an aversion to being lectured, or because they wish to present themselves in a positive light. Others do it because they want something from their doctor — like pain medication or a diagnosis that enables them to collect disability. Unfortunately, such deceit forces physicians to order unnecessary and increasingly invasive tests to diagnose the patient’s problem. Worse, it ups the odds that physicians might prescribe a medication that would react negatively with a drug the patient is already (secretly) taking.
“People might fail to disclose a serious risk factor like sexual practice or IV sharing, but the most dangerous is not being honest about what medications they are taking,” says Glen Stream, a primary-care physician with the Rockwood Clinic in Spokane, Wash. “Sometimes patients see more than one physician because they try to compartmentalize their health issues or view them to be unrelated. Perhaps they’re taking a psychiatric medication that they don’t tell you about and you’re seeing them for their blood pressure. You could prescribe something that could have a potentially fatal complication.”
A WebMD survey in 2004 found that 38 percent of patients lied or “stretched the truth” about following their doctor’s orders, while 32 percent lied about their diet or how much they exercised. Another 22 percent lied about smoking, 17 percent lied about sex, 16 percent lied about their intake of alcohol, and 12 percent lied about recreational drug use.
Younger patients — aged 25 to 34 — are more likely to lie about recreational drug use, sexual history, and smoking than patients who are 55 or older, while men are significantly more likely to lie about how much they drink than women, according to the survey.
Another study by the nonprofit California HealthCare Foundation in 2005 found that one in eight patients engaged in behavior presenting a potential risk to their health, to protect their personal privacy. That includes avoiding their regular doctor, asking their doctor to fudge a diagnosis, paying for a test because they didn’t want to submit an insurance claim, or avoiding a test altogether.
“They want to make sure they don’t shoot themselves in the foot and provide information that might keep them from getting life or health insurance,” says Stream, noting he’s even heard of two brothers who lied to their physician because one had health insurance and the other did not. “The one who didn’t have coverage claimed to be his brother — up to the point of literally having surgery,” he says. “That’s not just a trust violation. That’s fraud.”
How do you know?
There is no sure-fire way to know if your patients are lying, of course, but there are tools you can use to determine whether they might be holding back. The first is gut instinct. “When you ask them a question like, ‘Are you exercising?’ and they wait awhile before they answer I know they may not be telling the truth,” says Fred Ralston, an internal medicine specialist with Fayetteville Medical Associates in Fayetteville, Tenn., and president of the American College of Physicians. “If they’re exercising 45 minutes a day 5 days a week they’re going to tell you immediately.”
Though some suggest “guilty” body language — avoiding eye contact, fidgeting, and nodding dutifully in agreement — is a powerful indicator that a patient may be lying, Jeffrey Knuppel, a correctional psychiatrist who treats prison inmates, says nonverbal cues are unreliable at best. “People make a lot of assumptions that it takes more effort to lie than to tell the truth or that people get nervous when they lie but that’s actually wrong,” he says. “For some people, lying comes naturally. It’s the truth that may cause them more anxiety.”
When asking patients to answer health-related questions, he adds, you should always consider the patient’s motivation. “It’s good to develop a healthy skepticism — not to become cynical, but to think about their responses in terms of what might be at stake for this patient,” says Knuppel, who is also an assistant professor of psychiatry at the University of Wisconsin School of Medicine and Public Health. “What might this person gain or lose from their encounter with the healthcare system. Is it pride, disability payments, medication?” If someone’s disability payments are about to run out, he notes, “that’s probably relevant.” Likewise, if your patient indicates that they recently lost their job, financial uncertainty might explain why they’re not refilling their prescriptions.
You should also factor in your geographic location. “I’m in Spokane, Washington, which tends to be a politically conservative part of the country, and it’s the kind of place where you might be more likely to see patients and practitioners with a value and perspective mismatch,” says Stream. “For instance, women might be less likely to share that they’ve had a termination of pregnancy in the past for fear of being judged.”
It’s easier to read your patients, of course, if you’ve treated them for many years. Specialists, who see their patients only a handful of times, have a harder time with this than family doctors. “I’ve had patients who I’ve seen for 25 years and if they’re not being totally truthful I know them well enough, like my family members, to hear a change in their tone of voice or their expression,” says Stream. “It’s more challenging if it’s the first or second time I’ve seen them.”
Ultimately, though, lab tests are the most telling. If you’re prescribing a medicine that should be working but isn’t, it’s time to ask your patient point blank if they’re following their treatment protocol. Probe deeper, too, of course, for any other underlying causes for their continued symptoms. “When it appears from worsening clinical results (blood pressure, lab tests, etc.) that someone is not taking medicine or not doing something else which is felt to be necessary then it is usually important to confront them and ask if they are sure they are taking the medication,” says Ralston. “At that point, they will either admit to not taking the medication or remain quiet but improve at their next visit — having clearly gotten the message.”
For his part, Ralston says he uses an informal point system to ferret out the truth. “If your blood sugar is out of control, your weight is up, your blood pressure is up and you’re telling me that you’re doing all this exercise then I take that with a grain of salt,” he says, noting he continues to question such patients without casting judgment. “I tell them this isn’t about making me happy. It’s about making them healthy. And I tell them that if something bad happens I’m going to be sad, but it’s going to affect them more than me.”
With the aging population, he adds, physicians should also be sensitive to the fact that a larger percentage of patients may be struggling with memory lapses. “They really don’t know they’re not telling the truth,” he says. “Have them bring their bottles into the office. If it’s full three weeks later and it’s a four-week prescription, you need to get their family members involved. Have someone come with them to the visits.”
Another effective tool? Review medical histories before seeing your patients. “It pays to do your homework before you see someone,” says Knuppel. “The more you can review records beforehand the more likely you are to spot inconsistencies [with what your patients tell you.]” For new patients, or those you suspect may be trying to mislead, it’s useful to request copies of their medical records from other hospitals or clinics. “If they will allow me as their doctor to get copies of their medical records that’s very reassuring to me,” says Knuppel. “It still doesn’t mean they’re not lying, but the records themselves can help clarify their medical history and that increases the trust factor.”
Tell them the consequences
When the stakes are high and noncompliance or deceit could be life threatening, it’s time to play hardball. Let them know that if their current treatment plan fails, your next step will be more aggressive (and perhaps unnecessary) treatment that could include surgery or higher strength medication that might create other problems. “It helps to frame the discussion in the context of what they’re going to miss out on in their life if they don’t take care of their health,” says Stream. “If I’m talking to an older diabetic patient, I’ll explain that if they take their medication they’re less likely to have a stroke or kidney failure or lose their vision. If I’m talking to a 35-year old diabetic, who may think he’s invincible, I’ll tell him there’s a chance he might not see his kids graduate from high school, or get the chance to know his grandchildren if he doesn’t take care of himself.”
Likewise, Ralston reminds at-risk patients who clearly aren’t following his directive how they can benefit from preventive measures. “A 40-something patient who is on medication for blood pressure or cholesterol, but has never had a heart attack or stroke, might not see the need to take their medication daily,” he says. “At times, I may seem doom and gloom, but I also see people on the other side of that ledge and it changed their lives, so I try to get my patients to take it more seriously.”
Those who request pain medication, which can be highly addictive, are perhaps the biggest challenge for physicians. If you suspect your patient is being untruthful about his condition or use of the drug, you might consider getting him to agree to random blood tests before filling a new prescription. “If the test shows the patient is not taking her medication I’ll confront her,” says Stream. “Occasionally, people will admit that they’re giving the medicine to another family member because that person didn’t have insurance, or they fess up and admit that they’re selling it because they need the money.”
Before issuing a prescription, you can also ask your patients to sign a contract that states they will follow your treatment plan and not seek out similar drugs from other healthcare providers. “If a patient is abusing prescription medication and not following a logical, coherent treatment plan, get him to agree to see only one doctor or terminate the relationship,” says Ralston, noting most states and insurance companies maintain a prescription database for healthcare providers that tells them what other medications a patient has been prescribed.
While patients who mislead may be difficult to treat, Stream says it’s important to remember that trust is a two-way street. “The physician owns significant responsibility for establishing trust in the relationship and should never feel that patients should blindly follow his advice,” he says. “We’re asking patients to share things about their history that are potentially embarrassing.”
At the first patient encounter, he suggests, introduce yourself, shake hands with the patient, look him in the eye and try to establish a personal connection. If he has an accent, break the ice by asking where he’s originally from. Inquire as to what kind of work he does and if the reason for his visit is sensitive, make an effort to put him at ease. “If a patient is obviously having a hard time sharing something, or says, ‘OK, this is embarrassing,’ I tell them that I appreciate their sharing because I know people sometimes feel they might be judged for the decisions they’ve made, but that it’s important that they’re completely honest with me,” says Stream. In the interest of getting patients to speak freely, he also emphasizes confidentiality. “Patients sometimes hesitate to share because they don’t know where that information is going to go,” he says. “They’re not always aware of doctor-patient confidentiality so I’m very clear about what their rights are. That furthers the trust relationship so next time they’ll know this is a safe environment.”
Patients often act as their own worst enemy in getting their health concerns resolved — keeping information from their providers that they believe to be too personal, insignificant, or damaging to their cause. As a physician, you can treat those patients most effectively by weighing their responses against clinical results, considering any hidden agenda, and fostering an open, honest relationship. “One of the things you really cherish with your patients is the process of developing a trust relationship,” says Stream. “Patients know they need to trust their physicians, but they don’t often think about how their physician has to have trust in them, too, that they’re being truthful and doing their best to follow medical advice.”
Patients lie for fear of being judged, to please their doctor or because they want something from you. Consider these tips to encourage full disclosure and ferret out dishonesty:
• If clinical results belie what your patient tells you, confront them — but don’t be judgmental.
• Consider what they have to gain or lose from the encounter.
• Explain the consequences of failing to follow your advice, or misleading you about their condition.
• Establish trust in the relationship by making a personal connection and stressing confidentiality.
By Shelly K. Schwartz
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