When your patient lies

People don't tell the truth about their health for a variety of reasons—some of which could have dangerous repercussions.

By Patricia L. Elliott, MD
General Practitioner/Rapidan, VA

Recently, one of my regular patients appeared in the office without an appointment. Her toddler had been suffering from an upper respiratory illness for a week. Why she had waited so long and then popped in out of the blue was a mystery.

"Why didn't you call first?" my secretary asked.

"I wasn't at home and didn't have access to a phone," the woman replied. That answer might have been credible if (1) the toddler had suddenly taken ill, and (2) the woman weren't holding a cell phone as she said it. When my secretary mentioned the latter, the woman was unfazed: "There's only a minute of time left in it," she responded.

My secretary, bless her, kept her composure, and I saw the baby. I'd like to say this was an unusual incident, but this woman habitually lies to us. And, alas, she's not alone. Hardly a day passes when a patient doesn't tell me a lie that could have serious—even dangerous—consequences.

As a result of the sheer volume of the lies I hear, I've developed a finely honed instinct for when something sounds fishy. Here are some common situations that arouse my suspicion.

The patient tries to disguise his real problem. Ralph, 38, said he was "hyper" and unable to work as a security guard due to high blood pressure. I suspected him of being an alcoholic, which he denied. Could I prescribe something for his "nerves"? I wrote him a script for a month's supply of antianxiety medication. A week later, he was back for more.

I refused and ordered some blood work on him. When his liver tests came back abnormal, I phoned his home. His mother answered. He lived with her. "Is he alcoholic?" I asked. She acknowledged that he was, adding that she was very concerned about her son.

When Ralph next appears in my office, I'll treat him differently. I once saw a book with the title The Opposite of Everything Is True: Reflections on Denial in Alcoholic Families. That's it in a nutshell: Problem drinkers tend to be chronic liars. Doctors who appreciate this will be much more helpful to their alcoholic patients.

The patient is in denial about his symptoms. George, 47, had central chest pain for several days before finally admitting it to his wife—who sent him straight to me. But what did he tell me? "Oh, I feel a little tired and have a cold." If his wife hadn't phoned ahead, I'd have had to be psychic to know about his chest pain. After testing him, I found that his pain was the result of a compression fracture of a vertebra from a recent fall. He was lucky. Lying about his symptoms could have cost him his life if he'd been suffering a heart attack.

The same can be said of Ruby, 60, who appeared for her annual physical. I commented on her heavy, purulent vaginal discharge, which she hadn't mentioned when I asked if there was anything wrong. Now she looked scared. "Why didn't you say something?" I asked. Her response was that her husband would have been "so upset." Her real fear was that she had cancer. Her loopy logic: If she said nothing, maybe I wouldn't notice and the problem would just go away.

In the patient's family, lying is routine. Sadly, pathological lying among family members as a relational style is all too common. Recently my secretary called a teenage patient to see why she had missed her appointment. The girl's mother answered the phone and started to make a rote excuse. Then, exasperated, she said, "Just a minute," and without even bothering to put her hand over the mouthpiece, called to her daughter, "Mary, Dr. Elliott's office is on the phone. Come down here and make your own excuse for why you didn't keep your appointment."

The patient embellishes the truth. After an automobile accident, Nancy, 28, came to my office with a whiplash injury. "It was awful," she told me, savoring the gory details. "You should see my car. Glass everywhere, steering wheel bent, front end crumpled. The state trooper said it was the worst wreck he'd ever seen. It's a miracle I'm alive. But my neck hurts so much." Almost theatrically, she began to groan and grimace—as if inviting me to play a role in a drama she was scripting on the spot.

On succeeding visits, the accident got worse—and so did Nancy's pain. By then, she had retained a lawyer, was seeing a physical therapist, and seemed to have acquired an expert's knowledge of what symptoms and problems would win a big judgment in court. In cases like these, determining what to treat and how to treat it is an exercise in guesswork.

The patient attempts to manipulate the doctor. Classic lower back pain can, of course, be a legitimate ailment. Yet when a patient presents with it, experience has taught me to be suspicious. For instance, Barbara, 30, said she had been thrown from a horse and severely injured her back. At first, I believed her, but the melodramatic way she told her story set off a little warning bell in my mind. I gave Barbara a few of the pain pills she requested and scheduled an X-ray.

Two days later, a pharmacist phoned the office. Barbara claimed to have accidentally dropped most of the pills I'd given her down the toilet, and she was seeking a refill. The pharmacist told me that Barbara's boyfriend was addicted to narcotics. It was likely that he was sending Barbara out to scam drugs from us. Why was I not surprised?

The patient won't admit to any wrongdoing. Quite a few of my patients, to hear them tell it, are medical mysteries. I get pregnant virgins, for example. And I get spaced-out kids who swear they don't do drugs. I recently had a male patient who looked inebriated and smelled like a brewery. "I don't drink," he swore. Yeah, right.

The patient lies to avoid the doctor's criticisms. Some patients are loath to tell me about tests and treatments prescribed by other doctors, how long they've experienced symptoms, or any home remedies they've tried. They fear I'll be critical, call them stupid, or tell them they're now in deep trouble. This subverts my efforts to help.

Ray, 41, had high blood pressure. "Do you take any homeopathic remedies?" I asked. He said No. I waited for him to say more. "Well, just some Chinese herbs," he confessed. When he stopped using the ephedrine-like herbs, his blood pressure returned to normal.

George's extremely congested nose was impervious to my ministrations, until the 17-year-old's mother told me that he used an over-the-counter nasal spray several times a day. George neglected to tell me about it, because he was afraid I would object. I did, he stopped, and the medications I prescribed began to work.

The patient lies about a previous doctor's care. Perhaps to avoid explaining why they've switched physicians, many patients don't tell me that the condition they've come to see me about has been treated previously, or they blithely claim it's never been treated before.

Lynn, 25, did the latter. When I prescribed medication, however, she blurted out, "Another doctor gave that to me, but it made me sick." There was more: "And I've already had that test you want to order." It gives you a leg up, of course, to know what's already been done, but some patients think you'll be upset that they didn't come to you first.

When you suspect a patient of lying

You need to be on the lookout for prevaricators, and to trust your instincts, the author of the accompanying article advises. When you catch a patient in a lie:

• Be amused, bemused, or irate privately, not in front of the patient. It may only encourage him or her to lie again.

• Try to remain emotionally neutral when you explain to the patient that you can't do your best without full cooperation.

• People who tell lies tend to do so habitually. So when a patient lies to you, make a mental note of it. In the future, when you update this patient's history, remember that he or she may not be telling you the whole truth.

• If you think it may help, comment on the lie nonjudgmentally. For example: "You're aware that other members of your family have told me you have a drinking problem. What you choose to do about it is up to you. But when you come here, I need you to be straight with me. I can't care for you properly without your help."

• It may be necessary to confront an untruthful patient. But do it in the spirit of helping, not venting your spleen. Don't demean the patient or call him names. But don't pussyfoot around, either. Explain why telling the truth is important in a doctor-patient relationship. Then hope for the best.

 

Patricia Elliott. When your patient lies. Medical Economics 2002;3:95.