Saturday, January 14, 2012

Patients' Denials, Lies, and Forgetfulness

     This blog is not intended to be critical of patients, but to point out the various ways in which patients mislead their doctors, either consciously or subconsciously. Lawyers have told me that they  have a similar problem in that many of their clients do not tell them all the facts of the case. The people who lie the least to doctors are the parents of sick children (barring Munchausen by proxy or child abuse). I always tell my students and interns before I examine a new ward admission in front of them  not to feel surprised or embarrassed if I elicit different answers to the same questions that they asked. The patient may have been under more stress, or heard the question differently, or the spouse was present, or I phrased it differently, or they  are no longer as anxious as they were in the ER, or feel better, or didn't like the admitting doctor, or trust me more  because I am the same sex or the opposite sex or the same race or the same age or older or taller or they like my smile better or my voice better or whatever. There is also a psychological transference that takes place subconsciously in that the patient will, to a greater or lesser degree, involuntarily relate to me in a manner similar to his/her relationships with  previous authority figures such as doctors, parents, teachers, supervisors at work, ministers, spouse, older siblings, or whoever, and in addition  the admitting intern may have reminded the patient of someone the patient disliked intensely or had a negative interaction with.

     Many "lies" are memory lapses or a misinterpretation/misprocessing of the question. For instance, some men may  recall that they had a hernia operation as a child, but forget on which side. I myself broke my fifth metatarsal when I was 14 years old playing football, and I think  but am  not absolutely sure that it was on the right side. OTOH  I am certain  that I had a greenstick fracture of my right forearm because I vividly recall my inability to twirl spaghetti on my fork with my left hand when my right arm was in a sling. Many patients know that one eye is weaker than the other, but never remember which one, and often do not recall that their eyeglasses also correct for  their astigmatism, or if they were ever tested for color-blindness.

     A patient will answer "none" when asked if he/she had any operations, and then when you ask about a surgical scar on their abdomen they will say "Oh, I forgot". A female patient will answer "no" when asked if she takes any prescription medicine, but then answer "yes" when asked if she takes birth control pills, because  she associates medicine with treatment of an illness, and not the prevention of pregnancy. Patients will tell you they had open heart surgery as a child but have absolutely no recollection of what sort of surgery it was, or what condition it treated. Very few patients travel with a complete list of their medicines and their dosages,
and virtually no one recalls the date of their last tetanus shot, or if they ever had a skin test for tuberculosis unless the test was mandated because of work.

     Patients want to appear to be healthy and moral to their doctor, and this is where deliberate misconceptions come into play. They tend to minimize or forget to mention actions that they think the doctor will consider immature or unwise or immoral, not realizing that we have probably heard it all before. A wise and good family doctor will not appear to be a censuring moralist, lest the patient suppress uncomfortable truths. It is sometimes helpful to tell the patient  (and mean it) that you will not write down anything the patient does not want you to record in the medical chart for all the world (including the internet, the spouse, the employer and the medical insurance company) to see. I always do this----I keep a separate list of the patient's true medical problems that are not in the chart---(has a lover, had an abortion, uses cocaine) and I forward this information only verbally to the next treating doctor.

     Men deny many more symptoms than do women. The only symptom that I have seen to cause a man to come running to his doctor is when he urinates or ejaculates blood. Any other symptom, including rectal bleeding, coughing up blood, or chest pain usually has to recur at least two to three times before the doctor is notified (unless the wife is aware of the symptom). Patients who take their own blood pressure or measure their own blood sugar level at home usually do so two to four times at a single sitting, and write down the best numbers to give to the doctor at the next visit.

     As a final note, you can take it for granted that if the wife accompanies her husband into your consulting room and listens as you obtain his medical history, he will rarely tell you the whole truth. He will only tell you symptoms and worries that (a) he is willing to have evaluated, and that (b) he does not mind  his wife telling him what to do about. If the wife mentions a symptom, the husband usually promptly minimizes it. And if you interview the husband alone and the wife later calls you to ask you what you told the patient to do about his chest pain/erectile dysfunction/cigarette smoking/shortness of breath/overweight,  you are ethically bound to answer that you discussed the problem fully with your patient and that she is free to ask him about your answers, even if she has told  you of a symptom that the patient did not mention to you. It is a general observation of mine that wives worry more and show a greater concern about their husbands' health than the husbands themselves do. This seems to be a gender issue, in that husbands often do not want to have symptoms investigated if they think (a) they will not like the result or (b) they will not like the suggested intervention and treatment. I share space with a sleep-study lab, and I cannot begin to tell you how many men, when they come back to discuss their positive results, emphatically state that "If I had known that I would have to wear this d**mned mask every night, I would never have taken the d**mned test!".


1 comment:

  1. The above illustrates one problem with electronic medical records. There is no absolute guarantee that these records will be kept secret. We always read of medical record workers losing unencrypted CD's of patients' medical records in taxicabs, etc. If you were a bisexual, cocaine using AIDS patient, would you trust these very personal secrets to the security of the internet? The penalty to whoever enabled these records to be made public could never make up for the social and psychic discomfort that the release of such information about you would cause.