Practice Partner

Encouraging Candour

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Illustration of someone in a hospital gown, looking at them from behind where they're hiding crossed fingers
Illustration: Sandy Nichols

When patients aren’t forthcoming, it can affect their care

Doc Talk by Stuart Foxman

Of all the equipment that could assess what’s going on with patients, this might sometimes uncover the most: a lie detector. Patients aren’t always candid and forthcoming with their doctors. A study led by the University of Utah showed just how often.

Researchers conducted a pair of online surveys, asking 4,500 participants about scenarios where they might withhold medically-relevant information from their doctor. More than 80% of respondents in one survey (average age: 36) and 60% in the other (average age: 61) had been less than forthright with their doctor. The study was published in the Journal of the American Medical Association.

The results don’t shock Dr. Brian Goldman, an ER physician at Mount Sinai Hospital in Toronto. He says this is a case where the doctor-patient relationship mirrors the relationships that people have with friends, family, colleagues or anyone else.

“There are people you reveal yourself to completely, and people you reveal yourself to in bits and pieces,” says Dr. Goldman, who hosts CBC Radio’s White Coat, Black Art. “We make the mistake of assuming that the doctor-patient relationship is a completely open book. That’s not realistic,” he said.

The kinds of fibs that patients tell vary. As Dr. Goldman notes, they can range from lies of commission, i.e. telling a falsehood, to lies of omission. The University of Utah study and other research points to things like:

  • Exaggerating their exercise and/or diet habits.
  • Downplaying unhealthy habits.
  • Not revealing a health care concern, or risky behaviour.
  • Feigning understanding or agreement with the doctor’s instructions.
  • Not sharing information about all their medications or other care they’re getting.
  • Not taking medications as directed, or taking someone else’s prescription.

“There’s actively telling something that’s not the truth, no question, and then there’s failing to reveal yourself,” says Dr. Goldman.

Yet doctors, like patients, can fudge and dodge out of self-protection too. It happens, for instance, if you fail to admit that you don’t have the answer

Patients usually have their reasons for both types of lies. Sometimes they’re worried or in denial (“If I don’t bring up this symptom, then nothing is wrong with me”). Other times they’re embarrassed by the truth. Or find the truth painful.

In still other instances, patients can be disappointed in themselves, and want their doctor to think highly of them. They might also feel that their doctor will judge or lecture. Patients might pretend to agree with the doctor, or say what they think the doctor wants to hear, just to avoid a confrontation.

At times, patients aren’t totally honest because they feel rushed. Maybe the doctor hasn’t given them the proper opening, or probed in a way that draws out health concerns.

Many patients can also be selectively candid, talking about some aspect of their health with one type of care provider but not another. That’s their choice.

As Dr. Goldman notes, doctors themselves might not always be fully honest with their own physicians. For instance, he says that many doctors are reluctant to share their mental health challenges, feeling that they can cope or worried about where that revelation might lead. Which any patient might feel too.

When patients aren’t always forthcoming about their conditions, concerns, habits, etc., it can of course affect the quality of care they receive. Doctors don’t have the full picture.

Dr. Goldman says that physicians can waste a lot of time in pursuing a diagnosis when patients conceal a significant part of their health.

And if a longer-term relationship with a doctor is filled with lies (whatever the justification), there are other repercussions. “If it’s largely based on deception, the relationship will falter or die by attrition,” says Dr. Goldman.

It can be hard to get patients — or anyone — to tell the truth, the whole truth and nothing but the truth 100% of the time. Maybe the goal should simply be to make it a little easier to do so most of the time.

To set the stage for fuller and more frank discussions, start by recognizing how frequently patients could withhold information. Remind patients that it’s normal to be hesitant to share. Reassure them that they’ll never be shamed.

Think too about how you might encourage or (inadvertently) discourage honesty. Does your language or demeanour help patients to be comfortable and open? Do you seem present or distracted? Do you create a culture of shared decision-making?

Sometimes, just asking questions in a different way can elicit the truth. Dr. Goldman gives the example of alcohol consumption.

He says, “If you ask someone if they’re an alcoholic, they’ll say no. If you ask if they have an alcohol problem, they’ll say no. If you ask how many drinks they have a week, they’ll tell you, because they feel it’s normal behaviour. You can also ask questions like ‘Does anyone in your circle say you should cut down on your alcohol?’ If you show you’re interested, people will give you the answer.”

Perhaps not all the time. But don’t expect all or nothing. As one article on this topic noted, truth-telling is a process, not an outcome.

Being honest with patients

That goes both ways. Doctors, too, should be honest with their patients.

As in any interpersonal encounters, there can be lapses. One U.S. survey found that 55% of doctors in the past year had been more positive about a patient’s prognosis than the medical history warranted.

Maybe this sort of thing is seen as white lie, intended to spare the patient anxiety, or to offer hope. Similarly, a doctor might choose to not share, or to underplay, slightly abnormal test results that really have no bearing on the patient’s health.

Yet doctors, like patients, can fudge and dodge out of self-protection too. It happens, for instance, if you fail to admit that you don’t have the answer, or if you don’t reveal an error (especially if there were no consequences). The motives can be similar to the ones driving a patient’s lies of omission.

“As a group, doctors are more pejorative about lying when it’s on the part of their patients,” says Dr. Goldman. “But they’ll have professional and personal reasons for shading the truth. Instead of saying ‘I don’t know, it’s not my area of expertise’, we’ll sometimes make something up. That’s because we feel a certain sense of inadequacy.”

That’s not a critique. It’s just human. Yes, the more open the relationship, the more productive. However, people aren’t always honest when they communicate.

Don’t get hung up on lies, but focus on the thinking and emotions behind them, advises Dr. Goldman. People lie out of fear, to avoid unpleasantness, because of shame, and for a host of other routine and perfectly understandable reasons.

The patient who says everything is fine, and doesn’t want to come forward to reveal he has a mole on his back? Maybe, says Dr. Goldman, it’s because he has a family history of melanoma and is terrified – of a diagnosis, or losing control over his life, or of dying. “It snowballs, and it’s understandable that somebody might want to avoid that,” he says.

By all means, work to create a culture of honesty. But something more is needed. The last book Dr. Goldman wrote is called The Power of Kindness, about the role of empathy. That’s what it comes down to if you want a relationship of trust. “There’s an obligation to empathize with the patient,” Dr. Goldman says, “and to wonder how difficult it is to be that person, at that moment, and be as truthful as possible.”