In a previous column (“When Patients Lie (Bribe or Flatter),” October 1, 2015), I discussed the problem of patients lying to doctors and the many reasons why this can happen. Patients may wish that their medical history “looks healthier” or appears more disciplined than it actually is, such as with exercise. They may exaggerate symptoms to get an appointment or MRI sooner. And of course, there is the secondary gain inherent in personal injury cases. But the truthfulness of the doctor is just as important in the doctor-patient relationship. What are the reasons why a doctor would lie to his patients?
John Palmieri, MD, discussed this topic in a Article from 2009 In The Primary Care Companion At Journal of Clinical Psychiatry. He notes that doctors often downplay problems, fail to tell the whole truth, or resort to oversimplified explanations. Two examples of potential omissions are breaking bad news and admitting mistakes.
Bad news and mistakes
Many studies have examined why it is so difficult for providers to break bad news to a patient. Doctors sometimes downplay negative information or mislead patients by being overly optimistic, when the truth is very serious and sobering. No doctor wants to say, “Get your affairs in order,” which is an old-fashioned way of saying, “There’s nothing more we can do, you’re going to die.”
Nowhere is this practice more common than in Japan. In Japan, doctors have strong authority in the culture, and a patient who asks too many questions is often considered rude. As a result, bad health news is often distorted, omitted, or obscured by the doctor. If a grandmother is suffering from terminal cancer, for example, it is usually the doctor who breaks the bad news to the family, not the patient. Then the family can decide whether to tell Grandma the truth.
In Japan, practitioners often believe that they do not want to confuse patients, cause unnecessary emotional suffering, or eliminate hope. But a survey conducted by Miyako et al. BMC medical ethics showed that 86 percent of Japanese respondents said they would prefer full and truthful disclosure in such cases.
The second and most concerning omission of health care providers is the admission of errors by health care providers. Lisa Iezzoni, MD, et al., conducted an oft-cited investigation in a 2012 study Health Affairs article, asking doctors under what circumstances they would lie to patients. Nearly 1,900 doctors were surveyed; one in 20 people admitted to telling a “lie” to a patient in the past year. Two in ten people said they anticipated having to hide medical errors from patients in the future. In the case of a very serious medical error, a full third of those surveyed admitted that they would try to cover up or downplay the importance of the error.
When the doctors Need lie?
Sandeep Jauhar, MD, wrote a opinion column In The New York Times, February 22, 2014, entitled “When doctors have to lie”. It tells the story of a 22-year-old man who needed a heart transplant, but even that might not save his life. The young man’s father begged the doctor not to tell his son the bad news, but rather to tell him that everything would be fine as long as he followed the doctor’s instructions. Dr. Jauhar did just that, taking the next few days to help the patient understand his true, unfortunate condition.
Dr. Jauhar then explains in his opinion piece why he continues to believe it was the right thing to do. He adopted a “paternalistic” approach. The paternalism of the “healer” against the autonomy of the patient is not a new tension between doctor and patient. This is at the heart of a therapeutic relationship. At one end of the spectrum, the doctor might say, “Trust me, I know what’s best for you.” On the other end of the line, he might say, “Let me know what you want and I’ll do my best to make it happen.” »
On the one hand, the doctor attempts to eliminate or reduce the decision-making power of an adult, and on the other hand, he or she is hired to provide only a service, without any conflicting advice. On the one hand, it could be a five-level spinal fusion, and on the other, a “new nose” from the plastic surgeon.
Lying while promising cures
Providing unnecessary services to generate more revenue happens in health care as it does in auto maintenance. It exists and there is little need to discuss it at length. But what bothers me just as much is promising to cure the patient, when the probability is low or unknown.
This is not unique to any healing art, but I am particularly appalled to witness it in the context of chiropractic. What research does a DC rely on to tell a patient that he will need 150 visits over a year to correct his condition? A chiropractor cannot actually lie to a patient when a lengthy or questionable treatment plan is proposed, as the DC may hope the patient responds favorably. But reliance on evasion or omission may be in play to sell the plan.
What happened to “patient-centered” care?
Patients and doctors lying to each other may not be as common as this discussion suggests, but the topic deserves more in-depth and respectful study. The term patient-centered was used by the Institute of Medicine in 2001 as an essential element of a high-quality health system; the “true North” which should guide all health reform. This was 15 years ago, and it seems unlikely that the patient would have moved further towards the “center” of this reform.
Meanwhile, healthcare provider “paternalism” now appears to be increasingly shared, and perhaps controlled, by corporate payer/provider bureaucrats in liaison with government.
As patient and physician information becomes more public and easily accessible, obfuscation of the therapeutic relationship will become more problematic. Despite the best guarantees, anyone can now know almost anything about anyone. Social media can unfairly demonize a doctor or embarrass a patient.
But will our best health system be that of patients without secrets and doctors without power? We may long for the good old days of “white lies” and awkward conversations between providers and patients.
