The patient-clinician relationship is predicated on trust. Ideally, the clinician trusts that the patient is telling the truth about their condition, symptoms, and behaviors. To be optimally helpful, the clinician needs the information to be as accurate as possible.
However, a growing body of research suggests that this is not always the case and that many patients are not always transparent with their clinicians about critical information.1 Some research suggests that as many as 60% to 80% of Americans may not be forthcoming with their clinicians about information that could impact their health.1 Many also remain silent when they disagree with their clinician’s advice, do not disclose that they don’t understand treatment instructions, or that they have an unhealthy diet or don’t exercise.1
A recent survey of over 3000 US adults conducted by USA Rx corroborated that a significant number of Americans lie to their clinicians.2 The survey found that less than half (42%) of respondents have never lied to their clinician for any reason, while 58% acknowledged lying or concealing information. Mental health, exercise frequency, and alcohol consumption were the top 3 topics that respondents reported lying about most often. Other topics included diet, drug use, sexual activity, and smoking.
Disturbingly, the degree of comfort when talking to clinicians declined by generation, with 69% of “Baby Boomers” saying they felt “comfortable” talking to their clinicians, followed by 59.1% of respondents in “Gen-X,” 52.4% of Millennials, and only 51.8% of those in “Gen-Z.” There were also regional differences in the percentages of patients who reported lying to their clinicians, from 58% in Minnesota to 86% in South Carolina.
The most common reasons cited by respondents as to why they lie to their clinician were embarrassment, fear of judgment, and to avoid lectures (40.4%, 33.8%, and 32.5%, respectively).
To shed further light on these findings and their take-home messages for practicing clinicians, we spoke to Teresa Lovins, MD, a primary care clinician based in Columbus, Indiana. Dr Lovins’ practice is called Lovin My Health DPC. She is on the board of directors of the American Academy of Family Physicians (AAFP).
Were you surprised by the number of patients who report lying to their clinicians?
I wasn’t completely surprised. Especially when there’s a new patient, I always have on my radar the possibility that the patient isn’t being fully up front with me. After all, I don’t have much experience with that person and have not yet created a nice relationship with them. The patient likely wants to put his or her “best foot forward” and may not tell me the whole story.
I also wasn’t surprised by the topics that patients tended to be less-than-transparent about. I remember that in training, I was told to assume that whenever a patient was asked about alcohol use and provided a certain amount that he or she consumed, I should assume that it was probably twice that amount. But I also was taught to regard this as the patient underestimating alcohol use rather than deliberately lying. The same can be said for the other areas, such as drug use, sexual activity, or exercise amount and frequency. I think that sometimes patients do underestimate their use of a substance or overestimate the amount of time they spend exercising. However, there are other times when they might conceal the truth for a variety of reasons.
What are the reasons, in your experience, that people might conceal the truth from their clinicians?
The reasons are the ones cited in the survey. Many patients are embarrassed about their lifestyle choices, and many are afraid of being lectured or judged. But I’ve discovered that as my relationship with the patient builds and I get to know the patient better, I get closer to the actual truth. I create an atmosphere of safety and patients don’t feel judged.
In direct primary care, I have the luxury of a little more time to build rapport with patients and explore issues, compared to my colleagues who are in more traditional, typical practice settings, and so the patient has more opportunity to get out the information they want to, and I have more opportunity to ask the questions I need to ask. In more typical settings, the rapid in-and-out nature of patient visits creates more compression and pressure, where there is less time to explore what really might be going on for the patient.
In those settings, I advise communicating nonjudgmentalism and acceptance to patients through tone, demeanor, and wording of the questions so as to invite them to open up to and, when they do so, continue to communicate that acceptance, even when discussing subjects such as exercising more or eating less sugar, for example.
And when you’re taking a social history of the patient in that short visit, try not to gloss over questions about lifestyle, smoking, exercise, alcohol use, because of feeling rushed. Patients often sense that the clinician wants to get down to the “meat of the visit” and may think, “Oh, the doctor doesn’t want that information. Let’s just give her the answer she wants and move on.”
The survey found mental health to be an area that patients most frequently conceal from their providers. What are your perspectives on this?
I think that, despite positive changes in this direction, mental health struggles are still associated with stigma and many people don’t want to open up about them. I actually share some personal tidbits of my own to help patients feel more comfortable. I have told patients that I had issues with postpartum depression and that I understand the feeling of crying about things that don’t ordinarily elicit tears. I have told patients that I take medication for depression and that, when I am on my medications and feeling well, having my 4 dogs run through the house doesn’t bother me. But if my medications aren’t working, I become very irritable and the same 4 dogs drive me up the wall. I know that I can’t always control how I feel. Opening up to patients about my own experiences normalizes what they’re going through and invites them to open up as well.
I find that younger people are sometimes less articulate about what they’re experiencing, perhaps because they’re accustomed to using their computers or phones and don’t always know how to verbally express their discomforts,especially to someone older, such as myself. And teenagers tend to not be very forthcoming in general. It is sometimes like pulling teeth to elicit information or get an adolescent to open up. “Boomers” often open up to me more readily because I am in their age group. Nevertheless, putting people of all ages at ease and engaging in occasional personal sharing can pave the way for more open communication about physical and mental health issues.
What do you think might account for the variation between states, in terms of how many patients report lying to their clinicians?
My initial thoughts about why certain states have different levels of lies relates to several factors. One is what is the predominant generation in that state. From the data, the Baby Boomers were more comfortable with their clinician, so by result were less likely to lie to them. It would be nice to correlate the state report with which generation is the predominant generation in that state.
The other factor that may affect the state differences may be the age of the clinician in that state. When the patient and the clinician are at similar ages, the comfortable feeling is higher and more likely to have less lying. Looking at the age demographics of the clinicians may help see the difference in the state responses. The difference may even be simply in the personalities of the population in the states. I am not really sure what would cause some of the differences, but it is an interesting finding for me. I happen to work in a state with patients less likely to lie to their clinician. I am glad about that.
Are there other areas not covered in the survey in which patients are not transparent with their clinicians?
Some patients do not report their use of complementary/alternative modalities to clinicians. In general, I think there is a disconnect between the allopathic medicine that I practice and integrative medicine, in which clinicians prescribe or recommend supplements. But even in integrative practices and certainly in more conventional practices, many patients do not inform their providers that they are using supplements or alternative treatments. And unfortunately, on the “medical history” forms or during the clinical visit, many practitioners do not ask patients about their use of alternative treatments. This conveys the message that these therapies aren’t important enough to ask about, so it doesn’t necessarily occur to the patient to bring it up.
I always ask patients to bring every bottle of pills that they are taking. Sometimes they are taking 14 supplements but don’t recognize that these can have medicinal effects or can interfere with prescription therapies. If we don’t ask them about what they’re taking, they won’t think to let us know.
Some patients are reluctant to disclose their use of supplements because they are afraid of criticism. Here again, I think that the more open you are about listening to patients, the more they will open up to you. I say, “I want to know everything about what you’re taking into your body so we can decide what you do and don’t want to continue.” And if they’re taking a supplement, I ask whether a practitioner prescribed it and why, and what the supplement is meant to accomplish. I then tell them that I will be happy to look into the product to see whether it is compatible with the treatments I am prescribing. I say, “I want to learn as well and I’m always happy to learn something new.”
Another area of concern is exaggerating pain symptoms because the patient would like to receive an opioid prescription. If a patient is coming in with a complaint of pain, I check the registry of controlled substances to see if the data in the registry matches the medications they claim to be taking. I also see if the pain described by the patient matches the injury or condition. I think every clinician has a “radar” and mine tends to light up when I hear even a slight discrepancy in a patient’s story. And when it comes to illegal substances, although I’m a big optimist and I hope everyone is telling the truth, I have a spot in my head that’s skeptical and thinks, “Maybe that answer wasn’t quite truthful.”
How do you handle the situation if you suspect a patient may not be telling the truth?
In a nonconfrontational way I might say, “Are you sure this is what you mean?” Or I might suggest, “Let’s look at it in a different way.” I tend to be a nonconfrontational person, but if I see that the patient’s statements directly contradict what’s in the registry, I lay it on the line without an angry or upset tone of voice. I explain that if they are not being up front about what medications they are taking, I have to be cautious about believing other things they’ve told me as well.
Here’s an example. A patient came to see me because she was experiencing anxiety. She wanted a prescription for anti-anxiety medications. But there were pieces of her story that just didn’t add up. I realized that she had been taking opioids prescribed by another clinician and was going through withdrawal. I explained why I felt I couldn’t give her a controlled substance, because she had not been open about other controlled substances she had been taking, and she was more open with me at our next visit. I helped her find other ways to manage anxiety and withdrawal symptoms, and our relationship began to improve. My honest but nonjudgmental approach invited her to be more honest as well and to trust me more.
- Vogel L. Why do patients often lie to their doctors? CMAJ. 2019;191(4):E115. doi:10.1503/cmaj.109-5705.
- The States That Lie to Their Doctor the Most. USARx.com. Accessed June 13, 2022. https://www.usarx.com/states-that-lie-to-doctors.
This article originally appeared on MPR