Why Do Patients Lie to Their Doctors?
By William Morgan, DC
Anyone who has ever watched the television show House knows that the cranky title character has a cynical philosophy regarding patients: “I don’t ask why patients lie, I just assume they all do.” Cynicism aside, Dr. House has a valid concern. Many patients do lie. They lie about diet, alcohol consumption, drug use, exercise and symptoms.
Patients may be motivated to have their physicians think that they are more disciplined than they really are, but there are other factors that reward patients for lying. A patient who exaggerates symptoms may get an appointment sooner than if he or she tells the truth. Patients may provoke their doctors to order more extensive diagnostic procedures. They may lie to obtain secondary gain, to protect their careers or to acquire affordable health insurance.
A 2004 WebMD survey found that 45 percent of the 1,500 respondents admitted to lying to their physicians. What motivated them to lie? The primary reason half of those who lie do so is to avoid judgment by the doctor. The main reason that patients lie is to save face. What do patients lie about? Thirty-eight percent lied about following doctors’ orders, 32 percent lied about diet and exercise, 22 percent lied about smoking, 16 percent lied about alcohol consumption and 12 percent lied about illicit drug use. They also lied about seeing chiropractors and alternative health care providers, again to save face with their medical doctors.
In government employment, certain health questions can affect careers and security clearances. An alcoholic, drug abuser or someone practicing unsafe/indiscriminate sex may be motivated to hide information from physicians. Certainly, employment opportunities in the military preclude many pre-existing medical conditions or habits. Under-age drinking, illicit drug use and chronic health problems may affect a person’s chances of serving in the military, so these parts of a medical history are frequently hidden.
Patients filing for disability benefits or in litigation for personal injury damages may also receive secondary gain for exaggerating the extent of their injuries and hiding pre-existing ailments. Patients who want to obtain affordable health insurance also may receive secondary gain for hiding health concerns from their doctors, knowing that future insurers will review the doctors’ records.
Failure of Doctor-Patient Confidentiality
The Hippocratic Oath and the Chiropractic Oath both have provisions that protect patient confidentiality. However, these oaths become moot when patients are compelled to sign release-of-information forms by third-party payers, attorneys and (in workers compensation cases) employers. So our long-held devotion to patient confidentiality often is held for ransom. If the patients want the insurers to pay the bills, the patients must relinquish their rights to confidentiality. This in turn causes the patients to protect themselves from the consequences of having health secrets scrutinized by a third-party payer by lying. We have a dilemma.
What can be done?
Accept that patients lie and try to understand their reasons for lying. Replace Dr. House’s cynicism with a healthy amount of skepticism while understanding the reasons patients lie. Try to avoid presenting yourself as being judgmental of your patients, but be pragmatic. If patients smell like an ashtray, they are probably still smoking. If they are obese and have high lipid panels, they may be lying if they say they run forty-five minutes, five days a week, and have eaten a healthy diet for the past three years. Even if your patients lie, endeavor to coax them into healthy life choices.
Palmieri JJ, Stern TA. Lies in the doctor-patient relationship. Prim Care Companion J Clin Psychiatry. 2009; 11(4): 163–168.
Reprint from ACA News
Ethics: A Clear Drop of Water
by Mark Crawford
There is a world of ethical pitfalls out there for the unwary (or corrupt) doctor of chiropractic. Some are obvious, such as sexual misconduct and billing fraud. Others are less clear, including relationship boundaries with patients and staff, or selling multi-level marketing products to patients. There are also ethical violations that come about because of a lack of proper documentation due to inadequate or outdated understanding of insurance requirements.
“Having a sound understanding of current Medicare laws and statelevel interpretations is essential for accurate billing,” says Kenice Morehouse, DC, DACBN, an associate professor at Palmer College of Chiropractic-Florida. “Some chiropractors believe that cash-paying patient visits don’t require proper documentation. Others fail to provide adequate documentation of medical necessity.”
Informed consent is one of the most misunderstood moral issues today, according to data from the National Board of Chiropractic Examiners (NBCE). “Over the years, the NBCE Job Analysis data have shown that doctors think the signed paper is more important than the conversation with the patient about the proposed treatment,” says Stephen M. Perle, DC, MS, professor of clinical sciences at the University of Bridgeport College of Chiropractic. “This can be a serious problem. For example, a well-performed examination and treatment that results in an unexpected reaction could result in a successful malpractice claim based on the fact that the patient wasn’t given informed consent. Malpractice requires among its elements that there was a deviation from standards of care, and informed consent is really a standard now.”
There seems to be a trend away from counseling the patient on the meaning and implication of informed consent. For example, in 2005, the NBCE asked DCs about the importance of counseling on informed consent in its annual job analysis report. In the 2009 Job Analysis Report, however, that question was omitted.1
In the 2005 report, NBCE asked doctors of chiropractic how frequently they discussed treatment options with patients, obtained written informed consent and counseled patients about informed consent. Respondents were then asked to rank the importance of these three categories. Finally, they were asked where each category ranked in terms of risk to patients. For all three questions, discussing treatment options was ranked first (discussed most frequently, highest importance and highest risk to patients), obtaining written informed consent was second and counseling patients about informed consent was last.
“It is evident that doctors think getting written informed consent is more important than counseling the patient about the meaning of consent,” says Dr. Perle. “Since informed consent must include counseling patients before one can get written consent, either these doctors really don’t know what consent actually is or they are willfully avoiding the discussion, which is a breach of ethical conduct.”
Patients need a good understanding of their treatment plan. To that end, doctors must give patients the explanation they require so they have the background to give informed consent.
“Informed consent is not a piece of paper, but a process,” adds Dr. Perle. “Key steps include discussing the planned procedure, alternatives or recommendations, risks (including what might happen if nothing is done), and answering any remaining questions. For risk-management purposes, patients should be asked to acknowledge in writing that their doctor completed this process.”2
Everybody Becomes a Patient
Another common ethics issue has to do with staff, family, colleagues and friends. “Chiropractors sometimes adjust those close to them with little or no clinical history, physical examination, orthopedic or neurological testing or documentation,” says Dr. Perle. “This line of thinking probably started in college because this is how we adjusted our classmates— without most components of evaluation and management.”
The issue is that when doctors of chiropractic adjust friends and family, these people become patients. Doctors of chiropractic have the moral and legal obligations to treat them as thoroughly and professionally as any other patient.
“You wouldn’t treat a stranger without an examination and documentation,” states Dr. Perle. “Why would you treat someone you know in this way?”
Although colleagues, friends, family and employees should be treated just as any other patient from the clinical standpoint, reimbursements can be problematic. Insurance companies may contest reimbursing services that normally would be free or reduced. As the American Chiropractic Association policy states, “Third-party billing for assessment and treatment of parties of a close personal nature—that would by common practice and reason be furnished gratuitously—gives an appearance of self-interest, which is a professional impropriety and therefore may be unethical.”
The ethical bottom line is that DCs should not change their treatment or documentation methods based on their relationship with the person being treated. The only point in question is whether they seek reimbursement for services rendered.
Getting Better at Ethics
Ethics is a complex field that is constantly shifting, especially regarding litigation and legal interpretation. With increasing pressure to build strong practices (especially as reimbursements drop), staying on top of ethics tends to fall by the wayside for many doctors— or it’s tempting to say, “I’m too busy, and I know all that, anyway.”
However, says Dr. Perle, you will very likely be surprised by what you don’t know—even about the straightforward rules posted on your state board’s website.
“I teach ethics and risk management around the country,” says Dr. Perle. “To prepare for these seminars, I search the websites of the state chiropractic boards.3 In my seminars, I meet many doctors who are unaware of the state and federal rules and regulations that govern their profession. Remember that ignorance is not a valid defense. Fortunately, the Internet has facilitated access to this information. Visit your state board’s website regularly to stay up-to-date on rules and regulations. Also, maintain membership in your state association.”
“Attend continuing education classes, and become life-long learners,” advises Stephen Grand, DC, faculty clinician with Palmer College of Chiropractic-Florida. “Join inter-professional organizations such as the American Public Health Association and the National Wellness Institutes. Join both your state and national associations, read their journals and visit their websites regularly.”
In the doctor-patient relationship, an imbalance in power can put patients at risk for boundary violations. Patients might, for example, mistake professional intentions for more personal and intimate feelings, leading them to make sexual advances.
“Patients may agree to case management that is not in their best interest or consistent with their values and desires just because of their trust and dependency on their doctor,” says Dr. Perle. “Therefore, this power—and the patients’ trust and dependency— must be respected at all times.”
Upgrading Public Opinion
“One need only look at Gallup’s annual poll on the honesty and ethics in professions to see how poorly the public views chiropractors,” says Dr. Perle.
How can the profession change the public’s attitude and gain its trust?
“I’m reminded of an experiment that I did in grade school,” says Dr. Perle. “The teacher gave us a glass of water, and we put one drop of India ink into it. The water darkened. We then had to count how many drops of clear water it took to make the water clear again. I don’t remember the count, but it was huge. It’s up to each of us to be a clear drop of water. Don’t do what you know you aren’t supposed to do. Always put the patient first. If the patient comes before you, it is much harder to make mistakes.”
To become more familiar with issues involving ethics and Medicare, see the March/April issue of JACA Online.
1. National Board of Chiropractic Examiners. Job analysis reports available online at www.nbce.org.
2. Faden R, Beauchamp T. A History of Theory of Informed Consent. Oxford University Press:NY. 1986.
3. Federation of Chiropractic Licensing Boards. State boards’ requirements are online at www.fclb.org.
Reprinted from the ACA News
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