The Things We Don't Say To Doctors

By Dr. Adam Miller

Rapport : a close and harmonious relationship in which the people or groups concerned understand each other's feelings or ideas and communicate well.

A show of hands if you have ever withheld information from a doctor…

Yeah, my hand is up with you. I’ve lied to my doctor—and I did so with the subtle awareness that I was actually hindering my own treatment. I once lied to my primary doc’ about compliance with medications and supplements. I once lied to my cardiologist about my true level of perceived stress. There are other times as well—I’ve just got a curious case of amnesia about it at the moment. A constipated conversation between a doctor and patient can seriously impact the flow of an otherwise excellent treatment plan—yet it happens every single day.

The medical history cat-and-mouse game may even be getting worse. In this digital era of “give me anything I want now,” artificial intelligence, and e-relationships, many assume that new-era lab tests can compensate for a diluted patient health history. Sorry, but tissue-level testosterone studies, for example, are not as strong a predictor of erectile dysfunction as we would like to think. Although I am a huge proponent of direct-to-consumer lab testing, the number one diagnostic that I learned in medical school is still number one today—and you can’t buy it online.

My medical school professors taught me that 80% of diagnoses can be attained through a good patient history, and that lab tests are best used as a confirmation, rather than a screening tool. I was also taught, however, that a great history is hard to come by. Patients lie to doctors; have poor recall about timelines and quantities; and are stifled by white coat syndrome. Whatever amount of alcohol intake a patient reports, for example, we were taught to double it for a female and triple it for a male.

But, there are more layers to the “hidden history” issue than what I was taught in medical school. Doctors aren’t trained for rapport’s more productive big brother—relationship. Even if they were, the system I graduated into doesn’t allow enough time for doctors to challenge the elusive patient. An unexpected comment from—we’ll call him Mr.G—cracked the hidden history issue wide open recently, and I want to complete this dissection together. But, first…

Here are the pieces laid out before me for this operation:

★Patients feel entitled to outstanding medical care and yet they withhold relevant information from their doctors

★The psychological reasons for withholding information are often the root for several problems in a patient’s life

★Doctors are only as good as the information they get

★ Doctors aren’t trained to exercise rapport’s more productive brother—relationship—with patients

★ The healthcare system lacks the customer-first spirit of the rest of the service industry

★ The healthcare system doesn’t invite an exploration for the source of disease—which often has psychological roots

★ No diagnostic technology can take the place of a good patient history

★ No doctor is worth keeping if you can’t be honest with him

Alright, let’s put this thing together, so we can get home for dinner. Forceps please…

I was drawing blood on Mr. G and asked him about his attempts to curb alcohol when he made this incisively honest comment:

“Another patient and I decided that you can’t give us good care if we aren’t honest with you about everything - including the number of drinks we’re actually having. You’re only as good as the information you’ve got, right doc?”

Damn straight Mr.G!

I once had a patient nearly slough her facelift flap due to a hematoma that developed post-op day one. The surgery went beautifully, so why the #$!@ was she bleeding?!

I was pacing the halls of my home, when a nurse from the ER called me with the answer: “hey doc’, did she tell you that her naturopath put her on megadoses of vitamin E, garlic and fish oil (all known to thin the blood)?” Uh, No.

I had a patient book an elective surgery and hide the fact that he suffered a heart attack in Japan while golfing the week before. Thank God his personal assistant came clean with me. I’ve had airline pilots withhold symptoms of sleep apnea from my interview because they were afraid of losing their job. I’ve also had patients get upset with me if my sleep formulas didn’t work for them—only to find out later that an affair, bankruptcy, estrangement from parents, elicit drug use, or depression were the actual (hidden) causes for their insomnia.

Everyone agrees that health is the greatest wealth and acknowledges that doctors are handcuffed when patients withhold information. Yet, patients frequently lie about important aspects of their history. The result of this behavior is inefficient, costly care, and more treatment failures. I’m here to change things.

Let’s keep this dissection going by turning to the most appropriate next place - our enlightened Mr. G - for some answers. I finished Mr.G’s blood draw, slapped a band-aid over his antecubital fossa and asked, “why don’t patients share the whole story with their doctors?” I think Mr. G’s answer was spot-on:

“Shame. I feel like you guys in the white coats will judge me. And we already know what you are going to tell us to do and we don’t want to change.”

Rarely has such honesty perfumed a treatment room. “We’ve both got issues here,” is essentially what he was saying. Before I put physicians and the healthcare system under the OR light though, I think it’s important to mention the role of patient ignorance.

There are times when patients simply don’t know that the glass of wine before bed has an impact on the number of times they are getting up to pee at night—so they don’t mention it. That’s where an effective, trusted, doctor should pick up the slack. Our facelift patient may fit into the ignorance category, although she was probably withholding because she thought I would scoff at the recommendations from her naturopath. And the fact that she would think that about me points us toward some of the shortcomings on my side of this table.

This dissection cuts both ways. Doctors hide things from patients also—namely that we get sick; we have fears and insecurities; and we don’t know everything. The macro issue is communication, right? All business consultants put the “C word” at the top of their problem list. But, medicine is especially problematic in this regard because of—not a litigious society—but, a lack of the service industry spirit. We physicians were trained in a system that is grossly void of credos like “ladies and gentlemen serving ladies and gentlemen” found in every Ritz Carlton hotel. The prevailing credo in the healthcare system is “I’ll be a caring marksman, if you’ll point me to the target—in 12 minutes or less.”

I was taught, in essence, to build enough rapport that I can get a handle on a patient’s “chief complaint.” You: complainer, me: marksman.

Once I have the chief complaint in my sites then it’s either treat, test, or refer to a specialist. The problem is the “It’s my way or the highway” prevailing attitude that many patients complain of along their treatment path. The system just isn’t set-up to consider alternative perspectives—like nutrient recommendations from your naturopath. Therefore, patients clam up.

Patients, to be fair, are asked to tell-all in a system that doesn’t leave them felling like they are really being heard. The other inconvenient truth in this discussion is that doctors aren’t trained for the psychological waters of patient motivation, fear and shame-based behavior. Yet, that’s exactly where many treatment solutions swim.

I went to a Top 15 medical school (US News Rank), and had only a few hours of training in psychology and communication. Presented with an anxiety-driven eating disorder, the solution was—call psychiatry. Marriage problems? Call social work. Spiritual crisis? Call the chaplain. Allopathic medicine has done a fine job of educating doctors in the metabolic and physical domains of health, but has largely ignored the fact that the number one unmet public health need is mental health. Psychology becomes biology. The extra glass of wine at night matters because it helps your doctor treat your disrupted sleep pattern. But, the reason why you have increased your drinking is where your health cure begins.

If the doctor-patient information exchange now seems like a hot mess—with many opportunities for failure—I think we’re right where we need to be. Doctoring is messy and treatments often fail because of the things patients don’t say to doctors. When you dissect it out, however, the hidden history problem seems to be one fixable reason for inefficient, costly, and often ineffective medical care. The question is whether any of us—patients and doctors alike—are willing to change the status quo. Story makes the world go round, and it makes medical therapy go forward.

I no longer lie to my physician because I believe in a better path, one where the most important—but often hardest to share—elements of a patient history flow more easily. I had to become a patient in many different capacities; then get more psychology and motivational interview training, before I could leave the traditional medical model and invite my patients to be truly honest with me.

You want “everything now?” Well you can have it—at least you can have more of it. Treatment efficiency can go up, and costs can come down. The only hitch is that you need to tell me “everything I need to know” when we meet in my portion of the medical marketplace.

From the Clinic: Mr. G confided in me that he back slid into drinking more alcohol. He admitted that “empty nest syndrome” had hit he and his wife full force and was the main reason for his more frequent alcohol escapes. The solution I gave him didn’t require a prescription, stem cells, AA or brain-retraining - but it seems to be working nonetheless. His wife had purchased dance lessons for them and he was being obstinate about following through.

A swift kick in the butt from a doctor who actually cared about Mr. G was enough to get him out on the dance floor. I actually wrote “go dance- STAT” on my script pad. On Mr.G’s last follow-up he reported that his alcohol intake and his weight were down and he and his wife were actually enjoying the tango. I told him how happy it made me to hear the news. Mr. G blushed, and our treatment plan accelerated.

Comments? Email: adam@arisemd.com

Dr. Adam Miller is a physician, surgeon, and dentist who is trying to get to the heart of the matter.