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Picture 58 The most common question first year medical students ask me is how do they become efficient at taking a patient history.  Can they skip certain parts of taking the patient history and avoid asking about a social history, whether a patient drinks, smokes, uses drugs, or is sexually active?

When can they stop asking about the review of systems, a list of questions asked about each organ system?  A comprehensive history is used in the emergency room, hospital, or during an annual physical, not in urgent care or an outpatient appointment, right?

Wrong.

Patients lie and don’t even know it.  It’s not that they mean to.  In fact, they are trying to be helpful when giving a history of their symptoms.  Medical students concerns about taking a fast history reflects two things.  First is the reality of the limited amount of face time with patients, which unfortunately seems to be even less than the past.  Second, more importantly, is their fascination and desire to get started on real medicine — what are the diagnoses, treatments, and tests that must be learned to be a good doctor.

In fact, what they realize after working with me is that the most important part of being a doctor is talking to patients and listening.  Taking a good history is the essential part of being a good doctor.

Here are two examples of patients who I saw during the winter.  The practice is busy this time of year.  I’m often running late.  Like many encounters, I’ve never met these patients before.  In many ways, it can feel like an urgent care practice.  Which patient is lying?  Can you tell?


Young woman wanting a work note for the flu.  She was complaining of a three day history of diffuse muscle pains, headache and high fever.  That’s it.  She had no other concerns.  Just anxious to get home and go to bed.

OR

A young man with an ankle injury after playing soccer.  As an aside, he also asked about stomach flu which occurred a few days prior.  He had nausea, abdominal pain, and vomiting for a day.  He still had abdominal pain.

Which one was lying?  Both.

A medical student or doctor recently out of training might have not missed the diagnosis in either patient because they are still working on how to hone down their questioning.  In other words, they haven’t take the shortcuts yet and still ask comprehensive histories.  Yet, they aspire to just ask the vital questions to be efficient.  A more seasoned doctor who is stressed and busy may have taken mental shortcuts and moved on.

In other words, how do you know what is and isn’t vital until you ask?

Patients also have fallen into this trap believing this tradition of talking to their doctors is simply unnecessary, worthless, and an obstacle to getting to the truth.  With increasing out of pockets costs for office visits, I’m seeing more requests from patients to simply get a MRI or blood test instead of seeing a doctor not only to address the problem, the real reason for the tests, but also if testing is usually necessary (it isn’t in the vast majority of cases).

A good history is very much like the checklists pilots use and what Dr. Atul Gawande advocates in his book. Taking a good history also slows doctors down and allows them to avoid cognitive errors (as described beautifully in the book How Doctors Think), think more clearly, and avoid jumping to premature conclusions.  Even the time honored skill of thinking through a differential diagnosis and thinking hard to make a long list of possibilities is a checklist and safeguard to consider other alternative problems that wouldn’t appear when stressed.   Being a doctor requires thinking and less knee jerk responses.

So what did the two patients have?

The first patient didn’t have the flu.  She had a kidney infection known as pyelonephritis.  In taking the review of systems when asked about her urination pattern, she realized that it had changed during her illness.  Also, in asking questions, she had no other signs of having a upper respiratory illness, no cough, no runny nose, no head congestion.  Instead of simply writing a work note for a presumed virus and moving on to the next patient, this patient received antibiotics.  Untreated, pyelonephritis can be serious and require IV antibiotics or hospitalization.

The second patient didn’t have stomach flu.  In fact, patients also make similar mental shortcuts by telling us what they think is going on – “stomach flu” rather than telling us specific systems.  When people refer to stomach flu, like food poisoning, often there is nausea and vomiting which then is followed by diarrhea.  He didn’t have diarrhea just persistent abdominal pain.

He had gastritis, irritation of the stomach lining, due to alcohol abuse. Asking about his social history, he admitted to binging on a 12 pack of beers that day, a behavior, not uncommon for him.  Not only was he treated for this, he was also recommended to quit drinking.

So even experienced doctors can take a page from medical students.  It’s the taking the history that matters.  Everything else we do, the physical exam, lab work, and imaging tests are tools and not the truth.

Want to know, one other time a patient lies?

When you see an otherwise healthy young man in the office who simply wants an annual check-up just to be safe.  These types of patients are as common as seeing the Loch Ness monster.

The real reason he’s there?  His spouse, girlfriend, or significant other for a symptom he’s been complaining about but didn’t want to see a doctor.

If I don’t get to that truth, guess who I’ll be seeing next week?  The same patient again but with his spouse, girlfriend, or significant other.

Or he’s asking about Viagra.

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14 Responses for “Patients Lie”

  1. SteveBMD says:

    – “Being a doctor requires thinking and less knee jerk responses.”
    Sorry, my EMR won’t let me do that.

  2. inchoate but earnest says:

    “Patients lie and don’t even know it”
    Nice hook Dr Liu, but lies are intentional. To do it, you HAVE to “know it”. Otherwise, you’re dealing with “errors” or “mistakes” – not “lies”.
    While I like your fact-based approach to breaking down a patient’s current condition – ignore their labels, focus on the specifics they can provide – I am concerned about your theme. Does your apparent default assumption regarding your patients’ integrity tell us more about them, or about you & your practice?

  3. steve says:

    Just so you know, patients will also lie on purpose. I have had several patients lie about not having MS so that they could have elective surgery. Patients often lie about their functional status, especially ones with COPD. Sleep apnea? Yup, there is a good one they lie about. (Did you get to the ones who lie to get pain meds yet?) Double check with family when you can. Trust your instincts and your eyes. If they are 40, but look like they are 70, and smell like tobacco, they probably have more than one abuse problem even if they tell you they never indulge.
    Steve

  4. Yes one of the most important aspect of good doctor is good history taking, but I think a proper and thorough examination is more important.

  5. CanDoc says:

    Some good points. Inchoate but earnest, your comments are useless. Yes, I guess you are right technically they aren’t ‘lying’. He is not labeling patients at all, but rather explaining what often happens on the front lines. What are you talking about with your comment on patients integrity? The point of the article is centered around the importance of history taking and some of the complex subtleties that arise.
    Online Health Guy, I would have to say that history is the most important factor in making a diagnosis. Physical exam and tests are there to support diagnoses or fill in the pieces of the puzzle. But history is the key. It is what you base your differential off of.

  6. Its your nice health care place and one more relaited to you best Hearing Tests heath care place its also populate with Hearing Aids for last 15 years though We have focused more on hearing.http://www.audispeechandhearing.com/hearingaid.jsp

  7. Guzzo says:

    “Or he’s asking about Viagra.”
    Or the other vitamin V – Vicodin.

  8. Excellent stories! During our medical school rotation in a New York city hospital we were taught when taking a history to ” double the amount of drinking and half the amount of vomited blood” reported by the patient. We discovered that that was,in fact, good advice.

  9. Tom Leith says:

    @SteveBMD
    > Sorry, my EMR won’t let me [think]
    Are you saying you have an EMR?
    My doctor’s used an EMR for ten years now and I don’t see that it has prevented his thinking.
    t

  10. Thanks everyone for the comments. Patients are constantly asking to join my practice because I solve problems and I listen. The point of this article was to ensure that the next generation of doctors understand that even in the 21st century the best doctors are those who talk to patients and are not hung up on the technology or lab work. Because as doctors we take care of people, there are things they do, unwittingly, which might prevent us from getting them better. We need to be actively aware and mindful of this.

    Davis Liu, MD
    Author of Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America’s Healthcare System
    (available in hardcover, Kindle, and iPad / iBooks)
    Website: http://www.davisliumd.com
    Blog: http://www.davisliumd.blogspot.com
    Twitter: davisliumd

  11. Gertrude Kappel says:

    Listen! Two years ago I landed in the emergency room. Later I saw the transcribed history that had been taken, In addition to the misspelling of my name, I learned that I had previously broken my fibula (it was the patella), I drank two glasses of wine per day (vs the two per WEEK I said) and that I was married! Nobody… NOBODY gets this last question wrong! Somebody in that trauma unit mad house was not listening closely. I wonder what other incorrect information made its way into my file.

  12. Gertrude Kappel says:

    Listen! Two years ago I landed in the emergency room. Later I saw the transcribed history that had been taken, In addition to the misspelling of my name, I learned that I had previously broken my fibula (it was the patella), I drank two glasses of wine per day (vs the two per WEEK I said) and that I was married! Nobody… NOBODY gets this last question wrong! Somebody in that trauma unit mad house was not listening closely. I wonder what other incorrect information made its way into my file.

  13. steve says:

    I found your website is very good. It is providing all important details regarding Health solution. Doing well…Keep it up!!

  14. Gary Lampman says:

    Patients Lie and Doctor withhold the truth. By the way I have caught Doctors in a Lie as well. Such a honorable profession made up with Doctors who believe they have a right to withhold Information. That is not right .

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