Liar, liar…

Despite claims from a few deluded individuals it is a basic fact of the human condition that everybody lies, and I mean everybody. Me, you, the guy down the street, everybody at some time or other, for some reason or other has been a fibber, a falsifier, a fabricator, a deceiver, an equivocator, a perjurer, a teller of untruths, a spinner of yarns, a bull shitter. From the small white lie, to the big ugly whopper, and as difficult as this can be for some of the idealists, optimists, and happy clappers of our profession to accept, patients also lie.

Exactly how often patients lie to healthcare professionals is not well known as its difficult to detect and prove. However, I know I have been lied to a good few times in my career, from the patient who tells me they have done their home exercises diligently, yet can not demonstrate them when I ask a few minutes later, to the patient who hops in on crutches unable to walk, only for me to see them rushing around a supermarket the following day without any crutches and without any signs of pain or difficulty.

As annoying and frustrating as it can be when we suspect or find out that patients have lied to us, I think its important to try and recognise and understand why some patients lie to see if we can reduce its occurrence, minimise wasted time, energy, and resources, as well as avoid any potential adverse events such as over or under treatment.

Why lie?

Patients may lie to us for many different reasons, some simply because they don’t have the confidence or trust in the clinician they are seeing, causing them to withhold or distort information due to a fear of being judged, lectured, or embarrassed. This can lead to potential harmful or even catastrophic consequences, such as a patient who feels too embarrassed to admit some unusual symptoms of a serious pathology like bladder or bowel dysfunctions, or perhaps feeling too shameful too declare other socially awkward medical conditions or medications.

Some patients may also lie to avoid potential negative consequences, such as being told to stop doing an activity or sport they love doing, and this could be just as dangerous. For example the rugby player who just took a big hit desperate to continue on playing and tells us they have no symptoms after a suspected concussion, to the over worked self employed business man who denies the chest pain accompanying his shoulder pain they are having due to fear they are told to stop working with a big contract nearly signed.

Other patients lie to achieve a secondary gain such as exaggerating their symptoms to obtain sympathy, attention, medication, time off work, or even financial reward. For example the patient who claims their pain is a constant 10 out of 10 yet looking calm and comfortable in our assessment, or the patient who asks to be signed off work due to excruciating back pain, only to have been seen picking up a magazine from the low table in the waiting room without any aparant issue or restriction.

Finally some patients simply lie to us out of bravado and to cast themselves in a more favourable light, such as the patient who tells us they run 25 miles a week, or goes to the gym every day, yet can not tell us what their usual workout routine is or their fastest 5K time.

How do you recognise a lie?

The first thing to remember is that healthcare professionals are not secret service agents trained in the skill of deception and its detection (ref). In fact healthcare professionals usually operate under a ‘truth bias’ that is, they do not anticipate patients to lie to them and tend to presume patients’ presentations are true, complete, and accurate (ref). This can leave healthcare professionals a little niave and vulnerable and susceptible to missing clues that a patient is lying to them.

Now apart from obvious clues such as glaring inconsistencies in a patients story or symptoms, some of the most common and recognisable clues of a patient lying are in their facial expressions and speech patterns. For example a change in a patients voice pitch during a sentence can be a strong indicator of lying, as well as slips of the tongue, long pauses, evasiveness to answer a question, or even the opposite of offering more information than necessary (ref).

Facial clues can include false smiles, a lack of eye contact or head movements, excessive facial touching, head scratching, licking the lips, swallowing, blinking, fidgeting, sweating, and blushing (ref). However it should also be recongnised that all these non verbal cues can also be signs of pain or nervousness (ref).

What do you do about it?

If you do suspect a patient is lying what you decide to do is dependant on many factors. The first thing to consider is do you need to do anything at all. Not all lies in the clinical setting need to be addressed or confronted as this could be more detrimental than beneficial. 

Simply confronting a patient who maybe lying or exaggerating facts due to some social awkwardness or misguided bravado is foolish, particularly if there is no negative or adverse implications or consequences to them or anyone else.

And although it can be frustrating and annoying for you as a clinician to be fibbed to it is often in everyones best interests to let some patients minor indiscretions go unchallenged, rather than compromising a therapeutic alliance that may adversely affect a succesful outcome.

However, if you suspect a patient is lying and malingering and it is not so harmless, and there are potential risks or adverse consequences to the patient or others then this needs to be addressed. However first before you do it is paramount that you do not jump to conclusions or make accusations without ensuring you have robust evidence to support your suspicions and have discussed these with your peers, seniors, managers, or professional bodies first. Confronting or challenging any patient who you suspect of lying is not something you should do without at least checking with someone else first, and get some support and guidance on how best to do it.

In my experience I find that remaining calm, clear, and concise is best. Do not let your personal opinions or feelings cloud your explanation or judgement, stick to the facts of why you think the patient is lying and ask for them to explain why. If you think it will be too confrontational or there is a risk of escalation then make ask for support from those mentioned above.

So in summary, lying is a ugly, unfortunate, complex consequence of all human interactions. Healthcare professionals tend to be poor at recognising when patients are lying to them due to their empathetic nature, and as such all healthcare professionals need to be more aware and better at detecting the signs of deceit and deception. Finally they need to know who to ask for help and guidance from when they do suspect a patient of lying, and how best to deal with it.

As always thanks for reading

Adam

7 thoughts on “Liar, liar…

  1. NIce one Adam. The only patient I can remember where I felt I had to challenge him was a whiplash case where there neck on examination would be totally frozen in the examination room but he was able to fully turn his neck round when walking up the drive of the clinic…I couldn’t let that one go ! Happy Clappers..love it…permission to use ?

    • Cheers Gary, use away my friend… whiplash cases are notorious for bull shitters and malingers, had a few myself! One who had the audacity to ask me for a collar as they had there court case the next day and wanted to ‘look the part’ they were sharply told to go forth and multiply!!

  2. This is an interesting topic which deserves more attention. Patients will lie, and Healthcare professionals will lie. J. Palmier and T. Stern published “Lies in the doctor-patient relationship” in Primary Care Companion J. Clinical Psychiatry 2009 11(4)163-168 which presents suggestions how lies can be managed in the clinical setting.

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