Lies, damned lies and history taking

Lies, damned lies and history taking


Vijay Gopichandran


Dr. Gregory House, the protagonist of the famous American television drama “House MD” played brilliantly by Hugh Laurie, says “I don’t ask why patients lie, I just assume they all do”. This typifies the personality of Dr. House, the brilliant diagnostician, who does not rely at all on the history narrated by the patients but believes in deploying uncharacteristic techniques like breaking into patients’ homes to understand their lives. Many times, it is true that patients do not tell the full truth or hide some information about their illness. There are many reasons why patients lie about their illness. In this blog, I will narrate an instance in which a patient lied to me for a long time. I will explain how this seriously impaired the quality of my treatment. I will also try and describe what this episode taught me about lies, damned lies, and history taking. Unlike Dr. House, I still believe in the art of history taking. However, this incident completely changed my perspective towards patients, especially patients and the lies that they tell.


Mrs. Geetha, a 50-year-old lady was taking regular anti-diabetic treatment from me, about 7 years ago. She belonged to a reasonably well to do family from a nearby village. She had two sons and two daughters, and she was living with her eldest son. He would bring her to the clinic and discuss extensively the treatment during each visit. He was a highly involved son and was taking good care of his elderly parents. Mrs. Geetha’s blood sugars were constantly in the range of 300-350 mg/dl, which is very high for someone on medications. I had started her on Tablet Metformin at 500 mg twice a day and over a few months had steadily increased the dose and added more medicines and at a point of time she was on Tablet Metformin 1 gram twice a day, Tablet Glibenclamide 10 mg twice a day and Tablet Pioglitazone 30 mg twice a day, all of them potent anti-diabetic medicines at maximum dose. But still, her blood sugar was hovering around 300 mg/dl. I had repeatedly asked her about the regularity of taking medicines and she had assured me that she never missed a dose and was perfectly regular on the medicines. Over a period of about a year, I had come to a state where I had to start her on Insulin injections as the maximum dose of oral diabetic medicines were not helping despite strict compliance and good diet and exercise. I had spent many a sleepless night worrying about Mrs. Geetha and her uncontrolled blood pressure. I had been concerned because she was on very high doses of all the medicines, all of which could have serious side effects. That day, as I sat in the clinic, with Mrs. Geetha in front of me, her son standing quietly beside her, trying to counsel her to start insulin injections, she told me, “Doctor, I did not tell you one fact. I have been taking herbal medicine for diabetes, because of which I have not taken any of the tablets that you prescribed so long. I haven’t even been buying those tablets from the pharmacy.” When she said this, I was completely taken aback. I was shocked, felt cheated, let down, disappointed, frustrated and all those negative feelings which accompany the state of being made a fool of. I wanted to just pull her up from her chair, shake her and shout at her for lying to me. But I did not do any of those things. I swallowed all my anger and patiently asked her, “why did you not tell me about the herbal medicine?”. She gave me a sheepish look and said, “Doctor, if I told you, you would have shouted at me and prohibited me from taking those herbal medicines. You would have scolded me and put me back on the high dose of your pills. I was afraid of hearing your scolding and shouting and so I lied to you”. The answer was so simple and that moment was a transformative one for me. Before I explain how it affected me, I would like to analyze why patients lie.


Paul Ekman, the renown psychologist who has researched and written extensively on lying, proposes ten common reasons why people lie. His explanations are relevant to why patients lie within the framework of a doctor-patient relationship. The most common reason why patients lie is to avoid being reprimanded. This was exactly the reason mentioned by Mrs. Geetha. She did not want to hear me shout at or scold her for missing the pills. So, she lied about taking the pills regularly. The second most common reason for lying is to conceal the fact that a reward has been obtained by breaking the rules. A common scenario is when a patient who is non-compliant to anti-diabetic medications comes to a blood sugar test after taking a dose of insulin so that the test shows a low sugar level. Sometimes patients lie to protect themselves from something that they consider as harm. A patient who does not like to take vaccines, may lie about their vaccination status and say that they have already taken it. A patient may lie in order to win the admiration of the doctor or other health care providers. I have once had a patient who constantly lied to me that he did regular swimming every day in the pond near his home. I praised him and promoted him as a champion of physical activity for all other patients. But one day, when I had been to his village for a field visit for some other purpose, I realized that there was no water body in his village and the whole swimming thing was a charade to win my admiration! Sometimes patients lie to avoid shame and embarrassment. This happens more often, especially when there is a lack of privacy in the clinical encounter. I have had male diabetes patients who have denied having any sexual problems when my students are in the room, but once I send the students out for some chore, they would suddenly and hurriedly open up and spill the details about their sexual problems. There are also other minor reasons why patients lie. They may lie in order to sound polite. A lady kept lying to me that the pain killer medicines were helping her abdominal pain in order to be polite to me, while silently her gastric ulcer was getting worse, till one day she vomited a large volume of blood and had to be hospitalized on an emergency basis. Despite these many reasons for why patients, lie, the most common reason is to escape punishment and reprimand.


Mrs. Geetha’s incident taught me so many things. It taught me that patients lie. The lies told by patients can seriously hamper the quality of my treatment. I would have started her on unnecessary insulin. I would have over-tested her to find out the reason for why her sugars were not controlled. I would have sent her back and forth to specialists looking for a reason for the poor sugar control. All that would have been unnecessary and sometimes harmful. Having said this, it is not possible to completely prevent patients from lying to us. The best I can do, to prevent lying is to provide a safe, non-judgmental space for the patients to be true. If fear of reprimand or punishment is the commonest cause for lying, then if I remove reprimand and punishment from the equation, am I not providing a safe space for speaking the truth? This reality struck me, and I decided from then that I would NEVER shout, scold or reprimand a patient for adopting, following, not following, not quitting, quitting health-related behaviors. If a patient continued to smoke heavily after a heart attack, I would listen and explore reasons for why they are unable to do so, rather than scold them, lecture them or judge them for their tobacco dependence.


Yes, Dr. House was right in a way, all patients will lie. But that does not make history taking useless art. It only means that history taking should be carried out in an open, non-judgmental and constructive manner so that patients are not forced to speak lies. There is a common adage in Tamil which when translated means, “never speak a lie to a doctor and a lawyer”. I started understanding this differently. To me now it means, never create a space for a patient in your clinic in which they would fear reproach and lie to you. From that day, I try my best to provide an open, non-judgmental space for my patients in my clinic. Some of my students who shadow me in the clinic vehemently argue with me that not ‘scolding’, ‘advising’, ‘lecturing’ my patients on the importance of diet, exercise, quitting smoking, regular compliance to medicines, etc. is not appropriate. They argue that I must do these things. But to me having a patient not lie to me by providing them a non-judgmental space, is more important and helps me work together with them. I would rather they come straight on to my face and tell me, “I did not take the pills” than practice a non-sustainable, externally forced, health behavior.