Why patients lie to their doctors

A writer from the Wall St. Journal emailed me for ideas about why patients lie to doctors.  Here's what I sent:

A typical conversation between doctor and patient is much more compatible with glossing over problems than with exploring and cataloging them frankly and accurately.   The patient reports less risky and more healthful behavior, and the doc doesn't follow up or challenge.

 Docs expect patients to behave in ways the patients don't behave anywhere else in their lives.   As an example of this conflict of interest, doctors notoriously tell themselves that "compliance problems happen to other doctors' patients."  (In my case, thirty years in the controlled-delivery pharma field provided ample evidence of that.) 

It's also my impression from many MDs that docs don't particularly embrace patient-behavior change as central to their role.  Doctors see all kinds of evidence that tells them when you're lying.  The MEMS technology for clinical trials (where unscrewing a cap creates a precise date-stamp for each dose) reveals behavior by clinical volunteers that clearly doesn't match what those patients' self-report forms claim.   If you take a cholesterol measurement or have the patient stand on a scale, the patient has no opportunity to conceal or rebut the result. 

I'm an anthropologist who worked in pharmaceutical R&D for over 30 years.  One lunchtime, a pharma market-research director and I were discussing situations where people are asked to reveal undesirable behavior.  I said, "If you want to know how much beer someone drinks, a market researcher will send a questionnaire.  An anthropologist will go through your trash!"

But if the patient isn't ready to make a change, and the problem the doctor sees isn't life-threatening, its seen as the patient's problem, or someone else's.  Docs hang out where the best tools are.  And their best tools these days are medical technology and prescription drugs, not physician-instructed behavioral interventions.

Another reason patients choose flattering answers is because they can.  Patients know which answers describe healthful conditions or behavior, and which ones will get you "in trouble" with the doctor.  Query-designers have known for years that for any questionnaire response to be reliable, every answer has to be an honorable answer.  You can't expect a respondent to cast herself / himself in a bad light, just because you teed up a question where B, C or D describe unhealthful (or illegal, unethical or socially disfavored) behaviors.  It's the same with MD interviews during doctor visits.  Self-flattering behavior is omnipresent.  MDs are authority figures.  People don't want to be scolded by their doctor. 

Digging into behavior-based health issues is a textbook dilemma for the patient--you're behaving as you do, avoiding exercise, or smoking, or drinking or doing recreational drugs because it's easy, it's pleasurable, it comes naturally to you, it fits your schedule and peer group, etc. Telling your doctor those harsh truths is only going to create tension around a behavior that you're letting yourself get away with--as long as you don't do anything to invite confrontation.

The scanty and superficial training most MD curricula include in the area of applied behavioral science contributes to the problem.  Docs have embedded role conflicts as "friend / healer / benefactor" vs "authority figure / judger / punisher." Little that they learn equips them to overcome that role conflict and get to the bottom of patients' real behavior. Even if they had terrific behavior-mod tools and training, the duration of a typical visit is inconsistent with effective interviewing on conflicted subjects. 

So, the question may not be so much "Why do patients lie to their docs?" as "In their current roles, why do either patients or docs expect anything else?"

Asymmetrical layoffs and hiring

Geronimo took a swipe at explaining how the business cycle builds up staffing problems that don't get solved until the economy tanks, and employers can re-size their organizations while the media's overwhelmed.  Another NY Times Editors' pick

• Geronimo
• California

NYT Pick

After 20 years as head of HR at a couple Silicon Valley companies, some hidden aspects of layoff and re-hire decisions: 

1) In bull markets, companies concerned about their stock price avoid layoffs, even when they know they need them. They don't want to spook analysts, shareholders and investors with a layoff--a bearish sign that could tank the stock price.  So, when the economy turns down, a lot of postponed housecleaning needs to be done.  

2) Layoffs traumatize management as well as rank-and-file. Re-staffing is done with great caution, to avoid triggering more layoffs.  

3) When a layoff comes, it's always the least productive, most difficult employees with the most outdated skills to go first.  

4) Management knows this, so when the recovery starts, there's a strong preference to hire people who are already working, and skepticism about people idled by layoffs.

In an economic downturn, all companies are affected. That reverses the negative spin, so suddenly a layoff shows how tough and prudent the management is, which reassures stockholders and analysts--the reverse effect from a layoff during a bull market. And, the risk of being singled out for unwelcome media attention is far less.

The (liberal?) press covers the un-employment rate, but it's the employment rate--63%, lowest in decades--that reveals the number who have abandoned the workforce.

The biggest contradiction: employers want smart, high-skill employees, but the workforce needs more dumb jobs in the economy.

• April 6, 2012 at 3:07 p.m.
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And here's the link:

http://www.nytimes.com/2012/04/07/business/economy/us-added-only-120000-jobs-in-march-report-shows.html?_r=1&comments#permid=78

Geronimo unmasked by New York Times Dot Earth reporter Andrew Revkin

Andrew Revkin (NY Times Dot Earth columnist / blogger) made Geronimo an offer he couldn't refuse: drop the Chiricahua Apache persona, and Revkin would include Geronimo's latest rant in his column, under Harold's true name.  Harold and Geronimo met under the same hat, and decided it was worthwhile to accept Revkin's offer and observe the dress code.  

Recognition as an Editors' Selection has been the video game of choice for this blog since the beginning.  Geronimo's comments have won Editors' Choice a couple dozen times since the game began. The piece that got Harold to blink--and to have a heart-to-heart talk with Geronimo about making an exception to the rules--is below.  Laura, Harold's sister, asked, "Was it more fun to play the game, or to win it?"  Harold still hasn't figured out the answer to that.

2.

Geronimo

California

October 16th, 2011

6:26 pm

  








As the Great Recession meets the Green Revolution, two big factors get clearer: 

1) Global warming doesn't make a very good emergency, and doesn't go to the top of the triage list for most people; and, 2) The whole progress of the last millennium is tied up in energy-per-capita numbers, leaving the movement with an immobilizing lack of focus: "focus on everything!" Those marching orders are very hard for scared, busy, overloaded, underemployed people to integrate into their daily struggle to maintain their lifetime socioeconomic progress and pay their bills. Everything in our world that isn't rocks, dirt, or indigenous plants and animals was created as a result the result of energy expenditure by man--the vast majority of that, via fossil fuels. The dumbest fossil fuel advocates are easy to satirize, but Al Gore's credibility isn't exactly knocking it out of the park either. This will be a long, tedious series of pesky compromises over decades, not a glorious revolution where we rejoin some imaginary noble savage past of low energy consumption. The vast populations of developing countries aren't thrilled about the elite West's new cries of "move the goalposts" either, just as they're starting to see middle-class lifestyles percolate through their historically subsistence-level populations.

Looking to Machiavelli for a way to put some martial arts move on the West, and flip it into dense urban housing, bicycle commuting, and radical decreases in energy consumption may allow the green elite to feel superior. But the worldwide greening of industrial processes is more like a gentle fog creeping in to cool things off a bit than a revolutionary tsunami of raised consciousness and voluntarily changed lifestyles. Sorry about that.

Geronimo's record--two NY Times eds picks this week

Geronimo was tired, but a NY Times piece on employers' use of info from social media was just annoying enough to provoke a response. The NY Times editors liked it, again. That's twice in about 72 hours. After hearing the long string of NY Times "hits," some reproduced here, Geronimo's spouse once asked, "Why don't they offer you a job?"

The rules of my "video game" with the New York Times are approximately this: Geronimo submits something that he 1) feels strongly about (including just plain intellectual annoyance); and 2) believes will be contradictory to the article's slant, or to the NY Times' editorial policies, or both. The object of the game is to write it well enough that even--even--the New York Times editorial staff will see its merit, and will make it an Editors' Choice and gray it out.

Geronimo was beginning to lose interest in the game, when a couple silly pieces in the last few days perked him up. Here's the second Editors' Choice grade in about 72 hours, on Geronimo's self-imposed writing tests.

And, Earl Wallace and Geronimo registered a completed feature-length screenplay yesterday.  Not a bad week for the writing projects.  Here's Earl's story:


http://www.imdb.com/name/nm0908620/

HIGHLIGHT (What's this?)

Geronimo

California

July 22nd, 2011

9:33 am

Privacy?

How can "privacy" be the objection, when social media are intrinsically public? That is a lame argument, suggesting that the person doesn't know how the Internet works, or doesn't care, or has magical beliefs.

As head of HR at an S&P 500 company for many years, I know that the employer is at an information disadvantage in comparison to the applicant, who is the only person on earth who knows the whole truth about herself / himself. We never wanted an artificially negative picture of a job candidate. But we knew that most candidates were seeking to give us an artificially positive one. All we wanted was some balance.

We did nothing extraordinary, other than near-100% follow up on things the candidate asserted. Candidates who lied about degrees always lost that bet, because we always checked with the educational institution. Candidates who flunked their scheduled drug test, or failed to show up got no second chances. We told you it was coming, we told you your job depended on in it, we told you the day and time. If you didn't show up clean that day, it's only because you couldn't stop using, or you wouldn't stop. Neither was ok with us.

Ever hear of "negligent hiring?" If an employer fails to get info that's in someplace as easy and obvious as facebook, and an employee goes on a shooting rampage one day, believe this: the plaintiffs attorney for the victims' family is going to come in with facebook pages of anything that remotely suggested that the person was violent, unstable, or likely to conceal weapons. When the employer says sanctimoniously, "Oh, we consider it insensitive to look on facebook," they're done. Verdict for the plaintiff.

The biggest reason, though, that I think this stuff should be admissible and is fair game, is the most obvious one: posting antisocial stuff on facebook is evidence of bad judgment. At our company, we had no jobs that didn't require judgment.

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Recommended by 3 Readers

Report as Inappropriate

Diana Nyad's bucket list

Geronimo did it again. NY Times editors' choice Tues July 19, 2011

121.

HIGHLIGHT (What's this?)

Geronimo

California

July 18th, 2011

9:25 pm

Went back and read some comments, in "readers' recommendation" order. The negativity put me in mind of Tom Wolfe's observation about physical courage--that in the Korean War, the New York metro area produced three Medal of Honor winners, while Appalachia produced 78. Oh, and one of the three from New York had just moved there from the Appalachian region of West Virginia.


Give her a break. Nyad's a New Yorker by birth. She's not exactly attracting a bunch of copycats who'll be clogging up the ocean lanes, and she isn't using public money. What's on your bucket list?

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Cheating on standardized tests: NY Times

Another of Geronimo's comments picked by the NY Times editors as a highlight:

HIGHLIGHT (what's this?)

Geronimo

California

December 28th, 2010

9:36 am

I believe the only reason for cheating is to acquire something you haven't earned. It's the same as stealing.

The post facto analysis is a great idea. It's far more practical than some overburdening attempt to confiscate cell phones, a nightmare in the making. Any police officer will tell you that for sting operations, the crime has to be consummated--if the perp doesn't go through all the steps, there's no case. So, when a student who's "too cool for school," cheats to get ahead, and gets tripped up, it benefits the society into which s/he will matriculate.

Well do I remember a tenth-grade classmate who was very irritated that I wouldn't allow him to copy answers on an algebra test. He became a two-term mayor of our hometown, second largest city in our state, and appointed a crony small-time tax preparer as controller, dealing with the city's hundreds of millions with no prior experience or any demonstrated competence.

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NY Times likes Geronimo on mosque issue

HIGHLIGHT (what's this?)

Geronimo

California

August 22nd, 2010

2:48 am

Mr Kristof misses or avoids the tactical deftness of radical Islam, artificially pinning them down to a single position that enables him to make the point he so desperately wants to sell us. How about this, Mr Kristof:

1) If the mosque is built, radical Islamists will mine its presence for all the triumphalism an craftiness-credit that they possibly can. They love our tolerance, work it for all it's worth, and consider us fools for leaving ourselves so exposed. Khalid Sheikh Mohammed said upon his arrest, "I want to be tried in New York, with a New York lawyer." Could the point possibly be any clearer? Radical Islamists love our ethic of multicultural tolerance, and use it consistently as one jaw of the vise.

However, if the mosque doesn't go up, then: 2) radical Islam can sell their recruits the evidence that our claims of tolerance are meaningless, because we wouldn't allow a simple house of worship to be built.

They have their rhetorical engines all revved up, waiting for us to move. Whichever way we go, their arguments are already staked out, and they've got us coming or going.

So, why don't we just do what WE feel best about; trust moderate Muslims to search their souls and see that they'd do the same if the facts were reversed; and let the radical Islamists do what they always do--start with the conclusion that America and Israel must be destroyed, and work backward from there to condemn anything and everything we do anyway.