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.
• RECOMMENDED8

1. 

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