The concept wasn’t new to me: “The most basic lesson in medicine, medicine 101, that you should have learned in your first week: don’t trust your patients.”
I was reading a story in the Wall Street Journal, published earlier this week, about how a culture of doctors distrusting patients, and distrusting female patients, allowed Dr. Larry Nassar to abuse athletes in his care over many years. The quote came from Dr. William Strampel, Nassar’s boss and the former dean of the Michigan State University College of Osteopathic Medicine, and it is something he said in a meeting about an unrelated male student accused of abuse.
As I read, paragraph after paragraph, the thing that kept popping into my mind was this: The way that Strampel is applying that “basic lesson” is wrong. Trust is fundamental to the doctor-patient relationship, but it isn’t always straightforward. Patients can get their facts wrong, and sometimes they mislead us purposefully. But, we can’t just dismiss our patients’ stories outright — we need to carefully consider what they say.
What’s profound was Strampel’s refusal to give those athletes the benefit of the doubt, and to dig deeper. This is what we mean when we say “don’t trust your patients” — hear what they are saying, and then clarify, or verify. Doing so is how we provide the right — and the safest — care to our patients, and it’s something that I started learning early on in my career.
When I was in medical school, I asked a new patient if he had ever had surgery, and he told me that he had not. Later, when I told this to the attending surgeon, I was frustrated when we examined the man together and saw the scar on his chest from open-heart surgery.
That day, I learned that I can’t always trust what my patients tell me as objective truth. What patients tell me guides how I treat them. Even if what they say isn’t accurate, it’s still my fault if something goes wrong. No matter what that patient told me, I alone was responsible for my clinical decisions.
So, I quickly changed how I interviewed the people in my care. I started asking my patients extra questions like, “Has a doctor ever cut you open with a scalpel?” or, “Are you sure you have all the organs and body parts you were born with?” to help capture that forgotten appendectomy, tonsillectomy, or transplant.
And while my trusting (but not verifying) the patient who had open-heart surgery didn’t impact his clinical care, as I’ve assumed more advanced patient care responsibilities, I’ve seen that bad intel is bad for patient care. Blind trust might undermine our promise, as medical experts, to do no harm.
When I was an intern, I asked a patient in the hospital whether he was taking his medications, as directed, every day. This was important because he was taking something that needed to be increased very slowly over several weeks to reduce the chance of dangerous side effects, like large areas of his skin sloughing off. He said he was.
We checked his blood to verify — the levels of the medication should have been higher than they were —they were undetectable. Had we taken his word for it, and started on the high dose he was supposed to be taking, the results could have been disastrous and even deadly.
“[Ronald] Reagan said trust, but verify” my resident said, reflecting on our patient’s misinformation, “but in medicine, we verify and then trust.”
Medical distrust is discerning. It is cautious compassion used to pursue good health and good practice. And, in fact, such distrust helps us promote public health.
As part of the effort to curb the opioid crisis in Massachusetts, state law says we have to verify, via a state database, whether or when a patient has been prescribed opioids before writing another script. We do this to prevent overdoses or diversion of drugs into the black market.
But to be clear, distrust isn’t dismiss — Strampel was effectively calling the girls and women Nassar abused liars. That distrust is hostile, and it serves to absolve us of our duty to care.
This is especially true, given what Nassar was accused of. Even if we cannot be sure that what the patient is saying is true, when the potential for harm is so great, we can’t be liberal in how we treat the incident. This is why, in most states, including Michigan, doctors are mandated reporters. At the slightest hint that a child is being harmed, even if we aren’t 100 percent sure, we are obligated to report.
Strampel needed to take action on behalf of the patients and take Nasser out of practice willingly, even while verifying. His gross misjudgment and dismissal of dozens of young women — all telling the same concerning story — aided Nassar’s sexual assault of dozens of people during his time at MSU.
As a university leader and a teacher, this is how he failed his profession, his colleagues, and these patients, and this is why his statement about not trusting what patients say is causing such an uproar.
This is atrocious on many levels — how NOT to handle patient complaints: “This just goes to show that none of you learned the most basic lesson in medicine, medicine 101, that you should have learned in your first week: don’t trust your patients,” https://t.co/rR8kGjEE71
— Rogue Dad, M.D. (@RogueDadMD) March 19, 2018
Patients may be what we call “unreliable historians,” because they mistakenly mislead us. Other times, it’s because they lie to manipulate their care. While these possibilities always exist, it’s wildly inappropriate to approach patients as adversaries.
Care is collaborative, in the sense that doctors and patients are working toward a common goal. But, as doctors, we can neither blindly trust nor distrust. As we see with MSU, having no will to act — to investigate — can be catastrophic.
I need to be reasonably confident in my patient care decisions. My patients put their trust in me, and, in turn, I trust their suffering, even if I can’t take every single detail at face value.
And I hope, with each, “Are you sure?” or, “We’ll need to check,” my patients will understand I’m being thorough so that I will do no harm.
About the Author Reprints
I’m not sure what point is being made here. Comparing patients “lying”, or more like forgetting or not knowing what the question is… to a criminal ACT? Seriously? The girls were reporting a crime, not answering a question about their health?
For many years I have kept a record of my health care issues and the year, name of the physician(s); the diagnosis- and/or outcome of the treatment protocol.
I think that I have always reported any information, in a personal account of everything for my doctors, is because of my own personal responsibility for the collection I am required to request from my own patients who I have been treating as a psychologist. I especially keep an updated list of medications for the purpose of the times I had to know about the patient medications that would have a significant relationship to several different diagnostic behaviors that are witnessed in a patient’s behaviors; and for the psychiatric professional that I have referred the patient to for issues that are beyond my purview of treatment. It is imperative to know of not only medications, but also to know of the patient’s family history too. Again this information is shared with a physician who I often referred a patient for the treatment that is required for their own health issues that are beyond my ability to treat.
I have always been treated with the respect of my doctor(s), for providing them with more information about myself than anyone would want. I always begin with the last procedure first, and go down the timelines for the self report that I keep updated and sometimes leave the lesser health care issues out of the copy I provide to my physician; I inform the doctor that I have another patient information charting that includes treatment from my childhood and younger adult health issues that probably don’t have to be known at this stage of my life; I leave the decision for those non-so-serious childhood experiences. The most important report must include any medications that are currently taken, and the medications that have been used for what health issues that the medication was provided for the patient health care from the past. Everyone should know which medications that the patient has an allergy to or a difficult reaction from the medications.
Surgical procedures, what, when,where, why, and the outcome results are also significant for one’s current physician especially.
I thought that I might be helpful to others by writing about how much the medical doctors I have seen were so pleased with the entire history of a new patient especially. It is helpful for me too, and the last but not least information included a family history too. I simply go to where I have the latest information, and update the information as required. The day that a physician says that it is not necessary for my personal health care information, is the day when I realize that I am in the wrong place.
Thank you for the exceptionally profound insight you shared .You are so right as patients are not always honest or either simply forget .Knowing that health care providers have the delivery knowledge and wisdom it is their duty not to be adopters but evaluators employing the techniques you espoused.
I am really not sure what Dr. Okwerekwu’s point is in the article. She seems upset about Dr. Strampel’s distrusting the complaints of Dr. Nassar’s patients. Then she describes a situation in which distrusting a patient’s report was helpful. She concludes by recommending that doctors are responsible for verifying patient reports, which I am concluding is the point she is trying to make.
I have concerns about how this recommendation could have serious negative effects on the practice of medicine. My concerns are several.
First, by taking the responsibility for honesty away from the patient, we destroy one of the foundations of the doctor-patient relationship, i.e. trust. My patients have the right to expect me to tell them the truth about risks and benefits to aid in their health and not spin that based on some drug company propaganda or for the purpose of maximizing my billing. I have the right to expect my patients to tell me the truth even if it is uncomfortable. Lying is not a disease. It is a choice. If it becomes my responsibility to accept deliberate deceit and use methods of surveillance to expose that then my relationship with the patient has become that of their probation officer. That is not a healthy change.
Second, it is impossible to verify some patient statements. For example, if I advise a patient that she should not become pregnant on the medications I prescribe and she advises me that she and her partner are using adequate means of contraception, how am I supposed to verify that? Take hormone blood levels every week to make sure she is taking the oral contraceptive pills? Have her and her partner send me photos of him wearing a condom before sex? Dr. Okwerekwu’s insistence on verification becomes absurd. Even less absurd levels of verification shift the role of the physician toward that of participating more in what has become ever more surveillance on the part of the state and other powerful corporate entities. For example, the new Abilify pills that report on whether they have been swallowed.
Third, Dr. Okwerekwu’s example of drawing a blood level to verify the patient’s report of taking a medication simply does not scale up. The medication, most likely lamotrigine, can cause the highly lethal skin reaction (TEN) if the dose is increased too quickly. But that is still a rare event, and it is highly preventable if the medication is discontinued at the first sign of a rash. To be sure, getting the blood level enabled the treatment team to start the medication at a lower dose. But the titration can take weeks. Is she planning on getting a blood level every week or two to make sure the patient is titrating the dose as directed? If a patient on lamotrigine stops taking it for a couple of weeks then the medication needs to be retitrated. Is Dr. Okwerekwu suggesting that this patient should have blood tests every two weeks while on lamotrigine? If we are going to insist on that for this patient, then why not all other patients. Who is going to pay for all those blood tests? What if a patient refuses to get the blood test? Should we use profiling to determine which demographic groups of patients receive more verification? Verification adds significantly to the cost of doing medicine. That cost needs to be taken into account.
Fourth, the use of verification rather than insisting on a trusting relationship can lull the physician into a false sense of safety. In the medication case I referenced above, the medical team appears to have been fooled into thinking they could safely prescribe the medication because they had caught the patient in a lie. However, as I mentioned above, if the patient stops and starts the medication they are in just as much danger of the lethal reaction. In my medical opinion the more appropriate response would have been to advise the patient that I was not comfortable prescribing that medication as they were having difficulties being complaint. The non-compliance and the failure to report non-compliance and the dangers of each would have needed to be discussed.
Yes, I need to be diligent in observing inconsistencies in a patient’s report. However, inconsistencies between what the patient reports and objective data are concerning because a patient who is lying is destroying the therapeutic relationship and cannot be treated effectively. Using techniques of surveillance just glosses over the real issue which is the lack of trust due to the fact that the patient is choosing to deceive.
Joe
Well said PLUS as you pointed out the scalability of “verifying” every comment or data point is the exact OPPOSITE of the direction of US healthcare in the future
We are looking to LOWER costs not add more layers to charge for
if we have to stop and add in tests to make sure that the patient is, in fact, cooperating then who is going to pay that tariff
From a philosophical standpoint though why do we have to hand hold the patients to ensure they are not withholding or outright lying?
it isn’t OUR body it is theirs and if they want to mess it up that is on them and that is why I tend to over document and let them lie all they want
I have been at this for a long time and what I stopped doing in the 80’s was to bleed for the patients as well
When I started I was emotionally attached to every patient and every outcome. Then I got hit with a Mal-P case as the owner of the large group (procedure done by an associate but the ball always rolls uphill)
I read the deposition and realized that the patient was at her wit’s end. She had NO relief from any doc in like 6 states and one of my docs was willing to take the case on. She actually did really well afterward but to sedate her for the procedure they used IV and somehow the IV caused a partial anesthesia on that arm. She claimed in the suit she was an RN and could no longer feel enough with the non-dominant hand to practice.
Needless to say, this was a garbage case and she got squat but I realized that the old saying was true
No good deed ever goes unpunished.
From that day forward we shifted the whole mentality of the entire group. We all realized that regardless of how much we try if the patients want to either be elusive or lie or fabricate it is on them
To this day we have treated tens of thousands of surgical oncology patients and we assume 100% are withholding or lying and we also assume that each one is trying to set us up to gain a windfall
Surely that is NOT a fact but we assume it to be to protect us and to isolate us from their mindset
We have treated celebs and dignitaries from all over the globe literally and routinely have to shut a wing of the hospital down in order to satisfy some national security teams nonsense all the while listening to every word with an inquisitive mind wondering when the lie will happen
We also have had extensive training in questioning from some of the best detective units so we ask questions differently than they expect to be asked so we get closer to the real data and less typical BS
We never ask for example how do you feel today or how much pain are you in
Instead, we ask so Mrs. Jones today explain the feeling you are having in your abdomen or does your cheek feel full and swollen today
All of this CYA nonsense is costing everyone a fortune and the real sufferer is the patient in the room.
Dr. Dave
Great article
The issue is exactly as written the comments made by patients who for whatever reason are either less than factual or altered in “spin” dramatically affect how we treat them and since patients have virtually NO idea how we process information totally shifts their outcome by not simply “dumping the goods”
I start each Fellowship team with this exact discussion. If they are not careful what is being used to determine “facts” they very well might be driven down the wrong road and both causing dishonor to themselves but harm to their patients
For me, I am not hung up on patients who lie. I do my best to verify then make copious notes about the situation and move on
The key is to understand that there is NO such thing as “truth” that “truth” is a philosophical word implying facts and that everyone spins data to their own advantage or recollection
Suggesting that patient will lie is a stretch but going the other way and accepting what they say is also wrong
The key to properly caring for patients is to make the patient understand that we are NOT here to treat them in a vacuum. We work TOGETHER to get them whatever outcome they want (and that can be achieved) if they are not open forthright and “factual” then we function based on what we have and are NOT responsible for the outcomes based on mystery or hidden agendas or data
I HATE to be assumed to be their care provider I am NOT; I am the care team LEADER but the outcome is FAR more the responsibility of the patient then ANYTHING I could ever do
Dr. Dave
Awesome insightful comment. People are not always candid out of fearing a bad report.not knowing what to say or forgetfulness.The point is, as healthcare providers you all have the knowledge and wisdom or access to others as guides on how best to deliver medical care.
That to me does require first listening carefully to what a patient says and second doing your best to clarify through evaluative and assessment techniques the medical problems.Again great job.