Patients Lie

There’s a saying that “if you want a thing done right, do it yourself”. There’s also the saying “trust no-one”.

I think both of these are most relevant in the field of medicine. If a patient requires an urgent referral to hospital, don’t delegate the fax referral to administration staff. Do it yourself so you know it was followed up on. And if another doctor has taken a history and done an exam, don’t believe them. Do it all over again yourself to verify everything again.

Doing the above things really throws efficient time management and all things learnt about productivity out the window. But with something as important as healthcare and patient’s lives at stake, you can afford to sacrifice efficiency for safety.

The saying of “trust no-one” not only applies to other doctors, it applies to patients as well. Don’t believe everything that the patient says. Reasons why you shouldn’t always believe everything the patient says are:

  1. The patient is an unreliable historian. Or is extremely clueless about everything related to them .. ie an idiot. Eg “Q: when did you last have sexual intercourse? A: I don’t know doc”
  2. The patient has some secondary gain from intentionally misleading you Eg Lying about their pain to swindle some endone from you.
  3. The patient filters everything according to their biases

Recently, I came across a patient who fits under reason number 2. A 29 year old gentleman presented for the first time on Saturday around 6pm (afterhours) advising that he had 5 seizures since Thursday to Friday. He had been checked over by the Emergency Department at a tertiary hospital, and stated that no brain imaging was performed. When asked about substance use, he denied using any, except some marijuana every few weeks. Thinking that it was incredibly unusual for ED to not image a person who had seizures of unprovoked cause, I phoned the department, who noted he had taken 3 MDMA tablets and 3 tablets of Lyrica prior to the seizures.

When confronted about why he did not tell me he had used MDMA, he told me that he was afraid I would contact the police in regards to his illegal substance use.

I kindly advised the patient that with such a history of substance use, he wasn’t likely required to undertake brain imaging, and it would be safe to follow up with a regular GP (the patient came from across town to access our afterhours GP service) who could organize a brain scan if they felt it was clinically indicated. Being a Saturday, he would not have been able to get a CT scan till Monday if I gave him a request form anyway.

I think the above case best illustrates the importance of collateral history. It may seem like a lot of work (and it sure will take a lot of extra consult time), but the rewards are high. Without the knowledge that his seizures were provoked by substances, I would have wanted to order the panel of bloods and imaging as soon as possible, plus trying to manage the fact that this patient wasn’t likely to follow up (because he lived over 15km away, and was told not to drive due to his seizures – why would he continue follow up with me?).