There is very little research on why or how often patients keep secrets that might help a doctor recognize what’s going on. As one colleague put it: “Isn’t that the whole point? To deceive me? So how am I supposed to know when it is happening?”
I found myself running through in my head the possibilities for this particular patient’s deception.
Maybe she had hidden her ongoing tobacco use to circumvent what she expected would be my disapproval or, worse, wrath. I try hard to make my office a safe haven where anyone can feel comfortable disclosing anything. But perhaps an errant forehead crease or raised eyebrow had given her the impression that this was not so.
Or maybe we had discussed her smoking too many times and she had grown tired of talking about it. Recently, a patient told me that since I had first warned him five years ago that his sexual behavior put him at risk for contracting HIV or another sexually transmitted disease and he was still fine, he would prefer that we drop the subject altogether.
It was possible that my patient’s untruth was a byproduct of a messed-up insurance system. It is not uncommon for patients to request that I keep a particular piece of health information out of their medical record. Could it be that her concern about being closed out or priced out of a plan had motivated her to not share an important fact?
Finally, her response could have been pure and simple denial, a case of altered reality brought on by an intense desire to have things be different.
What little research does exist shows that the greater the social stigma connected with a behavior, the less likely patients are to disclose it to their doctors.
For example, in a survey of pregnant women, urine tests for tobacco byproducts revealed that 34 percent of women who said they didn’t smoke actually did. And people checking into a coronary care unit are more likely to underreport smoking than people at a routine doctor's visit. Similarly, alcoholics — especially those who relapse — often underestimate their drinking, whereas numerous studies show that moderate drinkers accurately report, or even exaggerate, their weekly alcohol intake.
Teens have the highest rates of deceiving their health providers, which makes sense because there is probably no phase of life where one is more fearful of judgment or persecution. A recent study of low-income teens showed that they were 35 times as likely to use illegal drugs (as proved by hair analysis) as to report using them.