“Which one of us do you think hears more lies?”

Something shared between two individuals is a secret. When those two people are a patient and a physician, nothing is more important than trust and confidentiality, and the art of medicine is predicated on this simple truth that what is shared between them is private and does not lead to judgment.
The art of medicine and the importance of atient privacy in healthcare

“Which one of us do you think hears more lies?”

I asked the question, not really in jest, of the patient in my exam room. He was a Catholic priest. I told him I was often frustrated when patients lied to me when their health was at stake, and wondered if they told as many lies when their soul was at stake. It started a conversation that lasted over the next three visits, and ultimately led to a friendship. On the fourth visit he said to me, “I’ve been lying to you. I drink at least a quart of vodka a day.”

This story is not about him. The story is about why he lied, and whether he would have confided in me if there had been anyone else in the room with me. He says – and I believe him – that he lied because he wanted me to think well of him. He ultimately told me the truth because he realized that I did think well of him and would continue to do so. This is a part of the magic of the doctor-patient relationship; the real guts of the art of medicine is establishing this bond. When people are concerned about privacy in healthcare, a major part of their worry is that they will feel, and be, diminished in the eyes of people who hear their secrets.

My Medical Sociology professor taught that sociology is the study of groups, and that a group is three or more. Something shared between two people is a secret and is the realm of a lover, a priest, a doctor, a lawyer. Anything shared with a third person is shared with the world. So anything I write in a patient’s electronic health record (EHR) is shared with the world. Insurance companies have the right to read my chart notes. My colleagues read them. Sometimes lawyers read them. If I sit in my exam room and type while the patient is talking, patients sense that their privacy is at risk. And if there is a scribe in the exam room, they are certain of it.

This is a real challenge for doctors. We all have experienced – or heard of a –  secret that wasn’t recorded becoming an issue in a malpractice case. If a patient asks, I have to say honestly that if it’s in the chart it is not something that is kept private. And I can’t vouch for anyone who is with me. One of my most trusted, loyal assistants turned out to be forging prescriptions for narcotics. How could I tell a patient to trust a scribe?

I don’t have an answer for this problem. I do know that if patients don’t think I respect them or don’t trust me, then I would have no enjoyment of my role as a physician. As a result, I do hear things that I don’t write down, and I do ask my assistant to leave the room. And in doing so, I put myself at risk. I can make the case that it might even put the patient at risk. However, if patients have no guarantee of privacy they probably won’t tell me the secret anyway.

To understand more about why people lie, and want to keep secrets, I suggest “The Presentation of Self in Everyday Life” by Erving Goffman. It is an old book that remains incredibly valid. You can also learn what patient’s expect from the doctor-patient experience by reading the results of a Nuance patient survey, Healthcare from the Patient Perspective, coming soon.

For the record, the priest is still a friend. We never decided who heard the most lies. He has been sober for over twenty years. As have I.

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  • Dr. Coleman, thank you for this honest and perceptive essay. An important implication of your writing is the idea that the patient does not want to lose the respect of their doctor by telling a secret that feels shameful (such as an admission of alcoholism). One of the reasons I love working with doctors is because of the rapport they can establish in the first 45 seconds of meeting a new person. Good doctors have the ability to convey “you can trust me, and my compassion will not diminish no matter what you tell me.” Crucial for good medicine!

    • Melissa Farnand

      Connell – thank you for taking the time to write this comment. You might be interested in the work of Dr. Aaron Lazare who has taught me a lot about interacting with patients. His article “Shame and humiliation in the medical encounter” is a classic in the medical literature.

    • Reid Coleman, MD

      Connell – thank you for taking the time to write this comment. You might be interested in the work of Dr. Aaron Lazare who has taught me a lot about interacting with patients. His article “Shame and humiliation in the medical encounter” is a classic in the medical literature.

Dr. Reid Coleman

About Dr. Reid Coleman

As the Chief Medical Information Officer for evidence-based medicine, Reid works to improve both the quality and safety of healthcare by implementing information technology solutions in the clinical setting. He is currently investigating the use of natural language processing (NLP) of big data sets to enhance evidence-based knowledge and clinical-decision support. Before joining Nuance, Reid practiced internal medicine on a full-time basis for 20 years. In 1998, he became medical director for a physician-hospital joint venture, and in 2001 became medical director for informatics at Lifespan, a four hospital, 1,150 bed integrated delivery system in Providence, Rhode Island. In 2010, he was ranked by Modern Healthcare Magazine as one of the “Top 25 Medical Informaticists in the U.S.,” and the following year received the Beckwith Family Award for Outstanding Teaching at Brown. Reid attended the Alpert Medical School at Brown University, where he also currently serves as an Associate Professor of Clinical Medicine. Reid moved to the Providence RI area with plans to stay for four years of college. He is still there today due to the influence of a woman, who has been his wife for the last 35 years.