The E.R. House of Smoke is Really Just a Looking Glass
With privacy ensured by doctor-patient confidentiality, you would think that individuals would tend to be a little more honest with their doctor.
Wrong. Wrong. Wrong.
Many people might be wondering what kind of person lies to their doctor. My informal poll of about 30 emergency room nurses and doctors revealed they find that 65-70% of patients told a significant or material lie during some part of their visit. I mentioned this informal statistic to a colleague and he said, “More, way more.”
It has taken me quite some time to get my head around the sheer lack of truth occurs in instances where the patient’s life and limb are literally in danger. My first response was to throw my hands up in wonder at just how reckless people were being with their lives. I wondered what mental process led these patients to show up to the Emergency Department with a serious illness or injury, telling a lie about some material portion of their medical history and then expecting the doctor to get the right diagnosis then choose the correct medication or invasive procedure.
Don’t get me wrong, not all lies are equal, and the motivations not always easy to discern. Here are the main types of lies I encounter on a daily basis during an average shift.
White lies are the types of lies that we are all familiar with, lies for the greater good that you tell so you don’t hurt someone’s feelings. “No, your butt doesn’t look fat in those jeans,” (not any fatter than usual) and “That is an amazing picture you drew,” (good thing you are a good at math/forget about that career in art).
In the ER, white lies often sound like,” I have been waiting 3 hours in triage.”
Don’t you realize we have computers and know that it’s been exactly 2 hours and 8 minutes since you walked up to the registration desk?
The reason: The person is stretching the truth in order to convey that they don’t wish to just say they are frustrated they had to wait to be seen for their emergent ingrown toenail. Simple. Understandable. Forgivable.
Lies by omission are the lies that “conveniently” leave out critical information. When a 70-year-old doting grandmother is asked if they know why they fell down the stairs and hit their head last night, they can’t think of any reason. All the while knowing their love for a couple tumblers of Absolut a day is what caused the fall. The uninitiated and naïve doctor would reasonably focus in on cardiac, neurological or other sinister sources and start ordering thousands of dollars of tests. Often times a doctor won’t think to ask about alcohol and drug use by a well put together senior citizen. A simple admission by grandma would curtail the process and lead to actions by the physicians and nurses that might actually help her instead of racking up her bill.
Lies by Exaggeration have many roles in our daily lives.
It is the spice of life. Used in our anecdotes and stories of our glory days can bring the room to laughter and astonishment, a little sprinkled into a compliment can make a chef or child swell with pride.
Ahhh, exaggeration in the medical setting. I think this is the one that can turn the warm heart of a triage nurse into an eye-rolling functionary in about 2 seconds flat. The most frequent violation of this particular type of lie has to be the “pain scale". Whoever imposed this measurement should be put on “the rack” until they experience a true level “10” pain.
Now for the uninitiated, the 1-10 rating scale is supposed to symbolize the entire range of the pain spectrum. “1” is mild discomfort. “3” is an annoying, nagging, pain. “5” you just got shot in the abdomen, you can walk but not far. “7” is a severe, blinding, cold sweat, you can’t concentrate on anything else (certainly not your cell phone text messages) pain.
And then there's 10.
In 15 years of trauma and emergency medicine, I don’t think I’ve seen a “10”. I imagine that type of pain is only found in dark torture chambers of the Marquis de Saade, but probably not a finger laceration repair in room 7.
Lies of denial are pretty simple. Humans wish to think the best about themselves and their situation. Our brain is powerful enough to construct and mostly believe an alternate reality of our own creation. We want to believe in our ideal self that doesn’t use drugs, wears seatbelts, doesn’t drink and drive, didn’t deserve the ass-whooping by the “two dudes” or “that crazy b***h”.
This type of lie is usually pretty easy to see through because the injury and the patient’s deceitful description of the encounter usually don’t match up. Furthermore, the fact that we are asking a direct question and they are denying it is usually a pretty good indicator that we already know the answer.
Lies of diversion usually stem from a need to obtain or service or good from someone else. In the outside world, these perpetrators take the form of con Men and women. The origins of “con man” is a confidence scam perpetrator. As implied by the full name, these people take the long road and rely on gaining their victims' trust before committing the fraud or crime.
Doctors and nurses routinely see this in the patient that has severe and mysterious abdominal pain, no identification, fictitious symptoms, and sometimes manufactured signs like sticking blood in a urine sample to create a kidney stone. For the patients who are rarely able to pull one over a medical staff, we often find ourselves saying “well done!” It is a shame that such a convincing acting and emotional depiction of severe abdominal pain is spent obtaining 8 Vicodin and a couple milligrams of morphine instead of selling the opening scene in Saving Private Ryan.
"It is a shame that such convincing acting is spent obtaining 8 Vicodin instead of selling the opening scene in Saving Private Ryan."
Paternal lies are those where the person feels that they know more than the other person in any conversation. These are rare in most workspaces. Most people wouldn’t have the guts to lie to their boss because they felt they knew better; the risks of being fired are too great. However, in medicine, there are plenty of hypochondriacs who come in armed with their newly-acquired WebMD knowledge and are convinced they have some bizarre or serious illness. They may, in fact, have 1 of the 10 symptoms common in the disease, but in order to get the evaluation and lab tests they desire will add a few more “untestable” symptoms to their list of complaints in order to build a case. This is most commonly seen in chest pain evaluation in the otherwise healthy 25-year-old male. We frequently see this in the young pregnant female who states she is bleeding and having cramps so she can have a same-day ultrasound just to look at her new fetus.
A concerned, non-medical reader of this article might come to the conclusion that perceiving most of your patients as “liars” paints them in a negative light. Aside from the fact that detecting lies provides some intellectual stimulation in an otherwise run-of-the-mill skin infection, this way of thinking shows a lack of understanding of the Emergency Medicine morality. The emergency room has its own code of honor and conduct. We are some of the least judgmental people on earth. You might be a crack-smoking prostitute or a homeless alcoholic, and that’s okay. You might even be an unfaithful John with a drip or tweaker with an abscess. In our minds, these are only your temporary “occupation”, of sorts. It is not who you are. To the ER nurse and doctor, you are a kind and moral person and will be treated with respect and dignity as long as you are kind to us in turn and you never, ever, tell us your pain is an “11”.