'Problem Patients': When Modesty and Honesty Get in Your Way

May 18, 2011

It may seem like a stretch to address these two very different concepts together, but soon you’ll see how closely related they are, and how understanding the background for both can help you improve relationships with your patients.

This is the third in a four-part series exploring better communications with your patients to enhance their visits to your practice. Scroll down to read more from this series and be sure to join us on Wed., June 1 at 8 p.m. EST for a Twitter chat with Trisha Torrey. 

It may seem like a stretch to address these two very different concepts together, but soon you’ll see how closely related they are, and how understanding the background for both can help you improve relationships with your patients.

The first time a doctor told me her patients lie to her, I was stunned. She went on to explain that in her work as an anesthesiologist in an academic hospital, she had to teach her residents how to accommodate for patients’ dishonesty when figuring out how much anesthesia they would need. Ask patients how many alcoholic beverages they drink in a week, and they will usually own up to only a fraction of their real intake.

Why would patients lie, or shade the truth? Like other patient communications problems, the answer is history.

We have all spent our lifetimes being judged, or assuming we were being judged, in particular by authority figures. When we were little, our parents judged us. Later, we were judged by peers, then teachers, then bosses, even spouses - all people we consider to have some sort of authority over us, no matter whether they did or do not.

Most patients regard their doctors as authority figures, too. We believe you will judge us and we won’t stack up. If I am overweight, I think you will judge me for eating too much or not getting enough exercise. I’m afraid you’ll be upset if I tell you I take ginseng to boost my energy. I’ll hide how much I’m smoking because you’ll be mad. Whether or not it is your intent to judge us, we patients believe you will. We are too embarrassed to tell you the truth, even if you can see right through us.

Which takes us to modesty.

The single biggest complaint I have ever heard from patients is about providers’ who violate their sense of modesty.

Why modesty? The answer is, once again, history; with the same basis as to why patients are less than honest. We have all spent a lifetime being judged for our appearances. Further, religion and culture dictate that certain parts of our bodies not be viewed by anyone but ourselves or our intimate partners.

Patients know, intellectually, that providers should be exceptions to those mores. But emotionally we can’t get past the standards that have dictated all other aspects of our lives. Some patients refuse to seek medical care at all because modesty issues control them. We are, simply, embarrassed.

However, the biggest complaints about violations of modesty aren’t usually about doctors themselves. They are complaints about the female nurse who preps a man for his vasectomy, or the other people in the hallway when the patient is led into another room wearing a backless exam gown. Those are not people we want to be intimate with. We are embarrassed, and blame you for putting us in that embarrassing position.

So now that we better understand how history affects patients’ behavior, how can you, as a provider, improve the veracity of the information your patients share, and remove those modesty barriers?

By providing evidence that patients can trust you. By giving us back some of the control we feel we lose when we are being judged.

Here are some examples:

• A patient who smokes will lie to you when you chastise him for doing so. Instead of sounding judgmental, ask him how you can help him quit. You become the partner instead of the judge.

• Tell the patient who continually returns to you for pain meds what your barriers are to prescribing them. Be candid. Explain what can happen to your license and your practice if you over-prescribe. Then ask her what she would do in your shoes. You won’t be judging her. You’ll be making her think differently.

• If your practice of medicine requires patients to yield some of their modesty to be examined or treated, build an environment where patients feel safe. Hire more male nurses, if necessary. Don’t leave exam room doors ajar when patients are disrobed. Provide gowns that cover patients’ entire bodies if they must move around in hallways. Emphasize respect for modesty issues among your staff.

Most patients begin a relationship with a new doctor by trusting, so it’s up to you to be sure you don’t violate that trust. If the trust ship has already sailed, then help patients better understand how they can control the situation so they will begin to return some of that trust you deserve.

Remember, it’s the patient’s perception that is important. Even if you don’t think you are judgmental, your patients may think you are. So be sure they understand that you are a partner. Building and maintaining that trusting relationship begins with you.

Next week, we'll look at one of the biggest issues I hear about from physicians: dealing with angry patients.

Trisha Torrey is "Every Patient’s Advocate," the About.com Guide to Patient Empowerment, and author of "You Bet Your Life! The 10 Mistakes Every Patient Makes (How to Fix Them to Get the Health Care You Deserve)." She focuses on helping patients and doctors work more collaboratively to improve outcomes for all.