Why patients withhold facts – and what you can do about it
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Why patients withhold facts – and what you can do about it

Jennifer Trueland Health journalist

Omissions of truth may be a patient’s way to avoid judgement, but can jeopardise care. Find out how to improve communication and help patients open up

Research suggests that most patients have withheld medically relevant information from healthcare professionals, including nurses.

Nursing Standard. 38, 2, 35-38. doi: 10.7748/ns.38.2.35.s13

Published: 01 February 2023

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Picture credit: iStock

Whether this is a deliberate lie – about the amount of alcohol they drink, for example – or a genuine misunderstanding, failure to disclose pertinent facts can have a detrimental effect on the quality of care the person receives and can even be harmful to their health and treatment outcomes.

If, for example, a patient says they are not taking any medications, but fails to say they are using supplements or something bought over the counter, there is the risk of a reaction with medicine they are prescribed. Or if someone says they are adhering to a treatment regimen when they are not, they risk having their treatment plan escalated unnecessarily.

So how can you recognise when someone might not be telling the full truth – and encourage patients to open up, even about something they don’t want to talk about?

Avoiding judgement or shame

Practice nurse Jan Procter-King, managing director of Et al Training, which conducts training sessions for healthcare professionals in primary care, says patients might have good reasons for not wanting to disclose information, and that nurses should be understanding of this.

‘The main one is that people want to avoid shame and they want to avoid judgement,’ she says. ‘They want the doctor or nurse to think they are nice, they’re good, they’re trying and they are following advice. Because they are lovely people, and they want that relationship to be maintained.

‘That’s where they are coming from. Do we say that’s lying? Or are they just telling us what they think is right so that they don’t feel judged or shamed?’

What motivates people to obscure the truth when talking to health professionals?

According to research published on JAMA Open in November 2018, around eight in ten people surveyed said they had avoided disclosing at least one medically relevant fact to clinicians.

Researchers from US educational institutions questioned people about what information they were most likely to avoid telling a clinician, and also examined the reasons for non-disclosure, for example embarrassment or privacy.

Survey participants were asked if they had ever avoided telling a healthcare provider that they:

  • » Did not understand the provider’s instructions

  • » Disagreed with the provider’s recommendation

  • » Did not exercise or exercise regularly

  • » Had an unhealthy diet

  • » Took certain medications (deliberately not mentioning a particular agent)

  • » Did not take their prescription medication as instructed

  • » Took someone else’s prescription medicine

If they said they had ever avoided telling a clinician any piece of information, they were then asked why.

Most commonly, people who did not disclose the truth about health behaviours, such as details about their food intake, said that they did not want to be judged or lectured about it. They also cited not wanting to hear how harmful the behaviour was; embarrassment; not wanting the clinician to think of them as a difficult patient; and not wanting to take up more of the clinician’s time.

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Patients’ body language can give clues to whether they are being truthful – and help healthcare professionals know what to ask next

Picture credit: iStock

‘These findings indicate that clinicians at times do not receive accurate, relevant information from patients, which may affect clinicians’ diagnoses and recommendations as well as patient care,’ the authors said.

‘The client-patient relationship requires honest and open communication between both parties to maximise the therapeutic benefit and avoid potential harms.’

They said that future research should test interventions aimed at improving trust and communication between patients and clinicians as well as patients’ comfort with disclosing information to their clinicians.

Source: JAMA Network Open (2018) Prevalence of and factors associated with patient nondisclosure of medically relevant information to clinicians.

Motivational interviewing

There are ways that nurses can address this, says Ms Procter-King, who trains healthcare professionals in skills including motivational interviewing.

‘One of the issues is that we often don’t explain why we need the information,’ she says. ‘People might think something is very personal, and they don’t want to tell us.

‘But if they understand that we’re asking for a reason, and that it can have an impact on their treatment, then they will make a judgement on whether to tell us or not.’

She advocates using motivational interviewing techniques to make patients feel comfortable – and to help them come to a decision about whether to disclose the full truth.

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‘If we’re uncomfortable with a question that we don’t want to answer, but we’re not good at telling lies, we’ll deflect it in some way’

Adrianne Carter, pictured, body language expert

The ‘ask share ask’ model

This includes the ‘ask share ask’ model, where you ask someone what they know about something – for example, a healthy diet – you listen to their response, then you ask if you can tell them some additional information or clarify misconceptions, then you ask what they have understood from that, and where they want to go from there.

Being careful about how you ask questions can also aid understanding, Ms Procter-King says. For example, rather than asking someone how many units of alcohol they drink, you might say ‘can you tell me about your drinking?’. ‘They are two very different questions,’ she says. ‘We tend to assume that people are health literate – we’re in a rush and just want to fill in a form – but a lot of people don’t know and we want to ensure people understand what we’re asking and why.’

Not making assumptions about the answers is also important, she says. ‘I remember an older woman who said she had a sherry every day, and I thought to myself, there’s a word missing – she means a small sherry. Turned out she was having a pint of sherry a day.’

Ways to avoid triggering shame

Even a hint of judgement from a health professional can be detrimental, Ms Procter-King adds. ‘Once you trigger shame, people go into defence mode, and no good comes of it. My fundamental belief is that people have a right to tell you what they want you to know. We have no God-given right to demand anything. But if you are kind and empathic and nonjudgemental, people will often tell you the truth.’

There can be other reasons why people do not tell the truth, such as saying they are eating healthily or are taking prescription medication when they are not. Again, they may be trying to please the health professional, but in some cases they might feel shame because they cannot afford to fill a prescription or buy certain foods.

In these situations, Ms Procter-King advises handing the dilemma back to the patient.

‘You might say, “I’m interested now, because you’re putting on a lot of weight, yet on the other hand you’re telling me you don’t eat. Why do you think is happening?”

‘You’re not judging, you’re not saying they’re lying, you’re handing it back to them so that they can come up with what they want to tell you.’

How to look for clues a patient may not be telling the truth

A patient’s body language can give valuable clues to whether or not they are telling the truth – but nurses should also consider what their own says about them, according to body language expert Adrianne Carter.

A trained counsellor and psychotherapist, she is also a qualified Facial Action Coding System coder, having trained to interpret body language objectively using the results of years of research based on millions of photographs and examples of footage of people.

Interpreting body language is an important skill for healthcare professionals to develop, she says, because it means they can read what people are actually telling them, but they can also ensure that their own body language is welcoming and non-judgemental.

She stresses that determining whether or not people are telling the truth is not simple. ‘There is no one sign of lying. If anyone says that there is, then they’re not really an expert. But there are tells, or clues, or things that people do.’

The ideal situation is where you know someone well, and detect a change in their behaviour, she says. ‘They might be talking normally, and then they’ll give a little laugh, or clear their throat, or start cleaning their glasses. They change their behaviour from how they were.

‘If we feel uncomfortable with a question that we don’t want to answer, but we’re not good at telling lies, we’ll deflect it in some way and the behaviour will change.’

There are other visual clues that suggest someone is uncomfortable, such as changes in skin tone. But this isn’t the case for everyone, she says.

‘If someone is a successful liar – and I’m not saying they’re a bad person, they’re just really good at lying – you probably won’t see as much change in behaviours. What you will often see, though, across the board, is when people put their lips together and sort of roll them in when they’ve said something untrue.

‘Say you’re the nurse, and you’ve asked someone how many alcoholic drinks they have, and they say four a week when it’s actually four a day, people will often press their lips together or put their fingers to their lips because they haven’t told the truth, and their body is reacting to that.’

Our bodies are much more truthful than we are, she adds. ‘It’s said that the feet are the most truthful part of the body – they will always point where the body wants to go. So if a nurse is asking questions the key for them is to look where the feet are pointing.’

If the feet are squarely in front of the nurse, then fine, but if they are pointing to the door, chances are they don’t want to be there. Similarly, if someone turns away, they are literally giving ‘the cold shoulder’ and expressing their desire to be elsewhere, she adds.

Tips for putting patients at ease and encouraging truthfulness

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Picture credit: iStock

  • » Make sure your own body language is open and relaxed Human beings are social creatures and we copy each other, so if a nurse looks tense and highly strung, the patient will pick up on that energy

  • » Use open language, both verbally and with your hands – open your palms and keep your hands visible

  • » Be friendly A genuine smile as someone enters a room will make them feel more relaxed and calm than greeting them with a ‘neutral’ or stony face

  • » Make eye contact and show that you are listening– we all want to be seen and heard

  • » Minimise barriers In healthcare settings, uniform can present a barrier, so try to ensure that you minimise other barriers between you and the patient – for example, keep your desk clear

  • » Consider body language Look critically at your own natural body language and how you might come across to patients (and colleagues)

  • » Ask if there is anything that the person would like to add, as it can be a simple way to encourage people to open up

By Adrianne Carter adriannecarter.com

Myths about body language

Nurses should also look out for the one-shoulder shrug, says Ms Carter, as this can also be an indication that what someone has said is untrue.

Conversely, there are a lot of myths about eyes, she adds. ‘Some people will blink faster when they’re lying, but others don’t. And some people will stare at you in the eyes because they are willing you to believe them, because they’ve heard the myth that if you blink and look away, then you’re lying.’

It can be hard to distinguish between the person who is lying and the person who is telling the truth but is anxious they will not be believed, adds Ms Carter.

And if someone believes the untruth they are telling – such as a person with dementia who says they walk to the shops every day, when in fact they never leave the house – then it is practically impossible to detect the lie, she says.

‘People have a right to tell you what they want you to know. We have no God-given right to demand anything. But if you are kind, empathic and non-judgemental, people will often tell you the truth’

Jan Procter-King, practice nurse and managing director of Et al Training

More from every interaction

Ms Carter believes that training in body language can help health professionals save time with patients by developing the skills that allow them to get the maximum relevant, truthful information in as short a time as possible.

‘In healthcare if you’re having interactions with people and you don’t fully understand facial expressions of emotion, and you don’t understand even basic body language, you’re missing massive opportunities,’ she says.

‘And if you don’t understand yourself, and what you’re revealing, you’re missing the chance to make even a small tweak that might make all the difference to the way that people respond to you.’

Further information

JAMA Network Open (2018) Prevalence of and factors associated with patient nondisclosure of medically relevant information to clinicians.

Adrianne Carter: The Face Whisperer adriannecarter.com

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