There is an open secret in medicine: Patients lie. They lie about how much they smoke and whether they are taking their medicine.
They minimise how much they drink and overstate how much they exercise. They feign symptoms to get appointments quicker and ask doctors to hide the truth from insurance companies.
"Doctors have a rule of thumb. Whatever the patient says they're drinking, multiply it by three," said Dr Bruce Rowe, a family doctor in suburban Milwaukee.
"If they say two drinks a day, assume they have six." Hippocrates, the father of medicine, is said to have warned his students around 400 B.C. that patients often dissemble when they say they've taken their medicine.
But lying can lead to expensive diagnostic procedures and unneeded referrals to specialists. It also can have disastrous results.
"I definitely learned my lesson. I could have ended up in a coma," said Michael Levine, a 28-year-old financial adviser in Los Angeles, who lied to a specialist he saw for a wrist injury. Misguided pride, he said, kept him from mentioning the Xanax he was taking for anxiety.
He didn't think the doctor needed to know. "He wasn't my regular doctor. He was treating my wrist," he explained.
The doctor prescribed the pain reliever Vicodin and Levine took it on top of Xanax. The next few days vanished in a cloud of grogginess. Levine slept through ringing phones and alarms and woke up exhausted.
His wrist pain was easing, but he could barely function. Eventually, he stopped the Vicodin, returned to the doctor and, under questioning, confessed.
"The doctor said, 'Why didn't you tell me? I never would have prescribed you that'," said Levine, who now realises how easily he could have overdosed and died. "For the future, I will always 'fess up."
Why do patients lie? The examination room itself is an environment that discourages honesty, said Los Angeles psychiatrist Dr Charles Sophy.
"You're naked in a gown and you have a guy standing there clothed, with a coat on and there's all sorts of things in his pocket. And you're sitting there, basically naked ... that makes it hard to come clean," Sophy said.
On top of that, the doctor may be rushed and convey that by the way he or she asks questions.
Researchers say patients often lie to save face. They want to be "good patients" in their doctors' eyes. Some researchers estimate more than half of patients tell their doctors they are taking their medicine exactly as prescribed when they are not. In reality, they don't like the side effects, can't afford the pills or didn't understand the instructions.
Cyndi Smith, a 45-year-old Weight Watchers leader in the north suburbs of Chicago, said before she joined the group she lied to her doctor about exercise and nutrition.
She lied because she was fooling herself, she said. "You convince yourself of certain things and it becomes true, when in reality it's not," she said. If her doctor questioned her more thoroughly, she said, she might have told the truth.
"I think doctors could be a little more point blank," she said. "And we need to be a little more honest."
Some doctors are seeking approaches that encourage more honesty. Dr Zach Rosen, medical director of New York's Montefiore Family Health Centre, asks his patients a series of questions to determine whether they're taking their medicine.
"I ask, 'What medications are you taking?' At first, I just want the names," he said. "They say, 'I'm taking X, Y or Z.' Then I'll say, 'That's great. How often are you taking that medication?' ... Then I'll say, 'Are you experiencing any problem in taking your medications?'"
Asking several questions takes more time. But the approach elicits better, more honest responses than a single question, Rosen believes.
Doctors also should avoid phrases that sound judgmental, said Nate Rickles, an assistant professor of pharmacy at Northeastern University. There's a big difference between
"Why aren't you taking the medication as prescribed?" and "A number of my patients don't take their medication as prescribed and they do it for a variety of reasons. What do you think might be going on with you?"
When alcoholics seek detox treatment from Dr Akikur Mohammad, an addiction specialist at USC School of Medicine, they must tell him exactly how much they have been drinking so he can give them the right amount of benzodiazepines to treat withdrawal.
"I tell them, 'You can lie to your friend, you can lie to your family members, but you came here for help and your report will determine the treatment plan. If I undermedicate you, you may have seizures and die'," Mohammad said. Despite the warnings, patients still sometimes mislead him, he said.
Some patients are drug addicts seeking to scam their doctors into writing unneeded prescriptions. Joanne Singleton, a nursing professor at New York's Pace University, teaches ways to outwit this kind of lying patient.
If the patient complains of back pain, the nurse practitioner might press on the patient's head and ask if it hurts. It is not really a way of diagnosing a herniated disc, but a drug-seeking patient might fall for it.
Leaving out information, not exactly a lie, can happen when doctors do not ask the right questions. A survey of 131 gay, lesbian and bisexual teenagers attending a conference in Los Angeles found that 35 per cent had told their doctors their sexual orientation.
"This is a very open group ... open enough to come to a conference for gay youth," said RAND researcher and UCLA paediatrician Dr Mark Schuster, a co-author of the study.
"They would be happy to be open with their physician, if the physician would ask." In fact, 64 per cent, when asked what their doctor could do to make them comfortable with disclosing their orientation, marked the survey choice, "Just ask me".
