When I was a medical student, I worked with a doctor who lied. One day, she lied by ordering a kidney-stone CT scan on a patient she thought had appendicitis.
Let me explain. I was working in the emergency department with this physician (let's call her Dr. Fibber) when a young man came in with belly pain. The man's story and exam were classic for acute appendicitis: over the previous six hours, he'd had worsening pain that had begun around his belly button and moved to the lower right part of his abdomen. The patient had many other findings that not only suggested appendicitis but also discounted other potential causes of abdominal pain. Dr. Fibber called the surgeon, who examined the patient and agreed that it was most likely appendicitis but requested a CT scan of the abdomen to be sure.
Here was the rub: the type of CT scan used for possible appendicitis cases a CT scan with contrast is a time-consuming process. The patient has to drink a container of contrast, or dye, then keep it down without vomiting until the stuff makes its way through the intestines. This is a problem: it could (and often does) take hours to complete a CT scan for appendicitis. But in Dr Fibber's patient's case, the surgeons and the operating rooms were available at that moment (a rarity!) and could have gotten pulled into a more urgent situation at any time. To top it off, our patient was feeling progressively worse; Dr. Fibber worried that he wouldn't get the contrast down or that his appendix would rupture. Assuming he did have an inflamed appendix, the patient would be better off if he received surgery sooner than later.
This is when Dr. Fibber lied by ordering a CT without contrast for our patient. A noncontrast CT scan is quick, doesn't require intravenous or oral contrast and is pretty good, though not great, for looking at the appendix. By claiming that she wanted to look for a kidney stone, she was able to get our patient the noncontrast scan.
"Your patient does not have a kidney stone," the radiologist who looked at the CT scan images sanctimoniously told my teacher. "He has appendicitis his appendix is severely inflamed. What made you think it was a kidney stone?"
"I didn't," said Dr. Fibber. "You confirmed my suspicion."
As she hung up the phone, she turned to me and explained, "My pretest suspicion for appendicitis was very high for this patient. Alone, the CT scan without contrast isn't quite as good as one with contrast. But an imperfect test, combined with a very high likelihood of appendicitis, was enough to confirm it."
Her justification for the lie: "We can now get our patient the surgery he needs hours sooner than if we had waited for all that oral contrast to percolate through his intestines. The radiologists never would have agreed to do a CT scan without contrast if I explained at the outset that we were looking for appendicitis." Dr. Fibber's reasoning wasn't perfect, but she got what she wanted, and our patient did well.
On its face, it isn't so shocking that fibbing occurs in medicine. Every industry that relies on regulations and rules encounters workers who game the system to accomplish a task. So why shouldn't health care workers, whose charge is to promote the welfare of their patients, circumvent a rule or two if it improves patient care?
Of course, it isn't so simple. Often, the rules, no matter how coarse, are there precisely to promote accepted standards of care. Moreover, we medical professionals insist on honesty and full disclosure from our patients because the complete story is essential to our ability to diagnose and treat. So when we tell untruths, it undermines the cause.
Another problem is that it isn't always so clear who benefits from white lies. For example, take the case of a doctor falsifying medical records so her patient can get tests and procedures paid for by his health insurance. Let's say that the patient has a long-standing symptom but new health insurance that won't pay for pre-existing conditions. Doctors have been shown to endorse writing on the chart that old symptoms are new in order to get their patients coverage. But is this done only for the benefit of the patient? If the physician is also benefiting from the lie by getting paid, it is now a conflict of interest and could be fraud.
An interesting study showed that medical residents will convey misinformation to their colleagues in order to obtain "restricted antibiotics" for their patients. Why? The study didn't state the residents' reasons, nor did it determine whether the misinformation was presented intentionally or not. One possibility is that junior doctors felt pressure from senior doctors to get the patients certain medications by any means necessary. More likely is that it was inefficient and unpleasant for the residents to take the extra time to look up the results of multiple tests for each patient and seek someone else's approval for what they viewed as good patient care (even if it wasn't).
I don't see many lies, even white ones, being told in the day-to-day care of emergency-department patients. However, in a high-pressure, time-sensitive, team-based environment in which competing tasks must be prioritized, getting stuff done often means conveying a specific message about your patient to a co-worker. Sometimes an exhaustive discussion of every aspect of the patient's story feels distracting. In the goal of getting the right person to pay attention to a patient about whom you are worried, conveying the proper message indeed, "selling" the significance of the patient's case becomes important. This, I think, is where spin (and sometimes a white lie) happens.
Dr. Fibber knew her patient would benefit from expedited surgical care, but she needed a test to prove it. She (sort of) lied to get the "wrong" test for her patient, who did end up benefiting. Of course, the whole plan could have backfired: if the noncontrast CT scan hadn't been able to determine that our patient had appendicitis, the consequences a second radiation-emitting test, further delays or inappropriate surgery could have been serious.
As medicine becomes increasingly automated, it will be harder for health care workers to mislead on behalf of their patients. Already medical records and test results are available for consultants, hospitals and insurers to review in real time. Also, the new ban on health insurance exclusions for pre-existing conditions will hopefully make doctors less inclined to feel the need to fudge medical records for their patients.
However, there are also new rules designed to measure and improve the way doctors and hospitals deliver care. While many of these efforts should help streamline and standardize care for patients with certain conditions, we know that many doctors will find these quality measures at times overly prescriptive and too inflexible for individualized patient care. So it's possible that new rules will bring even more white lies all in the name of patient care to the practice of medicine. We'll see.
Dr. Meisel is a Robert Wood Johnson Foundation clinical scholar and an emergency physician at the University of Pennsylvania. Follow him on Twitter at @zacharymeisel.