Deception

Medicine is saturated with facts, algorithms, regimes and protocols. Within each sentence, table and graph lies the answers to what we seek in the best interests of the patients under our care. Competence may be defined in this context as the ability of synthesising a clinical picture - the patient's presenting complaint and its history on the foreground; their past medical history in the background along with family, social life and profession in between. Integrate this picture with a sound understanding of anatomy, physiology, biochemistry, pharmacology, pathology and other critical topics of medicine... and you have the ability to understand the patient's situation as well as recommend a management plan that will hopefully help them get to their baseline, whatever that may be.

It all starts with clinical medicine - taking a comprehensive history and based on that, performing an examination. Essentially at the end of all this, one comes to a conclusion and investigates this conclusion to prove it and or exclude other causes.

But all of the above makes a great assumption - that the patient is telling the truth. It also assumes that the patient is less knowledgable than the doctor. One need not look further than Addiction Medicine for these 'break-downs' of classical medicine.

I was at a General Practice seminar today, where one of the activities was the video-recorded role playing. Two students are selected, one taking the role of the doctor and the other being the patient in the context of a complex consultation.

A good friend of mine, Jay, was playing the doctor and a colleague, Em, was playing the role of the patient. The patient began the consultation by stating that they require a script for Valium; a known drug of addiction that is common in the community. It is also used as an anxiety suppressant and is obviously quite effective. Jay explored the reasons why Em required the Valium and the responses were that she was a single mother of two children and needed stress relief. She also added that she had muscle cramps in the evenings that were relieved by Valium. Further, Em stated that her regular prescribing doctor was away on leave and this is why she presented to Jay.

Em elaborated as Jay requested - I have been taking them for 6 years now and I've cut down. I've cut down in the past 6 months because I know they are addictive. So I'm only on half a tablet a night and only take them a few nights a week. 


Jay became more comfortable but didn't offer to write the script and did not respond to Em's repetitive requests for one. The video recording and interview were terminated by the observers - General Practitioners.

Each party was asked to read their scenario. Jay read Em is a 28 year old female who has never presented to you before and requests a script for Valium due to stress and muscle cramping. 

Em's patient perspective was quite interesting: You present to Jay, a local GP whom you've never seen for a Valium script. You are currently a single mother of two children and work full time. However to deal with anxiety you take up to 8 tablets of Valium a day and see several GP's a week to renew scripts for the medication. Not only that, you know the indications of anxiolytic therapy and the common conditions in which it is prescribed. Your excuses for presenting to a new GP varies from overseas normal prescriber, urgent matters, muscle cramps among others. You lie compulsively and are persistent but not disrespectful. 


When Jay heard that was Em's script and based on how the consultation went, almost broke down in front of the crowd. Her intention was to truly help her patient by appreciating the circumstances behind the presentation and giving the patient the benefit of honesty.

But we all paint a picture of honesty of our patients because if we didn't, the medicine we practice today would completely collapse.

This entry is a reminder to me of how complex the clinical interactions can be and that no assumption leads to safe ground. We are constantly negotiating a minefield that could have catastrophic consequences if coursed poorly. It was heartbreaking to partially understand the gravity that compels patients to go to incredible lengths to lie and provoke us to formulate a false clinical picture. They have the capacity to understand our thought processes and can infiltrate our education, experience, differential diagnosis and clinical management plans.

I just couldn't believe it.

Even now - it's hard enough for us to come to conclusions when patients are legitimate and honest, forthcoming.

This is a whole new clinical scenario - one that must always be lurking around in the fog of a minefield, that is clinical medicine.