Pinocchio in the Clinic: Navigating the Honest Patient-Provider Relationship

June 8, 2023   |   PA

Regardless of what your professional title may be, we are collectively lumped into the category of HCP (Healthcare Provider). We are also adults who have experienced the various stages of life: we read about Pinocchio as children, read the story to our children and grandchildren for the purpose of forming their character. I challenge some of my readership to write a short story about this familiar character and allow it to morph into the relationship between a patient and their medical provider. Make it short, attractive, and personable, yet truthful and direct. We must educate our patients on the need for honesty in our relationship. Remember, this short message also reflects on our need to be honest with them about a diagnosis, a treatment, and a prognosis.

According to the available literature on a subject search, Pinocchio is definitely in our practice, although he is known by another name; 28-70 percent of our patients may wear this nameplate from time to time in our relationship. What constitutes a patient who does not tell the truth? Most are not malicious but are perhaps fearful, embarrassed, manipulative, or embellishers – and this is the short list. Our responsibilities in patient care are to search for the source of a problem, formulate a differential diagnosis, and then apply our knowledge and ability to order appropriate testing to confirm a diagnosis. Is it unfair for us to be suspicious of this large percentage of patients who are dishonest and are navigating a map to drugs or treatment?  “A double minded man is unstable in all his ways.”

What subjects seem most common for patients to become unreliable sources of information? Sexual affairs and insecurities, alcohol use, drug use, how a foreign body became lodged in a body cavity (think drugs and toys), eating habits and diet, exercise, internet self-diagnosis, using another person’s drug or OTC medications, interpersonal relationships, and previous encounters with medical care specialists. As I mentioned in the previous paragraph, this is not an all-inclusive list and perhaps you can add to it. Regardless, an accurate diagnosis and treatment plan rely on provision of information from the patient.

In general, people and patients ignore the truth and either exaggerate or diminish their symptoms and behaviors for a variety of reasons, some of which can have dangerous or even fatal consequences. I once had an honest heart-to-heart conversation with one of my patients about the subject of veracity. He became my professor for the next ten minutes as he explained how people like himself managed to deceive and manipulate the HCP, like a puppet master with the end point of receiving certain prescriptions. The sum of his conversation was describing the utilization of “Dr. Google” and pharmaceutical websites to discover the drugs he was interested in obtaining and the diseases that the drugs were used for, with the accompanying list of probable symptoms. He tutored me on the fact that not every presentation can be proven by lab studies and radiological tests. He also tutored me on this conclusion: an HCP needs to document a history, and if the history is accurate, then the provider is almost obligated by the legal term of failure to diagnose, to write a prescription. Not surprisingly, this patient is an attorney.

At this point, I would advise us that not every encounter is as simple as the alphabet. Patients may embellish the truth for their own purposes. They may manipulate by exaggerating an injury in order to receive certain medications or even physical therapy. Some may have elaborate stories as to why they need a prescription refill. We have all heard that the pills fell in the toilet, but who takes their medication in the toilet? How did their children or dog discover their medication and drop it into the toilet? Some of the better responses were that they were stolen from my car, pocketbook or jacket pocket. A fairly new response is that my guest or sibling must have accidently taken them while they were hurriedly packing and I discovered it just in time to miss my next dose. All hypothetical responses but, once again, I challenge you with the question, “What do you do?” How do you react without outright calling them a liar and creating an adverse relationship? The patient has the ability to study the same psychology books that we do, but they sometimes study with an aim – to create a logical response. We do not possess a crystal ball, unless we are practicing a very unique alternative medicine.

In conclusion, how can an untruthful history create a medical problem or catastrophe which ultimately leads to a lawsuit? Sometime in the past I wrote, “the greatest number of malpractice suits are not due to technical error.” The greatest number of lawsuits come from the same problem, “failure to diagnose.” You authored a medical chart statement in your words and without suspicion of the fact that not all of the information in your chart was reliable or correct. You cannot alter that chart in any manner. You formulated a working diagnosis after carefully listening to your patient, totally unaware of the veracity of their assertions.

Their comments and history are not the subject of this litigation; it is your treatment! There is no procedure for establishing the truth and now you are the victim. The scenario has the potential for you to wish that you had chosen another profession. What is your recourse as you sit in the courtroom? For yourself and the thousands who have preceded you or who are about to become victimized, there is only one golden umbrella – a current, up to date, personal liability insurance product with your name only as the policy holder. This requires a personal decision with a personal investment that provides you with a secure future. Whether you are a new graduate who receives a reduced rate by superior rated insurers, or you have practiced a few years and have heard horror stories involving culpability in your profession, you can make that choice today. Stand on this instrument which is solid rock rather than an institutional policy with vague assurance. This decision can create a secure situation for you today, as well as for both you and your family in the future. My best wishes for a great decision.

Written For CM&F By: Robert M. Blumm, PA, DFAAPA, PA-C Emeritus
CM&F Clinical Advisor


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