E21: 7 Domains of Lying (to Your Doctor)

Counting down. Let's get started about lying. I'm really ready. No, I'm not really ready. That was a lie. Okay, let's talk about lying. And we're going to do the 7 Domains of Lying today, and 7 Domains of Lying in women's health specifically.

First of all, we lie a lot. People who study lying suggest we either tell two big lies a day on average, or if we add up all lies like, "How are you doing?" "Oh, just fine," but we're not really fine, that's a lie. Or, "I'm so glad to see you," but you're not really, that's a lie. People who count those lies say we might lie as many from 10 to 200 times a day. So we lie a lot. And it's important to think about how lying affects our health and the way it affects how people care for us and how we care for people.

So there are white lies. "How are you today?" "Oh, fine," when you're not fine, or "Do these jeans make me look fat?" "Oh, no, they're just great." So white lies are lies that are supposed to have very few moral and social consequences.

Now, there are white lies that are part of the butter that greases social interactions, that we might many times a day tell white lies. There are lies of commission, meaning we tell a lie, we know it's a lie, it's not the truth, and it's a lie. And then there are lies of omission, which aren't lies kind of the truth, nothing but the truth, but not the whole truth. And I'm going to tell a little quick story about that.

When my son was little, not so little, maybe 7, I asked him if he wanted to know where babies came from. And he said, "Mom, I know." And I said,"What do you know?" "Well, Mom, the doctor takes the needle and sticks it in the ovary and takes out the eggs and adds the sperm and puts it in the lady's uterus and cuts the baby out when the baby is ripe." And I said, "Oh, well, that's how some babies are born, and that's what I do for a living, but that's not how you were made and that's not how most babies are made."

So I told him how he was made. And he looked at me and he said, "What you and Dad did is sick and disgusting and you lied to me." And I said, "I didn't lie. I just didn't tell you the truth." So those kinds of lies by omission lead us right into Linda Ronstadt who's going to cover her ears and close her eyes.

[Soundbite of "Telling Me Lies" by Dolly Parton, Emmylou Harris, and Linda Ronstadt]

Well, what happens when you lie? Lying is often stressful. There's the concept of cognitive dissonance, meaning it's hard to hold two separate things, two separate realities in your head at the same time. And depending on your moral upbringing, or if you're a sociopath and lying comes easily, lying is often a fair amount of work if this is a really big lie of commission.

It is stressful and people release stress hormones. You can watch the brain go into overdrive. The emotional center of the brain, the amygdala, gets hyperactive as you're trying to decide how you feel about this. And this is stressful and it releases stress hormones and your blood pressure may go up.

In fact, lie detectors, which don't actually detect the lie, they detect the physiologic consequences of you being in a moral dilemma of telling the truth or a lie. Little changes in your blood pressure, little changes in your pulse or the irregularity of your pulse, little changes in the sweat in your fingertips, all these things are how a lie detector detects stress, which can be associated with lying.

So for many of us, it's just easier to tell the truth. But there are reasons where we try to protect ourselves, we try to protect others, we do it for personal gain. There are many reasons we might lie. And lying is a huge topic, but we're going to focus down on lying in medicine, lying in the clinic.

And to help us with this, I'm going to introduce Dr. Karly Pippitt who's here in our virtual studio. Dr. Pippitt is a clinical associate professor and the Assistant Dean of the Community Faculty at the University of Utah Health. That means she sees patients, she actually teaches, and she helps coordinate clinical care in our community health centers.

She is the Director of Medical Student Education in Family Medicine. And she's the co-director of a course called Layers in Medicine. And in fact, this course is the most amazing course about how we try to teach students about lying and a lot of other things. It's really the course about the 7 Domains in medicine that I never got taught when I was in medical school.

Dr. Jones: So welcome, Karly.

Dr. Pippitt: Thank you so much for that lovely introduction.

Dr. Jones: This is going to be the Karly and Kirtly show on lying. So let's start with lying in the clinic. Has any patient ever lied to you, Karly?

Dr. Pippitt: Some that I know about and probably plenty that I don't know about.

Dr. Jones: Well, why do patients lie to us?

Dr. Pippitt: I don't think that patients lie to us intentionally or to harm. I think there's a power dynamic that happens in the clinic, and that can make telling the whole truth pretty intimidating. You're in a vulnerable situation as a patient, and I think you maybe don't want to disappoint your provider if they ask you something about, "How often have you been exercising? How much have you been drinking?" You might downplay those a little bit because you don't want to disappoint that person who's asking you about yourself.

Dr. Jones: So there are some studies on how much people lie when they meet someone new. And within the first 10 minutes of meeting someone new, you might tell as many as 10 different lies. And they're mostly to protect yourself or make yourself look a little bit better. So when you're meeting a new doctor, you might not tell the whole truth because you want them to like you.

Dr. Pippitt: Yeah, you want to present your best self so that they'll think you're a good patient.

Dr. Jones: So not wanting to be yelled at . . . I think diet, exercise, smoking, those are the domains in which people most commonly don't tell the whole truth.

Dr. Pippitt: I think definitely those are probably the biggest categories. I might add alcohol use. It's often the things that we know we should be doing better at, but we don't want to feel like we're in the room with one of our parents.

Dr. Jones: Well, another kind of area where people might tell us the truth are reasons around which people feel shame. And this could be shame because of the social construct of their behaviors. I think of sexual identity, sexual infidelity, or other intimate issues where people don't want to tell you because they're a little ashamed.

And this is important to me as a reproductive physician because I treat people differently, I screen them differently, I counsel them differently if they are sexually active or not, or they have more than one partner. Is this something that you run into, or is this just us gynecologists who don't get the truth?

Dr. Pippitt: Oh, no. Definitely in primary care, this is part of what we manage all the time. We are in the season of physicals. For anyone out there who is on the university insurance, this is WellU physical season, as you know. So this is the time where I'm really asking people a lot about not only diet and exercise, like we talked about, but also about sex. And sex is a really important part of our lives and it's important to make sure we ask.

I liked what you said at the beginning about lies of omission, because often I think things are going on in people's sexual lives that they will talk about if prompted, but they won't necessarily volunteer that information.

Dr. Jones: Right. And sometimes I will ask at the end of a visit and say, "Is there anything else you need to tell me so that I can take the best care of you?" Now, that's kind of an open-ended question, and you're always kind of afraid someone's going to drop a little, "I've never had an orgasm, thank you for asking," and you've only got one minute left in your schedule. So that's . . .

Dr. Pippitt: You can't explain that in one minute? Come on now, Kirtly.

Dr. Jones: I can't. Well, I want to help people out, but I can't do it in just a minute. I say, "That's a really important thing. I'm glad you told me about that. I think we may need to have another visit."

Dr. Pippitt: Absolutely. I think trying to set the stage with patients so that they feel comfortable asking anything, letting them know that there are things that we may talk about in the room that may not necessarily get documented, that you're not going to put the full nitty-gritty details of everything about their sexual lives in the documentation of the note, for some people, that can make them feel a little bit better about sharing information that they feel shame or even perceive shame about.

Dr. Jones: So that's the other area where I think lying is particularly poignant, and that's the fear of disclosure. I mean, this is a not-so-critical example, but I remember asking a young woman if she has had any surgeries. And she said, "No, I've never needed surgery." And then I'm doing her physical exam and she very clearly has had breast implants. So I said, "Oh, I see you've had breast implants." And she looked at me and says, "Oh, you're not going to write that down. My husband doesn't know." I didn't want to say, "Your husband doesn't know?" But she was so afraid it would be in the record, an issue that she had withheld from her husband. It had been done before they got married. She was afraid of that.

And there are much more serious issues that people don't want to put in their medical record. It may be things like infidelity, or substance abuse, or sexually transmitted infections.

So how are we managing to take care of people, transmit information that might be important for my partners who might take care of them when I'm away? But the partner could be that person's bishop or it could be in their neighborhood. I mean, how do we leave things out of the electronic health record?

Dr. Pippitt: Yeah, this is a really great question. And to complicate it further, I would add as a family physician, sometimes I care for parents, children, partners. And so they might not want to tell something to me for fear that somehow I will give this information to their partner, which, of course, I won't. That's against the law to do something like that.

An important thing for patients to know about, and I think as physicians we sometimes forget, is that we don't actually own the medical record, right? This is actually the patient's medical record. And I think we've come a long way in terms of making this something that patients can access and can use as part of their healthcare.

All of our notes are now available for patients to see and read, which I think is a great way to make sure we're communicating information clearly to patients. But now, with that change, it's no longer just the language I might write to communicate to you when I send a patient to you. So how do we include information that is salient and yet not every detail that is not germane to their healthcare?

Dr. Jones: But even sometimes things which are critical in a small town . . . I mean, clearly we're speaking to people who might be listening to us from within the University of Utah Health System. But other people listen who are outside of our system, might live in a small town where everybody knows everybody, and access to your health record, although it is your health record, might be by the nurse who is your next-door neighbor or is your cousin.

Dr. Pippitt: Absolutely, or is the person who answers the phone when you call. Are you going to say, "I'm having vaginal discharge," when that may not be what you want everyone to know about?

Dr. Jones: Yeah. Well, I think one of the biggest issues, which is common, is adolescents who don't want to tell you whether they're sexually active, that's just an example, or are smoking cigarettes or drinking alcohol. And you as a primary care physician take care of the whole family. But I always try to tell the young person, "You are my patient in this room. Your mother, who may also be my patient . . . but any of your information is private to you, and I will try to keep it as private as I can." And I think that's a tough one with kids, young adolescents.

Dr. Pippitt: Absolutely. I saw a teenager just this week who I take care of the parent as well, and the other parent came in the room and had some questions sort of about what we were doing and what was the progress and how did we make sure that we communicated that with the parents. And I said, "Well, first and foremost, I hope that it actually happens through your child. I can understand how you can feel like maybe you're not getting the whole story, but this needs to be a conversation with your child, not just about your child," especially because this was an adolescent.

You want to empower them and make them take charge of their healthcare and feel like they can make decisions for themselves, and yet have the backup and support of their parents, but not necessarily have them be in there controlling things, because you should get to make that decision at a certain point in life.

Dr. Jones: I was happily amazed that adolescents matured about 10 years when the parents walked out of the room.

Dr. Pippitt: Definitely.

Dr. Jones: Then they look at me as a person-to-person, whereas when their parents are in the room and they're looking away. So the whole dynamic of truth-telling changes when their parents leave the room, as does the maturity of the kid. And that's an important sign to try to read in the kid and the parent, I think.

In my field, there's this fear of disclosure. And disclosure, particularly in advanced reproductive medicine, is how a particular child was conceived. So, in my business, maybe a couple or a woman used donor sperm, or maybe she used a donor egg, and I always talk to the couple or the woman when she is considering this, "What are your plans for disclosure to your child when they become older?" And they say, "Well, I don't want my child ever to know."

So here we have information that currently belongs only to the woman, the intended mother, but that information about identity will belong to that child who will be an adult someday. So who gets to choose who owns that information? And by nondisclosure, the mother is lying to the kid about their identity.

Dr. Pippitt: I think it's amazing that you ask that question so early on, because I don't know that many people consider "How would we explain things to our child in the future about where they came from, who their parents are?" And while things like ancestry and other sort of genetic testing are so popular, one of the biggest things that comes out of those that people don't think about is non-paternity.

Dr. Jones: Right, meaning that your daddy isn't your biological daddy. We used donor sperm.

Dr. Pippitt: Yeah, and that's an important thing to consider.

Dr. Jones: Yeah. Well, I try to say that lies are like mines in a field, and your family is walking across this mine and you don't know who's going to step on it. Maybe your sister knows you used donor sperm, but you made her swear that she wasn't going to tell anybody. But lies are juicy and people tell people, and then you never know when your kid is going to find out. It will not be under your control.

There's some data regarding the old-fashioned problem of telling adopted kids that they were adopted, which was very common in the '40s and '50s and '60s and '70s. And that is it's best if your child . . . thinking about my son who thought he was conceived by IVF. It's best if your child never can remember a time when he didn't know or she didn't know the truth. So it's part of their origin story.

You get to control that story if you start very early. If you wait until they're an adolescent and then tell them, "Oh, by the way, your father isn't your biological father," then the whole issues of identity that come around adolescents bubble up in some really big ways. And it's best to have it be part of their always life, I think.

Dr. Pippitt: Absolutely. And then you avoid some of the hurt and mistrust that never gets introduced because, just like you said, it's the story they've always known.

Dr. Jones: Yeah, and my kid thought what my husband and I did was sick and wrong and I lied to him.

So, anyway, there are lies which are nondisclosures, where you don't tell, or you let the child assume that their daddy is their biological daddy. And I think that it's best to just get it out there early. Of course, then you have the 4-year-old who tells everybody in their kindergarten class about where they came from. And that's always a little bit embarrassing.

Dr. Pippitt: Embarrassing, but I think perhaps more common than we know and maybe just makes for an awkward parent-teacher conference or conversation with your neighbor kid's parents, something like that. But on the whole, it's less damaging, I would say.

Dr. Jones: Well, I think so, but that's just me.

Well, I'm going to flip a little bit and let's talk about lying by clinicians I'm going to lead this in with a little musical clip by Annie Lennox and the Eurythmics on "Would I Lie To You?"

[Soundbite of "Would I Lie to You?" by Annie Lennox, Dave Stewart, and Eurythmics]

Dr. Jones: So we lie to patients, we don't mean to, or sometimes we do, just in the way we give them information. In the intellectual domain, we want to give patients the information they can use to make decisions. But sometimes the way we frame it with numbers or the numbers we give them are so useless as to essentially be a lie.

And I think of an example, particularly in oncology or in cancer care, we want to maintain hope, so we tell someone who's got a very advanced stage of cancer that this new therapy will increase their chance of a cure by 50%. And what the patient hears is that they've got a 50% chance of a cure, but maybe it increases their chance of a cure from 2% to 3%. And that's a 50% increase.

So if patients don't understand the numbers that you give them, that ends up being a lie. It's sort of omission and commission. We try to tell the truth, but we don't know enough, or we don't want to tell people the truth about their diagnosis.

Dr. Pippitt: I think sometimes we don't have all the information. And I think COVID is actually a really good example of that with some of the long-term complications that patients are having. We don't have enough information to answer questions.

And so we might try to come up with something on the spot or try to come up with some ideas for answers. And even if we do say, "I don't know," which isn't a lie, you also want to make sure that you're continuing to have the trust and confidence of the patient. And so you might sort of fudge some numbers or make up some . . . not even really make up information, but just massage things to make it seem like things are better than they are, or you might understand more than we do.

Dr. Jones: And when we teach students the foundations of medical ethics, which include beneficence, which means we should do good and non-malfeasance, which means we're not supposed to do bad, and autonomy, meaning we treat patients as if they have a right to make decisions about their bodies and about their treatment, and justice, underlying that is sort of the assumption that we tell the truth, veracity. What we call the Georgetown Four are those first four that I mentioned.

But in some cultures and sometimes one thing fights with another. We want to tell people the truth, but in someone's culture, we're not supposed to tell the granny that she's got cancer. As Americans, we tend to be, "Just get it out there. Spit it out."

Dr. Pippitt: Yeah, absolutely. And I think culture, language barriers, it's hard to know sometimes if you're explaining something in a way that makes sense to people or that fits in with their cultural understanding of their own body.

I feel like diabetes is a good example for some reason just because it's so common and it can affect so many different aspects of your life. So I can feel like I'm explaining it well. And back to that idea of patients not wanting to disappoint their physician, I think often patients will say yes. They will agree with you. They will tell you that they understand. And then sometimes when they come back and you talk through, "Okay, so what happened? Your A1C went from something normal to even higher. Tell me what you understood, and how can I help you take better care of yourself?"

Dr. Jones: Right. They'll nod, even people from other cultures where you're supposed to please people with authority. They'll nod when in the back of their mind . . . I'll say, "Well, are you going to fill this prescription?" and they'll nod, but they're not going to. They're afraid to hurt my feelings or make me upset if they say, "No, I have no intention of taking that."

So I think that those kinds of interactions where we want to try to do good, but we just don't know someone well enough . . .

Dr. Pippitt: And sometimes they may have something that they're looking for as treatment. If you either can't figure that out or don't answer that question of, "Oh, I think that this headache I have might be a brain tumor," and you don't address that in some way, maybe because you didn't ask that question or maybe they felt silly saying, "Oh, I'm worried that this new headache is a brain tumor," they may not want to come back to you. They may not be very likely to follow up in treatment because you didn't get at really the thing that they were the most worried about.

Dr. Jones: Right. Well, I think about specifically asking patients when they come with a particular complaint and say, "Well, what do you think is going on, or what are you worried that is going on?" and trying to get people where they are.

This is part of the way we approach the 7 Domains of Women's Health because many people are afraid to talk about the finances, or they're afraid to talk about what this means to them socially, or they don't have the words or the cultural competence to even frame it. But if I just open up, "Tell me what you think is going on or what you're afraid is going on," or, "Tell me what kind of therapies you've been thinking of," it lets them at least give me a hint of where they might be going. If I have a Plan A and they've got a Plan B, I better hear about what their plan is because mine isn't going anywhere if they've already decided what they want to do.

Dr. Pippitt: Absolutely. I kind of like it when patients disclose to me that they've been looking on Dr. Google or WebMD. They will sort of look at me sheepishly when they bring it up. And sometimes I will say, "Wait, let me guess, you have cancer or you're dying." And they'll start laughing. But there are a lot of things that can make you think of that in medicine, and so those are pretty common things that are going to come up on the list when you put symptoms into Google.

Dr. Jones: Right. Well, I think that sometimes for me in terms of how much people want to know, and it's always hard when there's a whole family in the room, is, "Tell me what you want to know so you can participate in the medical care of your illness as much as you want to." Or, "With whom do you want me to share this information? Do you want to hear this from me? Would you like me to talk to your son or daughter?"

Rather than telling someone a fib or a lie or not knowing what the right thing is to even tell them, you ask them, "How much do you want to know? Do you want to know everything?" For me, it would be like, "Every single detail. And I want to know all the resources so I could read the papers." But not everybody takes that approach.

Dr. Pippitt: Absolutely. And then this can be complicated by whomever else is in the room. So maybe there are conversations you don't want to have based on who's in the room, but how do you . . . You don't always know what the news is going to be when you walk in the room. So maybe you do want someone with you, and maybe you don't. How can you change that on the fly and be . . .

I mean, sometimes I'm happy to be the bad guy in the room so that patients don't disrupt something going on with the family. But that adds another complication to, just like you said, how do you tell grandma what's going on? Maybe grandma doesn't want grandkids to know something and vice versa.

Dr. Jones: Yeah, there was an Oscar-winning film, I think, from 2020 about an Asian family where the grandma has got some lethal illness, but no one wants her to know. So it's this big secret. They want everybody to get together to be with her, but they don't want to tell her why they were getting together. So they make up this fake thing as to why everybody is getting together.

Once again, I don't know the cultural norms from culture-to-culture to how to disclose things. And that's a little difficult. I think we're trying to get smarter.

What do you teach medical students about lying? Nobody said anything when I went to medical school in a previous century. No one taught me anything about what was good lying and bad lying or . . .

Dr. Pippitt: I think one of the biggest things we teach students is that it's really complicated. And medicine is much more gray than you ever think it's going to be when you learn it.

In the first couple of years, you're assessed primarily by single best answer on multiple-choice questions. And we often will tease that patients don't come with a multiple choice on their chest, and there's often not a single best answer. I'll often tease patients in the room, especially with a student that, "You're not really following the textbook of how this diagnosis is really supposed to be."

I had a really good conversation with one of my students in clinic actually this week who had a lot of medical conditions, and they asked the question, "Did I know if this person had a past history of trauma?" just because of the number of medical conditions that were going on and no real underlying cause. And I said, "Well, I do know that there's some trauma through our earlier conversation. I don't think it's explicitly documented in her chart." And then we talked about how you delicately broach that conversation.

The well-written book is called "The Body Keeps the Score." Sometimes there are ways that your body reacts to past trauma or things that have happened that aren't under your control, aren't things that you're trying to have happen, and not have that be heard by a patient as, "This is all in your head and there's nothing wrong with you."

Dr. Jones: Yeah. As we wrap up, I want to talk a little bit about the spiritual domain because there are clearly some people for whom lying is easy and they don't carry the lie that they told in their little purse of bad things that they've done. But how do we come to some kind of peace with our truthfulness or our less than truthfulness as patients and as clinicians?

I think our lies can keep us from inner peace, and big lies we carry around are hard to dump. I know if you belong to certain religious traditions you can be absolved of certain kinds of lies. But if you don't, you just carry it with you.

In the end of the day, if you have lied, then you need to do what you can to be a good person about it, and you have to forgive yourself at some point or have someone forgive you. But going forward, lies often keep us from feeling whole and worthy.

Dr. Pippitt: I think that's actually a really profound thought. One of the sessions we do in the Layers of Medicine course is actually called Worthy and Unworthy in Medicine. It's intentionally a provocative phrase. And we think about that not only from a "Which patients might you think of as worthy or unworthy?" but what about yourself in medicine and in life? How do you feel worthy and unworthy? Maybe you've either told a lie to a patient or maybe not been entirely truthful. That's something you may carry and will carry from room-to-room, even if it's not with your next patient.

Dr. Jones: Right. So on the whole, not only is lying hard on your body right now in terms of your cortisol and stress response, but it can be hard on your body repetitively. It's the gift that keeps on giving if it's a big lie. And it's better if you can, understanding that sometimes you can't, but it's better to try to tell it like it is.

So I want to thank Dr. Pippitt for joining us as we talk about lies in medicine and the 7 Domains of lies. And as we always do, we're going to end up with the 7 Domains of Lying haiku. But before I do the haiku, this is a reminder to thank everybody for listening. And you can listen to more of our podcasts wherever you get your podcasts or at womens7.com.

And to head out with our lying haiku, here it is.

Tell me your best truth
I'll tell you truth as I know it
Our hearts will sing true