DECEPTION

How does a doctor help a patient who intentionally lies?
 
Having been around the track a few times I admit I’ve forgotten much of things taught in medical school.  But I’ve remembered one thing one professor advised when the matter came up.  He said, “Always believe the patient’s medical history.  Because if you suspect patients are withholding or falsifying their medical history then you’ll end up not treating anyone.”  Or at minimum, you’ll be less effective than you otherwise would be.
 
So Wally, not his real name, in his late 20s presented as a new patient recently requesting a refill on Klonopin, a long-acting tranquilizer used to treat anxiety.  As proof of his legitimate need for this medication he placed on the table an empty bottle of the medication, dated one month previously, and with his name and the doctor’s name on it.  Interestingly, it had been filled at a Hattiesburg pharmacy and he himself had moved to Mississippi from out of state.
 
Giving him the benefit of the doubt without medical records being available, he was prescribed one month’s worth until previous medical records could be reviewed, to which he agreed.  He denied taking any other prescription medication, claiming he only needed this to control the stress he experienced working in the kitchen of a local large employer.
 
Two hours after the visit a Hattiesburg pharmacist called to report that Wally had filled a prescription for 120 Xanax tablets just 5 days previously.  The pharmacist was instructed to void the Klonopin prescription, for obvious reasons, and to have the patient call the office for clarification of this new medical history.
 
A few minutes later Wally called incensed, explaining (screaming) that Xanax and Klonopin “were the same.”  I suppose he meant in the same way that gasoline and kerosene, or sugar and honey are the same.  He further pled that his California doctor had prescribed the Xanax, even though he specifically denied such when he was asked.
 
Anyway, after he hung up, slamming the phone down, more or less, I had my nurse call him back in an effort to see if he might be amenable to returning to the office in order that a better understanding could be had as to why he felt a compulsion to take frequent doses of Xanax while simultaneously taking Klonopin (his doctor-hopping to be explored later).  The obvious reason was for abuse or misdirection for sale and profit on the street.  But perhaps there was an approachable other reason, a mental health one.  He was not interested in doing this, even at no charge. 
 
Two days later his medical records arrived by fax from his California doctor and there was nothing in them with respect to Xanax.
 
In this day of patient empowerment I’m not sure how many doctors follow the good professor’s advice.  I doubt if any follow it carte blanche.  Besides, no physician can detect deception 100% of the time.  But I would venture to say that most doctors probably give patients the benefit of the doubt when trying to help with emotional disorders and medications that are commonly abused.
 
But it’s interesting to have seen over the years how the expectations of patients, and their perception of a physician’s role, has changed.  In the 80s there seemed to be little interest in being deceptive.  Now it is much more frequent, maybe the result of affluence, maybe the result of a bad economy.  But we see little of this in indigenous populations.
 
The most memorable example of this is a personal experience from the early 80s when I served as the doctor for a Christian mission team from Pascagoula which had been serving a mission in the mountains of Las Cruces, Honduras for several years.  The 25-member team, including dentists and nurses, rotated every month with other groups, staying a week and serving a steady line of people from sunrise to sundown.  To receive medical care some locals walked from as far away as 20 miles (That’s like a round trip walk from Biloxi to Gulfport).  Every single Honduran expressed gratitude, either with a word, a nod, or a handshake.  They were humble and submitted to whatever care was given.  We’d brought many medical and pharmaceutical supplies.  Their complaints varied and were many, but deception was nonexistent.  Such a contrast!
 
There are several reasons patients withhold or embellish certain aspects of their medical history.  They being the desire to keep something private, to avoid embarrassment, to avoid being lectured to, or they lack assurance of confidentiality.  These reasons are pretty much in line with and understood from a human nature standpoint.  But the more devious deception is the one in which a person lies in order to obtain prescription medication that either a) alters his/her consciousness and self-pleasure, or b) sell them to others on the street for money or services.
 
Along these lines, over the past two months, there’s been an intermittent flow of folks from Jackson County, riding 30 miles to Biloxi, with the singular complaint of cough – the purpose of which is to obtain a certain prescription cough medication with codeine.  On the street the cough syrup is mixed with a particular soda and a particular candy for coloring and its sugar content, and an instant euphoria is obtained when it is downed.  If it weren’t so sad and pitiful it would be comical as each person forcefully coughs to ensure the doctor is aware of the seriousness of their complaint – in hopes of obtaining the desired and cherished codeine prescription.
 
A call to a local rehabilitation facility affirmed suspicions of the medication’s abuse on the street.  One woman admitted she sold her prescription for $300.  The famed hip hop singer, Lil Wayne, it is reported, has paid as much as $800 for a bottle of it.  By the way, Lil Wayne suffers from a seizure disorder that’s reportedly exacerbated by his long habit of the codeine street concoction, though he and his agents have disputed that claim.
 
How can deceptive patients like Wally be helped?  Until they come to their senses, suffer a traumatic event as a result, or happen to change by the grace of God, the only way I know that can make a difference is to pray for them.  Which is what I did for Wally.