Is House, M.D., always right?

Gregory House, M.D., stated in one of his memorable if misanthropic aphorisms, that patients lie. “I don’t ask why patients lie, I just assume they all do” (Moran & Spicer, 2004). This is true. On the other hand, the patient, like the customer, is always right. This is also true. Reconciliation of these aphorisms leads us some way to understanding the art of medicine and the tribulations of palliative care. Ninety percent of our consultations as a pain and palliative care service in a comprehensive cancer care are for pain (Pain and Palliative Care Service). Patients are constantly “lying” about their pain: They exaggerate, minimize, or are incapable of providing a textbook description. A patient was referred with a large mass in his pelvis eroding the sacrum. He appeared to be in pain and could not even lie flat for his scans. When asked how bad his pain was he demurred indicating he could cope and the chemotherapy would fix it. Eventually we convinced him to take the appropriate analgesia, the pain was relieved, and he was a new man. Why did he lie? There are many reasons patients minimize—or are deceptive about—their pain: through fear of disease recurrence or progression, a need to be stoic or heroic, a fear of medications (especially of opioids), and a wish to please the doctor. Similarly, patients may exaggerate—though not fabricate—their pain: in fear they will not receive adequate attention, as an expression of psychological distress or spiritual angst, due to personality traits, and the influence of cultural norms. Patients do not lie out of dishonesty; rather they mislead for psychosocial reasons. If we as healers subscribe to Engel’s (1977) bio-psycho-social model, then we will interpret the complaint through the prism of context. We will not simply ask the patient to complete the visual analogue scale of pain and prescribe accordingly. Rather we will watch and listen to how the patient reports the symptoms. While asking about the pain, we will enquire about their lives—who they are, where they live, what their views are about single-malt whiskeys. All the time in the back of the mind making a psychosocial overview as a prelude to the medical assessment. Engel, a psychiatrist from New York, wrote a seminal paper in 1977, published in of all journals, Science. (His paper was followed by an article on how to identify “complex precipitates in steel.” The dissonant juxtaposition is telling.) Engel decried the notion that disease is defined as a “somatic” disorder and that psychosocial issues are no longer part of the clinician’s sphere of responsibility. He thought this artificial split adversely influenced doctors’ attitudes to patients and families. Engel quoted one authority who called for a “disentanglement of the organic elements of disease from the psychosocial elements of human malfunction” (Engel, 1977). The biomedical model, Engel noted (1977), “embraces reductionism, the philosophic view that complex phenomena are ultimately derived from a single primary principle, and mind-body dualism, the doctrine that separates the mental from the somatic.” To say that patients “lie” is to be “reductionistic” in the sense that Engel bemoaned. Infrequently is there a unitary objective scientific truth in clinical medicine. There is the illness and the patient who has the illness. The patients—with their psycho-social makeup, influence both the diagnostic process and the management. Thus, if a biopsy confirms lung cancer, then lung cancer it is. However, the patients’ personality and culture play a big part in bringing them to the biopsy (early or delayed) and later, choosing which treatment, when to stop, how to die, and so forth. A patient presents with thalidomide-induced peripheral neuropathy. The electromyographic studies and linear-analogue pain scales alone will not tell me whether to start medications. Rather, by careful listening will we discover that the patient is more frightened about the significance of the pain and not that the pain is so significant. A detailed Address correspondence and reprint requests to: Simon Wein, Palliative Care Unit, Davidoff Centre, Rabin Medical Centre, 39 Jabotinski Street, Petach Tikvah, Israel 49100. E-mail: wein1@ bezeqint.net Palliative and Supportive Care (2009), 7, 1–2. Printed in the USA. Copyright # 2009 Cambridge University Press 1478-9515/09 $20.00 doi:10.1017/S1478951509000017