One evening in the clinic’s bullpen provider office, a colleague of mine wondered aloud how to respond to a difficult question a patient asked via patient portal message.
A physician within earshot responded, “Just because someone asks you a question doesn’t mean you have to answer that question.” I tried to empathize with where the physician was coming from.
Some actions don’t require empathy as much as correction.
Even so, the physician’s response seemed like a red flag to me, clashing with my own sense of personal integrity. Is it ever ethical to intentionally avoid answering a patient’s honest question?
During face-to-face conversations, I can see how it is occasionally appropriate to redirect a conversation for the sake of preserving the rapport that has been built during that patient-provider interaction.
in the clinic that evening, the physician wasn’t advising our colleague to sidestep a patient’s question in the context of an in-person encounter; rather, the physician was conveying that it was OK to dodge a patient’s question altogether.
I realized that the physician was an expert at a particular communication tactic known as “paltering.”
According to Todd Rogers, a behavioral scientist at Harvard Kennedy School, paltering is “the active use of truthful statements to convey a misleading impression.” In short, paltering is deception, yet he and his colleagues found that “the person doing the paltering believed it was more ethical than lying outright.”
Unfortunately, it is difficult for people to recognize paltering in real-time, which is one factor that makes it such an effective communication tool.
I’ve noticed that most of the “effective communication” is used for a doctor to defend himself against a patient.
Conveniently, paltering enables those who employ this tactic to easily justify their behavior. If challenged, they can claim, “I told the truth. I wasn’t lying!” and technically, this is accurate.
However, despite the absence of lying, the reality is that those on the other side of the conversation are still intentionally misled.
The same research shows that in fact, “The individuals who had been deceived […] did not distinguish between lying and paltering.”
Paltering is common and not necessarily malicious.
However, in the context of health care, we must always be vigilant about the ethical ramifications of such behavior. Is it ever OK to deceive patients or to condone this deception? If so, in what circumstances?
Paltering usually goes unrecognized and unchallenged, but when it is identified, it
- erodes trust,
- destroys confidence, and
- contributes to cynicism
This is exactly what’s happened in pain management. Doctors believe and tell us that our pain “isn’t that bad” because it’s not an open wound or cancer or broken bone.
Doctors are being taught that non-opioid drugs and psychological therapy are as effective as opioids and they seem to believe it and insist that pain patients believe it too. Yet they don’t ask the obvious question: then why are non-opioid drugs and psychotherapy used only for invisible pain and not for visible pain, like in horrible accidents, shingles, cancer, or invasive surgery?
Isn’t being honest, in the truest sense of the word, the only ethical and acceptable way to practice medicine?
Shannon Casey is a physician assistant.