Many Patients Hide Life-threatening Issues From Clinicians

Encouraging Communication, Building Trust Are Key to Mitigating Threats

September 10, 2019 01:11 pm Michael Devitt

Sometimes, what patients don't tell their family physician is just as important as what they do tell them -- maybe even more so. Some topics may be difficult to discuss, but if patients aren't willing to open up, FPs won't be able to provide all the care they may need.

[female physician talking with patient]

Research published online Aug. 14(jamanetwork.com) in JAMA Network Open sheds light on how often patients conceal potentially important information from their clinicians. The authors of the study found that a substantial number of patients who experienced imminent threats such as abuse or sexual assault routinely withheld that information from their health care professional, which, of course, precluded those clinicians from helping patients resolve these problems.

Research Methods

For the study, researchers from various medical and educational institutions examined data from surveys(jamanetwork.com) conducted in 2015. One survey posted on Amazon Mechanical Turk targeted individuals 18 and older; an identical survey conducted via Survey Sampling International sampled adults 50 and older. In all, 4,510 U.S. adults responded.

Story Highlights
  • A new study found that a considerable number of patients who experienced an imminent threat such as abuse or sexual assault did not discuss the threat with their clinician.
  • Most patients who withheld this information from their clinician said they did so to avoid embarrassment.
  • The study's findings highlight the importance of improving trust and communication between patients and clinicians so these situations can be identified and potentially mitigated.

Participants were asked if they had ever withheld a wide range of medically relevant information from their clinician (defined as a physician, physician's assistant or nurse), such as whether they took prescriptions as directed or drank when they shouldn't. Regarding imminent threats, participants were asked whether they had ever avoided telling a clinician they

  • were depressed,
  • had suicidal thoughts,
  • had been abused or
  • had been sexually assaulted.

Participants who reported withholding information were then asked to select reasons for not disclosing that information.

Relevant Findings

Altogether, about 61% of participants in the survey groups reported experiencing at least one of the four imminent threats. Depression was the most frequently reported threat, followed by suicidality.

Of those who had experienced at least one threat, nearly 44% chose not to tell their clinician about it.

The degree to which certain threats were withheld varied slightly by survey group. In the MTurk sample, abuse had the highest nondisclosure rate, followed by depression, suicidality and sexual assault. Abuse also had the highest nondisclosure rate in the SSI sample, but then was followed by sexual assault, suicidality and depression.

In both survey groups, participants who were female and those who were younger were significantly more likely to withhold information regarding an imminent threat. In the SSI group, patients with poor self-reported health also were significantly more likely to withhold information.

The most common reason participants gave for choosing to withhold information was to avoid embarrassment. More than 70% of people in both survey groups reported they were embarrassed to discuss an imminent threat with their clinician.

Other reasons for withholding information given by more than half of participants who experienced an imminent threat included

  • not wanting to be judged or lectured,
  • not wanting to make a difficult change (such as seeing a therapist or taking antidepressants) that the clinician would then recommend, and
  • not wanting the information in their medical record.

The authors noted two important limitations to their research.

First, they stated that using online surveys allowed them to obtain samples that were more demographically diverse but did not represent the U.S. population at large.

Second, they suggested that some participants may not have shared all of the information they withheld -- for example, a person actively contemplating suicide may not have disclosed having suicidal thoughts -- meaning the percentage of patients not sharing information about imminent threats with their clinician may have been even higher than the survey results indicated.

Despite these limitations, the authors contended that their findings illustrate the importance of maintaining open communication between clinicians and patients.

"If patients commonly withhold information from clinicians about significant threats that they face, then clinicians are unable to identify and attempt to mitigate these threats," they wrote. "Thus, these results highlight the continued need to develop effective interventions that improve the trust and communication between patients and their clinicians, particularly for sensitive, potentially life-threatening topics."

Family Physician Perspective

Rita Schindeler-Trachta, D.O., chair of the Academy's Intimate Partner Violence Member Interest Group and an independent contractor physician with Hospice Austin in Austin, Texas, told AAFP News that from her perspective, children are a leading reason patients choose not to report instances of assault or abuse. She explained that many patients fear that by reporting an episode of IPV, they could lose custody of their children or put their children at risk.

Schindeler-Trachta said that because FPs typically have ample opportunities to routinely screen patients about imminent threats, they have an advantage over other health care professionals in this area.

"FPs can normalize the questions for screening," she said. "For example, 'Every relationship has conflict at times; how do you and your partner resolve conflicts?' Or (FPs can) put posters up in the waiting room, the bathrooms and the exam rooms about what a heathy relationship looks like or have trifold pamphlets available that a person can slip into the lining of a shoe when they are in the bathroom.

"The patient may not disclose (an imminent threat) for years, but the messaging that she or he gets over time will increase the chances they may eventually disclose, and then the physician must have a plan ready to implement at a moment's notice of what to do next. So there is plenty a family physician can do now."

Lalita Abhyankar, M.D., M.H.S., a family physician practicing in New York City who has written about young patients struggling with suicidal thoughts, told AAFP News that she often encounters young patients she sensed had experienced an imminent threat but were hesitant to discuss it.

"I get this all the time," Abhyankar said. "It's most obvious in my adolescent patients whose parents want to tell me everything because I'm the doctor -- but I'm still a stranger, so the teenager is often mortified."

When patients start to show their discomfort, "I usually back off," said Abhyankar. "But I do emphasize why it is important to know the information, while also acknowledging that they have to be ready to share. I offer that they can always come back to talk further when they're ready."

Schindeler-Trachta agreed that the process of getting patients to open up can take time.

"I believe we have to assume that this is a health issue that a person may not admit to for years," she said. "But we can be there when they are ready. In the end, the patient has to take the action to want help. FPs have a huge role to play by continued screening, gentle questioning, providing information such as helpline numbers and local shelter numbers, and gaining the patient's trust to allow the disclosure."

Abhyankar said that FPs could use the study's findings to focus on their own awareness and patient readiness.

"We have to be aware that there is a lot of information that we just don't know about our patients, no matter how well we think we are assessing their risk for abuse or suicidality," she said. "Some of us might fly through questions that we don't think are relevant for the patient sitting in front of us because of time or implicit bias, so this study might be the reminder we need to slow down during our day."

"I hope this sort of study also helps doctors see that a patient needs to be ready to share in order to ask for help," Abhyankar added. "Sometimes we can create a safe environment and still the patient just isn't comfortable sharing, but that's completely OK."

Moving Forward

Schindeler-Trachta said that the IPV MIG will be reviewing the study, along with best practices for screening, diagnosing and treating IPV and current AAFP guidance on this topic, with the goal of identifying for members how FPs can best help identify and manage patients who experience IPV.

"With one out of four women and one out of seven men affected by IPV, we must address this public health epidemic," she said.

Related AAFP News Coverage
Leader Voices Blog: What a Patient Taught Me About Subtleties of Communication
(5/29/2018)

Annals of Family Medicine
Study Offers Insights on Communicating With Patients

(3/2/2018)

More From AAFP
Policy on Intimate Partner Violence

Patient Care: Depression and Mental Health

Patient Care: Mental Health Clinical Recommendations and Guidelines