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Symptoms: Vaginal Bleeding

Leap, Edwin MD; Wiler, Jennifer L. MD, MBA

doi: 10.1097/01.EEM.0000307637.91265.1c
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Dr. Leap is a member of Blue Ridge Emergency Physicians, an emergency physician at Oconee Memorial Hospital in Seneca, SC, and an op-ed columnist for the Greenville News. He welcomes comments about his observations, and readers may write to him at emn@lww.com and visit his web site and blog at www.edwinleap.com.

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So this really happened: I saw a young man who wanted pain medication. His story was sketchy, he didn't seem in pain, and he had no apparent injury. Let's say his name was Alex. I discharged him. About two hours later, he returned. He had on the same clothes. He had the same hair. This is the essence of the conversation:

“So, sir, you say your name is Susan.”

“That's right, I'm Susan.”

“I just saw you two hours ago. Your name is Alex.”

“No, my name is … Susan.”

“No, your name is Alex. You were here earlier, and wanted pain medication.”

“No, really, my name is Susan. I have an insurance card, see?”

“Do you have a picture ID with Susan on it?”

“No, but my name is Susan. Can I get something for pain?”

Incredulous and insulted that he believed I was the stupidest physician on the entire globe, I said: “No, Susan, but you can leave!”

And he did. Or she did.

There are a couple of schools of thought in medicine now. One is that everyone who says they hurt should have all the pain medication they want and a wheelbarrow to cart it out in, while the other says, not so much. But more insidious, there is apparently one school of thought that says patients never lie, and another that says, “Excuse me?”

I belong to the second of each demographic. I believe that not everyone needs endless narcotics. But more importantly, I believe that human beings, not just patients, sometimes lie. And in an age of political correctness, tolerance, and acceptance, that's an apparently unpopular viewpoint.

Once, I suggested this viewpoint on lying in a column. I was met with an angry response from a physician-reader who asked, “Who do you think you are, to say patients lie?” My answer (in my head) was, “Well, a person who interacts daily with human beings.”

I wondered what my detractor did as a physician. She suggested she practiced emergency medicine, but I can't imagine any emergency department where one wouldn't get a flavor of, shall we say, falsehood every now and then.

But on some level, I understand her frustration. The idea that someone might not tell the truth is very difficult for us. Most physicians and nurses are hard-working, driven individuals. We tend to be honest, except when we say things like, “You'll only feel a pinch!” or “You'll be fine, I'm sure of it.” We all chose a career that we knew would involve caring for sick and injured human beings.

What that means is, we value honesty, we expect it from others, we can't imagine the benefits of dishonesty, and we think other humans are exceptionally valuable. Given those facts, it seems almost sacrilege for us to think someone would lie, especially when we're caring for their physical needs.

But guess what? Read carefully: Humans have been telling lies for as long as we've had language. Here's a clue to that reality: If it's in the Ten Commandments, people do it. That doesn't make the Decalogue irrelevant; it makes it a pretty good predictor of human behavior. And it also suggests, in pretty clear terms, that lying is not acceptable or healthy behavior.

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So what's a demoralized doctor to do? Should we, as so many moral relativists might suggest, say, “Who am I to judge?” Do we give people what they want, and say that their lives are their own business? Do we ignore their false claims? Is it our place to be involved in searching for lies and exposing them?

I think it comes down to a question of value again. Do we really think people are worth helping? Because if we do, then discovering some of their lies and confronting them might just be the most caring, engaged thing we can do for them. “No, ma'am, I won't give you more drugs. I think you're a drug addict.” “Your grandma isn't having a stroke. She's been drinking.”

It sounds mean, but it's ultimately an act of genuine concern. And sometimes, that sort of truth is exactly the kind of ice-water reality that saves a life, as someone is confronted with the thing they themselves knew all along but managed to deny.

Think about it. When we point out a lie, we aren't necessarily judging. We're not making a decision about the ultimate value of the person, or even of the things that drove them to lie, like addiction, alcoholism, abuse, or even criminal behavior. We're using discernment. I looked up some definitions of discernment: “the trait of judging wisely and objectively,” “perception of that which is obscure,” “keenness of insight and judgment.”

When we figure out who is telling the truth and who is lying, we are simply using good judgment; we try to perceive the barely perceptible. And in medicine, that's often the most important thing we have. It's far more valuable than our medicines or technologies because the uses of those things emanate from good judgment.

It isn't evil of us or wrong of us to ask penetrating questions about our patients' stories. It isn't cruel of us to question their need for drugs, their need for work excuses or court-date excuses, even their need for the disability ratings that they carry (even as they deer hunt, water-ski, and work as mechanics).

Seeking out the truth is our duty. If we choose to ignore it once we know the truth, fair enough. We can elect not to report the spouse abuse if we feel morally bound by the patient's pleas not to do so. We can decide that maybe, despite the obvious addiction, the patient will be better off with more benzodiazepine to keep them from seizing. But we can only make a decision with the truth, when we know the truth.

Attila the Hun once said, “Even in his glory, man is nothing but a liar.” See there? I was lying. I have no idea what Attila thought about lying, but you believed me! I wasn't betraying your trust as a reader. I was trying to confirm what you already know. And what you know is this: We have to be careful.

As ugly as it seems to admit, there's a world full of liars out there. They aren't always patients; in fact, sometimes they're our fellow doctors, academics, researchers, politicians, lovers, spouses, and all the rest. None of them is above telling whoppers. If you have children, you know.

“Did you hit your brother with a hatchet?”

“No, sir.”

“Then why are you standing over your brother and holding a hatchet?”

“I don't know.”

Children are among the most brazen liars of all; God love 'em!

The people who lie to us make us crazy. They make us angry. They cause us extra work and burn up hours of our time. They sell drugs on the street. They drive while impaired. They harm other people. They embarrass us when their schemes work and we later discover the truth. They break the hearts of the ones who love them.

Because lies are so obviously horrible, we should look for the truth. As equally valuable humans, we deserve to know the truth. As professionals charged with our patients' lives, we need the truth. But as we search, as we sometimes confront and anger people, we should remember that even liars deserve our concern and intentional acts of love. And even liars need our wisdom and compassion. After all, they aren't the only ones who broke one of the Big Ten. To find someone else, just look in the mirror.

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A 47-year-old woman presents to the emergency department complaining of vaginal bleeding for one week. She has soaked through 10 pads per day with occasional dizziness, but denies syncope, chest pain, palpitations, shortness of breath, melena, bruising, rashes, hematuria, hematemisis, or a history of trauma.

She mentions she also has had abdominal distention for one year with crampy diffuse abdominal pain for one week and occasional nausea and vomiting. The patient has a history significant for colon cancer with a diverting colostomy and reversal in the distant past.

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What is the cause of her vaginal bleeding and abdominal distention? See p. 20.

© 2008 Lippincott Williams & Wilkins, Inc.