Why patients might withhold information and what to do about it

The majority of pharmacists have seen a patient who they suspect did not fully disclose relevant health information or provide the full clinical picture. In these circumstances, it can be challenging for pharmacists to make a responsible decision because the provision of professional services relies on honest disclosure. Given the importance of a person’s health, it might be expected that patients are scrupulously truthful with healthcare professionals; however, the results of a survey of more than 3,000 people in the United States, published in 2024, revealed that 42% of respondents said they had never lied to their doctor for any reason^​1​.

In medicine and healthcare, truthfulness has long been a subject of debate. A lie is defined as ‘a false statement made with intent to deceive’^​2​. Philosopher Immanuel Kant, famous for his Kantian theory on social justice and the rights of the individual, determined truth-telling to be a moral duty. 

However, utilitarians, who believe in the ‘greater good for the greater number’, believe that dishonesty can be justifiable if associated with positive consequences — for example, lying to a potential aggressor to prevent them from causing harm could be justifiable^​3​.

Historically, healthcare professionals were likely to have adopted a paternalistic approach to their practice and, at times, may have felt ethically justified in not always being completely truthful with patients. This could have been to prevent confusion, avoid causing unnecessary pain or not risk eliminating the hope of recovery.

After WWII and the emergence of the Nuremberg Trials and Code, healthcare ethics changed considerably in response to the atrocities committed in the name of medicine and science^​4​. This change was followed by the introduction of principles of bioethics that have contributed profoundly to contemporary healthcare practice around the world^​5​. Modern healthcare has steadily moved away from paternalism in favour of promoting honesty and transparency that supports greater patient autonomy and enables shared decision-making and informed consent^​4​. Patients, however, are not bound by professional standards and codes of ethics, and healthcare professionals will often be aware of occasions when they suspect patients may be purposely withholding clinically relevant information. While there may be signs that a patient is not fully disclosing details about their health (e.g. a change in voice pitch, slips of the tongue, forced false smiles and other incongruent non-verbal behaviours), these can be difficult to detect.

There is little literature on patient non-disclosure within healthcare, but some studies have explored the issue. In 2000, Simmons et al. found that — rather than admit non-adherence — 30% of patients actuated their metered-dose inhalers more than 100 times within a three-hour interval at least once during the first year of a clinical trial^​6​. Results from two 2019 US online surveys suggest that more than one-third of respondents did not articulate their disagreement with a doctor’s advice. Even worse, many respondents did not ask for clarification when they did not understand treatment instructions^​7​. The findings of a survey conducted by Riley et al. in 2024 showed that people avoided disclosing full information, mostly about their state of mental health and general social habits (e.g. exercise levels, alcohol consumption, diet and sexual activity). Some of the reasons why patients may withhold information from healthcare professionals are presented in Box 1^​1,3,8​.

Potential consequences of patient non-disclosure

Unfortunately, patients do not always consider the possible consequences of withholding information. There is a potential for misdiagnosis if healthcare professionals do not receive full or accurate information when taking a medical and social history. This can result in inappropriate treatment being initiated or, conversely, patients not receiving the care they need^​9​. Extra costs may be incurred with further investigative (and possibly invasive) tests, or root problems may not be addressed when, for example, medicine is continued unnecessarily. If patients intentionally withhold information about adherence to treatment, doses may be inappropriately increased, or additional medicines added to achieve the desired effect, only to increase the risk of toxicity and side effects. To avoid these scenarios, healthcare professionals should actively encourage open and honest dialogue in their interactions, empathise with patients and work to build trust.

How openness and full disclosure can be encouraged from patients

If patients do not feel able to speak openly with the healthcare professional they are speaking to, good-quality patient consultations focused on patient-centred care and shared decision-making cannot happen. Healthcare professionals have a responsibility, therefore, to foster a good relationship with patients and create an environment where patients feel able to speak openly and honestly. If the right tone of tolerance and non-judgement is set, patients are less likely to feel ashamed or embarrassed to admit when they have deviated from any norms or expectations, or engaged in behaviour that is harmful to their health.

Below are some strategies to consider in your practice for both creating the right environment and communicating effectively, which may encourage full disclosure from patients.

Create the right environment

• Create an open, friendly, inviting environment: Ensure the pharmacy team is welcoming and non-discriminatory, so that every person is treated as an individual with respect and dignity. Reflect on the posters that you display in your pharmacy. Are they welcoming to all in society? Do they reflect your local population? Cultural sensitivity is extremely important in creating a safe, welcoming environment. Avoid making assumptions based on how a person presents themselves: use respectful language to avoid offending people, ask how people would like to be addressed, consider your use of pronouns and try to pronounce unfamiliar names correctly. You can check with the patient if you are unsure and apologise if you get them wrong. Also be aware of and avoid micro-aggressions. Micro-aggressions are statements, actions or incidents regarded as indirect, subtle or unintentional discrimination against marginalised members of a racial or ethnic minority^​10​.
  
  
• Consider any staff training needs: Cultural competence is evolving, and it is important that you and your staff identify any learning needs and address them. The Centre for Pharmacy Postgraduate Education has a self-reflection tool that helps identify the areas that need developing. Resources for staff training include, for example, the Pride in Pharmacy interactive online resource, which has short learning modules regarding the inclusivity of the LGBTQ+ community.
  
  
• Ethical considerations: Providers must balance the need for accurate information with respect for patient autonomy and confidentiality. Offer a private consultation where appropriate and assure confidentiality. Always obtain consent, including when you might want to share information about the patient with another healthcare professional. Also, remember that informed consent goes beyond signing a consent form — it involves a discussion with the patient. See the General Pharmaceutical Council’s ‘In practice: guidance on consent’ for further information.
  
  
• Understanding the reasons: Patients may not fully disclose information for several reasons, such as fear of judgement, embarrassment or misunderstanding the importance of certain information (see Box 1). Recognising these motivations can help healthcare providers approach situations with empathy^​11​.

Effective communication

• Clear and open communication is essential: Healthcare providers should explain the importance of accurate information for effective treatment and reassure patients that their honesty is important for their health. Avoid asking leading questions that can be answered with a simple ‘yes’ or ‘no’. Instead, ask open-ended questions that encourage patients to share more information. Example questions include:
  • How are you feeling today?
  • What are your symptoms?
  • Can you tell me more about your symptoms?
  • What level of pain would you call it out of ten, with zero being least pain and ten the most severe?

• Consider how you frame your questions so that you do not come across as judgemental or patronising. Many pharmacists are already considering this when working within the New Medicine Service framework. For example, when asking about compliance, it is recommended to start with a general observation: “People often miss taking doses of their medicines, for a wide range of reasons. Have you missed any doses of your new medicine, or changed when you take it?” Taking this approach encourages the patient to be truthful, as it lessens any fear of judgement.

• Take note of cues: Pay attention to your patients’ verbal and nonverbal cues, such as body language and facial expressions. These cues can provide valuable information about their true feelings and intentions. Examples of what to look out for include: 
  • Too little or too much eye contact;
  • Fidgeting;
  • Difficulty controlling tone and volume of speech;
  • Shrugging;
  • Rolling of the eyes; and
  • Frustration/anger (particularly when their story is going off-track or not believed).
    
• Take a non-confrontational approach: Address non-disclosure of information in a non-confrontational manner and use language that avoids putting the patient on the defensive. Ask open-ended questions and express an understanding of the patient’s situation. If the patient’s first response does not seem complete, ask the same question in a different manner, without reacting to the first response. For example, if a patient complains of tooth pain and asks for a combination analgesia by name, do not question their previous, possibly regular, use of the painkiller. Instead, ask them to elaborate on their symptoms and discuss the possibility of seeing an emergency dentist if the pain is severe. Also explain that relying on over-the-counter codeine-based products is not recommended, owing to problems with addiction. If appropriate, you could recommend paracetamol and non-steroidal anti-inflammatory drugs in combination instead.
  
• Validate their feelings: Acknowledge your patients’ feelings and perspective, even if you don’t agree with them. This can help to build trust and rapport; for example, you might say, “I can see that you’re worried that the medicine will make you feel ill,” even though you may think the risk of that happening is actually very small. However, if they demonstrate frustration or anger, or provoke you in some manner, try not to react to this and remain as calm as possible. Demonstrating annoyance or anger is counterproductive.
  
• Be honest with the patient: Talk openly about the risks and benefits of different treatment options, which includes the option of doing nothing. Remember that a patient may have a variety of reasons for making a decision that you might not agree with. The patient’s individual preferences, values and beliefs must all be taken into consideration, alongside the evidence base. For example, a patient may choose not to try a new medicine because they know it can cause weight gain. Even though clinically you believe this to be the best option for the patient, the patient may not be willing to risk experiencing weight gain. Through shared decision-making, you are empowering them to make decisions that are right for them. A shared decision-making learning package is available on the National Institute for Health and Care Excellence website for anyone who would like to upskill in this area. 
  
• Build a trusting relationship: Establish a strong, trusting relationship with patients. This can be done by being polite and considerate, empathetic, non-judgemental and respectful. For more detail on this topic, see: ‘How to build and maintain trust with patients‘. When patients feel safe and respected, they are more likely to be open and honest. Active listening, showing empathy and maintaining a non-judgemental attitude all foster trust^​12​. Your own use of open body language is important, which includes making good eye contact, mirroring the patient’s feelings and not interrupting the patient. Also, paraphrase to show active listening and be willing to act as an advocate for your patient if necessary.

Summary

From the limited published literature available, it seems that patients sometimes find it difficult to be honest and disclose full details about their health and lifestyle choices. The onus is on healthcare providers to ensure that we create the right environment — one that encourages patients from all backgrounds to see pharmacy as a safe and welcoming space where they can access the care they need in a friendly, non-judgemental and respectful manner. This requires pharmacists to reflect on the messages portrayed through the physical space that is presented to patients to consider the way the pharmacy team communicates with patients and continually upskill when further learning needs are identified.