A significant number of patients in the US lie to their doctors to get antibiotics they likely don’t need, according to two new studies. While that may not be a startling revelation, the studies drills down on the phenomenon, finding that the lies patients tell are generally bad ones—and yet, they work almost all the time.

In the two linked studies published Friday in JAMA Network Open, a team of researchers led by Alistair Thorpe at the University of Utah analyzed online survey data from over 1,000 adults. They found that over a quarter of people reported having lied to a clinician at least once to get an antibiotic prescription for themselves or a child in their care. Patients lied by either exaggerating symptoms, making up symptoms, or—most often—both.

But interestingly, the lies people told to get antibiotics involved making up or exaggerating symptoms of infections that wouldn’t be treated with antibiotics. For example, the most common falsehoods were symptoms associated with colds, such as fever, cough, and sore throat. That’s despite the fact that colds are caused by viruses, not bacteria—which antibiotics treat.

Further, while the data suggests many patients were being dishonest, clinicians responded with what could be considered their own form of dishonesty; in most cases, the dubious fibs led to antibiotic prescriptions. Specifically, 77 percent of adult patients and 87 percent of caregivers said their lies worked, leading them to get the antibiotic prescriptions they wanted.

“These findings signal a significant issue for health professionals making antibiotic prescribing decisions and for the fields of antimicrobial stewardship and public health,” Thorpe and colleagues concluded.

Detailed deception

For the study, the researchers reviewed survey responses from 1,371 online respondents and found 959 responses that were valid and complete. Of those, 268 (28 percent) respondents reported misrepresenting their symptoms to get antibiotics. Of those, 108 reported exaggerating symptoms, 19 reported fabricating symptoms, and 141 reported doing both. In a separate analysis of 263 respondents who identified as caregivers, 63 (27 percent) reported misrepresenting symptoms of a child to get antibiotics.

The most common reported reasons for lying were that people: felt their illness or the illness of a child in their care was particularly severe; believed that antibiotics were the only thing that would help them; believed antibiotics would help them return to responsibilities (work/school) faster; or felt they should have personal autonomy (thinking they know more about their health status than the clinician or feeling like they should get to decide their own treatment).

Those who misrepresented their symptoms tended to be younger and feel their symptoms were not taken seriously by clinicians. They were more likely to believe that antibiotic resistance is a hoax, such as a scare tactic by the government or a gimmick by drug companies to justify charging more for antibiotics. People who lied were also more likely to have more underlying conditions, view lying as more acceptable, and report needing help reading health-related materials. On the other hand, those who didn’t report misrepresenting their symptoms tended to have greater antibiotic knowledge and aversion to taking antibiotics.

For people who reported misrepresenting symptoms, the online survey gave them additional questions about the types of symptoms they fabricated or exaggerated. The most common falsehoods, reported by 65 percent of dishonest patients, were to misrepresent cold-related symptoms. After that were misrepresented stomach symptoms (49 percent), joint or muscle pain (46 percent), eye symptoms (34 percent), rashes and other skin conditions (32.5 percent), urinary symptoms (31 percent), or a general feeling of being unwell (37 percent). Respondents could also report not remembering what they lied about.

“To be clear, none of these are specific indications for antibiotics,” Jeffrey Linder, of Northwestern University Feinberg School of Medicine, wrote in an accompanying commentary, highlighting that these lies shouldn’t have helped patients get unnecessary antibiotics. “In fact, of the 8 categories offered that patients could have exaggerated or made up to get antibiotics, only 1 of them (urinary symptoms) clearly justified antibiotic prescribing,” he wrote.

While symptoms of respiratory infections can be due to bacterial infections in some situations—namely, acute sinus infection, strep throat, or pneumonia—those conditions have specific clinical guidance and/or associated tests to confirm the diagnosis, Linder highlights.

Dishonesty all around

Given the magnitude of the deception, the findings raise concern that the ill-gotten antibiotics could contribute to the rise of antibiotic-resistant infections. Misuse and overuse of antibiotics are known to drive the development and spread of drug resistance. This week, the Centers for Disease Control and Prevention released an updated report on antimicrobial resistance threats, finding that drug-resistant bacteria and fungi are now causing 9.7 million infections and 50,800 deaths in the US each year.

But in the accompanying commentary, Linder said that an even more concerning consequence may be the “erosion of trust” between clinicians and patients. Linder acknowledged that drug resistance is a concern, but said that on the basis of an individual patient, in most clinical circumstances, the development of drug resistance is “probably irrelevant.”

To Linder, the more pertinent question doctors must face is: “Is this prescription more likely to help my patient or hurt them?” The answer is that it’s more likely to hurt; unnecessary antibiotics provide no benefit, but pose risk of adverse events, allergic reactions, and disruption of healthy microbiomes, which can provide an opening for opportunistic pathogens, such as Clostridioides difficile (which is classified as a “serious threat” in the CDC’s newly updated antimicrobial resistance threat report.)

“For these non-antibiotic-appropriate diagnoses, prescribing antibiotics is medically incorrect and could itself be considered a form of dishonesty or lying mainly to assuage the patient,” Linder wrote. That dishonesty is corrosive, he said, quoting philosopher Sissela Bok, who wrote extensively about lying and, even specifically, about lying to get antibiotics. In 1978, Bok noted that antibiotics are “sometimes used as placebos” and many parents “come to believe that they must ask for the prescription of antibiotics every time their child has a fever or a cold.” But Bok argued that when clinicians prescribe medications more likely to harm than help, such “practices lacking in candor” threaten “the entire institution of medicine.”

Linder concludes by reminding readers that “Clinicians’ obligation is to act in patients’ best interest, even if patients are hoping we do something different, even if patients do not like it, or even if patients lie about their symptoms.”

Thorpe and colleagues, meanwhile, conclude with a call to address the reasons patients lie in the first place, writing: “Strategies to improve communication about antibiotics are needed to address patient concerns, support understanding of appropriate antibiotic use, and strengthen patient-clinician relationships.”