Some clinical encounters can stir up strong feelings in us as clinicians; one such situation is when we do not believe what our patient is saying to us.

I (Adam Polnay) recall, as a trainee in accident and emergency (A&E), attending to patients who came in with severe abdominal pain. For a few of these patients, it would transpire that they were not ‘really’ experiencing abdominal pain, or at least not to the extent it initially appeared. I would sometimes feel tricked — especially if I had given strong pain relief or taken time to arrange investigations — feelings shared by colleagues on shift. At times, we acted on these feelings by discharging these patients from the department in a somewhat perfunctory way, believing they had wasted our time.

At the time I thought, as many would: perhaps they’re just faking it. But this may not be the whole story. Looking back, I regret, not necessarily that we discharged these patients from A&E, but the manner we went about it, and our lack of curiosity about why they needed to engage with care in the way they did.

Our response of annoyance is not unique.1 When a patient’s presentation evokes feelings of disbelief, we may sometimes respond in ways that inadvertently make things worse. Rather than taking an approach to a patient that they are either telling the truth or lying, we suggest it can be helpful to consider a middle way: the patient may be faithfully describing a problem, but doing so in a coded or implied way. Perhaps related to past experiences, they may expect that telling their story in a straightforward manner does not work.

In trying to understand this kind of clinical encounter, it may be helpful to consider one of the ways we begin …