Doctors Talking to Patients About Themselves: How Much and What?

There has been much consideration about how much a physician should talk to the patient about him/herself. More importantly beyond “how much” is the concern about “about what”. The question is whether there is an ethical and professional boundary which physicians should not cross when revealing their own lives. There appears to be evidence that some revelation is therapeutic providing some confidence to the patient that the physician and patient are working together, avoiding a patient impression of physician paternalism. There is some evidence that patients may sue physicians less often if the physician says the appropriate words about him/herself.

What do physicians reveal? From Journal of General Internal Medicine vol 19, nr.9, 2004, there is an article describing a research study on this topic titled
“What Do Physicians Tell Patients About Themselves? A Qualitative Analysis of Physician Self-Disclosure” by Mary Catherine Beach, MD, MPH; Debra Roter, DrPH; Susan Larson, MS, Wendy Levinson, MD; Daniel E. Ford, MD, MPH; Richard Frankel, PhD
The following is the abstract of the article:

Objective: Physician self-disclosure (PSD) has been alternatively described as a boundary violation or a means to foster trust and rapport with patients. We analyzed a series of physician self-disclosure statements to inform the current controversy.

Design: Qualitative analysis of all PSD statements identified using the Roter Interaction Analysis System (RIAS) during 1,265 audiotaped office visits.
Setting and Participants: One hundred twenty-four physicians and 1,265 of their patients.

Main Results: Some form of PSD occurred in 195/1,265 (15.4%) of routine office visits. In some visits, disclosure occurred more than once; thus, there were 242 PSD statements available for analysis. PSD statements fell into the following categories: reassurance (n= 71), counseling (n= 60), rapport building (n= 55), casual (n= 31), intimate (n= 14), and extended narratives (n= 11). Reassurance disclosures indicated the physician had the same experience as the patient ("I've used quite a bit of that medicine myself"). Counseling disclosures seemed intended to guide action ("I just got my flu shot"). Rapport-building disclosures were either humorous anecdotes or statements of empathy ("I know I'd be nervous, too"). Casual disclosures were short statements that had little obvious connection to the patient's condition ("I wish I could sleep sitting up"). Intimate disclosures refer to private revelations ("I cried a lot with my divorce, too") and extended narratives were extremely long and had no relation to the patient's condition.

Conclusions: Physician self-disclosure encompasses complex and varied communication behaviors. Self-disclosing statements that are self-preoccupied or intimate are rare. When debating whether physicians ought to reveal their personal experiences to patients, it is important for researchers to be more specific about the types of statements physicians should or should not make.

As I noted on a previous posting on this blog, ethicist Robert Veatch has written about the importance of the patient finding a personal physician who carries the same goals and values as the patient and perhaps also the same culture or religion. This would suggest that at some point, the physician would engage in self-disclosure to make this information available to the patient.

There is no doubt that empathy is an important tool in making a connection with the patient and his/her illness. As noted in a previous post (March 3, 2005), the words of Harry Wilmer: “Sympathy is when the physician experiences feelings as if he or she were the sufferer. Sympathy is thus shared suffering.Empathy is the feeling relationship in which the physician understands the patient's plight as if the physician were the patient. The physician identifies with the patient and at the same time maintains a distance. Empathetic communication enhances the therapeutic effectiveness of the clinician-patient relationship.”

And for empathy to be most true and not “acted”, the physician must have had some similar life-experience. Thoughtful documenting that experience to the patient can validate empathy, this more real understanding by the doctor of the patient’s concerns.

What has your doctor told you about him/herself? ..Maurice.

ADDENDUM: You may wish to also read a subsequent posting on September 19, 2005 titled
"The Charisma of the Vulnerable Human Physician: The Decline of Charismatic Authority?" which I think is related to the topic of physicians self-disclosure.

Deletion of Bioethics Discussion Blog2

This message is to notify those interested that I have deleted the Bioethics Discussion Blog2 which I started recently when this original blog was sick. The postings to the substitute blog have been transferred to this blog. I hope this action hasn't confused or upset any visitor. ..Maurice.

What's in a Name? and The Fading of 9/11

Here are the two posts which I orignially was unable to post here but was posted on my substitution blog "Bioethics Discussion Blog2". I now include them in this blog for completeness.



Monday, September 12, 2005
What's in a Name?>

From the September 11, 2005 issue of the New York Times

EACH Katrina is handling the problem in her own way.
One, Katrina Petrillo, 13, an eighth grader at Convent of the Sacred Heart school in Manhattan, got so tired of being mocked as "Hurricane Katrina" by her summer vacation acquaintances that she told teachers on the first day of school on Thursday that she is now going by "Kat."


A wonderful narrative of a mother speaking to her daughter named Katrina was posted on the Medical College of Wisconsin bioethics listserv and I am reproducing it below with the permission of the author.

What's in a Name?
by Grace Fill

It's 2:30 in the morning and I'm safe and warm in my tent on what
may be the last really great camping weekend in northern Illinois this season.
I'm enjoying a rare bout of inadvertently caffeine-induced insomnia and my thoughts
inevitably turn to my now grown and only daughter, Katrina. It is less than a
week since the hurricane of the same name struck the gulf coast.

For Katrina, the daughter, it is suddenly troublesome to bear a name which
is associated with so much destruction and terror and suffering. Her name
will be forever linked to the worst natural catastrophe in the history of the
United States. Overnight the entire country knows how to pronounce and spell her
once uncommon name (Catarina, did you say? Krystina?)

Katrina, the hurricane, though no longer physically present, has
left chaos, uncertainty, violence and unspeakable horror. It is these negative aspects
that cause embarrassment for my daughter now when she is asked her name.

But Katrina, the hurricane, may also wield her power for good, shining an immense light into some profoundly dark places. In her wake lies also tremendous opportunity. Perhaps Katrina, the hurricane, will one day be seen as a
very critically needed wake-up call, Mother Nature's way of delivering a message
in no uncertain terms.

In the weeks and months and years ahead, no doubt there will be endless
debate about homeland security and the failure of our federal government, whose
focus is so much and so tragically elsewhere, to care righteously and properly
for its own citizens. But talk is cheap, very cheap indeed.

Katrina, the hurricane, has brought some things to light that cannot be
further ignored. The human beings who have suffered the most in New Orleans are
the same human beings who have lived in poverty for generations. And if we
choose to see, in the light that Katrina so amply provides, if we choose not to
turn away from a truth that existed before the winds, before the flooding,
before the cries of betrayal, if we have the courage to look, it is clear:
Poverty makes people vulnerable. The same poverty that makes people vulnerable to
disease, to ignorance, to violence, to early deaths, makes human beings
vulnerable in times of crisis, during natural disasters, and in the wake of catastrophe. A system that perpetuates poverty, perpetuates vulnerability. If we couldn't see this before, the force and power of Katrina ought certainly to make
it visible to us now.

And so, Katrina, my daughter, let me say this: You are no longer a
child, but I am still and will always be your mother. Allow me, if you will,
one more opportunity to offer some motherly advice, woman to woman, as you make your way as a young adult into our uncertain world. You are a strong force, not
unlike the hurricane that shares your name. Bear your beautiful name with
pride, Katrina. Know your power and use it wisely. Shine your awesome light into
the dark places and do not cower in the face of what you see there. Have
compassion, daughter for all living beings. Care about the most vulnerable, as
you always have. Keep doing what you can to help make this world a
better place.

What do YOU think about the ethics of assigning a persons name to a hurricane for identification purposes. Has anyone thought before about the emotional and social implications of that naming of a destructive event to the person with the same name? ..Maurice.

posted by Maurice Bernstein, M.D. @ 12:19 PM




Sunday, September 11, 2005
The Fading of 9/11

Petula Dvorak writing in today’s September 11
Washington Post discusses the possibility, as suggested by historians, that the 9/11 date and what happened on that day will fade as the years go on with the day becoming another Labor Day, Memorial Day, Presidents’ Day. Even December 7, the day that the United States was attacked, Pearl Harbor bombed, “a date that will live in infamy” is probably only vaguely in the memories of those who were not alive then.

Though the media describe some memorials going on today throughout the nation, I would guess that most of the population of the United States and certainly those from the Gulf Coast are thinking of the consequences of hurricane Katrina. And when you think about it, why not? Almost 3000 individuals lost their lives on 9/11 but they are gone and the most personal effects of their deaths is being carried year after year by their living loved ones. In a way, the New Orleans and Gulf Coast disaster has produced a even more profound loss of life---actually a loss of the lives, the living lives of over a million people or more. And they live to daily suffer the losses and uncertainties. In addition, the physical damage to the city of New Orleans and the other affected communities within three states, represent far more to rebuild and rehabilitate then essentially a couple of towers in New York. So I am not surprised if September 11 is found to be fading today.

You know, beyond the damage and loss of life or lives, there is an awful similarity between the two events. Have you also noticed too that our country and our government was unprepared for either? ..Maurice.

posted by Maurice Bernstein, M.D. @ 10:09 PM

My Original "Bioethics Discussion Blog" is Fixed and Working

This note is to all who are interested that this website, my original "Bioethics Discussion Blog" has the posting problem fixed (there were too many posts on the home page) and I intend to continue posting on this site. ..Maurice.

The Spelling of KATRINA

The Spelling of Katrina
by Maurice Bernstein, M.D.

K is for the Knowledge that was ignored
A is for the Aftermath that was not early acknowledged
T is for the Test of leadership that failed
R is for Recognition of the deficiencies that was delayed
I is for Insight that was unfortunately late in coming
N is for the Needs that were too long unmet
A is for Again. Will it all happen Again?

Posting Problem with This Blog

To Anyone Who Can Read This: I suddenly have not been able to post to the front page of my Bioethics Discussion Blog for over a week because of some error disorder unknown and untreatable by me. I am trying to make contact with a live helper from blogger.com but so far to no avail. At present I am in good health and I am eager to continue posting but, until I get help, I ask all my faithful visitors to be patient. If you want to console me, my e-mail address is: DoktorMo@aol.com
Thanks ..Maurice.

Ethics of the New Orleans Disaster: Absence of Justice

Later on there will be a dissection of what went wrong with the management of the current New Orleans disaster. But one ethical issue strikes me right away. It is the issue of ethical justice that I see had been ignored.

Here was a natural disaster anticipated for several days. An order was given by city officials for the population of New Orleans to evacuate. And many did, driving out of the city and fending for themselves somewhere. But where in the planning for this order was there thought that for evacuation, transportation is required and that only the economic class of people who have cars that run and have gasoline can follow the order? The justice issue is that it appears that there was no thought of the other class of people, the sick or infirm or those who could not afford to have cars to take them away from the potential danger.

There was no attempt for the city to provide transportation out of the city for this class of people and they were allowed to remain and suffer the consequences of the flooding of the city and perhaps perish. This ignorance of the lives of this class of citizens represents total lack of ethical justice, denying equal protection to all the citizens of New Orleans.

One wonders what was the rationalization by city officials for this unequality. Did it represent some class prejudice or just official amnesia?

Any thoughts? ..Maurice.