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.
posted by Maurice Bernstein, M.D. @ 9:00:00 PM
11 comments
11 Comments:
At Friday, September 30, 2005 7:49:53 PM, aquarius said, by error,on a posting with a different topic:
Hi Dr. Bernstein - what does the medical ethics say about dual relationships? Say, engaging in doctor-patient and friend relationships with the patient or even the patient's family members? We are learning about psychologist ethics in class and just wanted to get a sense of what it is like for physicians? Would the general guidelines be slightly different for psychiatrists? Thanks!
My response to aquarius:
AMA ethical policies E 8.14 and E 8.145
regarding romantic relationships is as follows:
Sexual contact that occurs concurrent with the patient-physician relationship constitutes sexual misconduct. Sexual or romantic interactions between physicians and patients detract from the goals of the physician-patient relationship, may exploit the vulnerability of the patient, may obscure the physician’s objective judgment concerning the patient’s health care, and ultimately may be detrimental to the patient’s well-being. If a physician has reason to believe that non-sexual contact with a patient may be perceived as or may lead to sexual contact, then he or she should avoid the non-sexual contact. At a minimum, a physician’s ethical duties include terminating the physician-patient relationship before initiating a dating, romantic, or sexual relationship with a patient. Sexual or romantic relationships between a physician and a former patient may be unduly influenced by the previous physician-patient relationship. Sexual or romantic relationships with former patients are unethical if the physician uses or exploits trust, knowledge, emotions, or influence derived from the previous professional relationship.
Patients are often accompanied by third parties who play an integral role in the patient-physician relationship. The physician interacts and communicates with these individuals and often is in a position to offer them information, advice, and emotional support. The more deeply involved the individual is in the clinical encounter and in medical decision making, the more troubling sexual or romantic contact with the physician would be. This is especially true for the individual whose decisions directly impact on the health and welfare of the patient. Key third parties include, but are not limited to, spouses or partners, parents, guardians, and proxies.
Physicians should refrain from sexual or romantic interactions with key third parties when it is based on the use or exploitation of trust, knowledge, influence, or emotions derived from a professional relationship. The following factors should be considered when considering whether a relationship is appropriate: the nature of the patient’s medical problem, the length of the professional relationship, the degree of the third party’s emotional dependence on the physician, and the importance of the clinical encounter to the third party and the patient.
In addition, other relationships such as a business relationship with the patient which could cause conflict of interest or lead to undue decision-making influence on a vulnerable patient must be avoided. More casual relationships such as playing golf with a patient might be OK but it is best if the physician attempts to maintain a non-professional distance from the patient. ..Maurice.
Hello Dr. Bernstein,
I have in counseling since September of 2006 with a psychologist. I have since found myself very attracted to him, but I know there are boundaries, and I would never jeopardise the progress I have made or my doctor for that matter. I did make my doctor aware of my feelings, on two occasions. I even asked if I should discontinue treatment because of the way I feel. He told me that he is commited to working with me in a professional and ethical manner, yet my thoughts of him have yet to be addressed, and I'm uncertain if I should bring them up. I do find therapy with him helpful, yet my attraction gets stronger with each session, since it seems that our banter gets easier and more lighthearted with each visit. Help! I almost want to discontinue therapy, yet I still want to see him.
This feels like a tidal wave. Any suggestions?
Abby
What disorder and the symptoms you are being treated for are important in the evaluation of your question. However, if you find a change in "banter", this may be reflecting both a change in your feelings toward the psychologist and perhaps, depending on the diagnosis, a sign of improvement on your part. However, it also could reflect a change in your psychologist's attitude towards you. I am glad that you are aware of the issue of professional boundaries. You are wondering about talking to him about your feelings about him. I would strongly advise that you do so since it is a part of diagnosis and therapy for the psychologist to be aware of the patient's feelings whatever they are. With regard to discontinuing treatment with this psychologist, if he expresses any non-professional interest in you or shows any signs which you might interpret as such, it becomes very important that you find another therapist or else your psychologist also becomes a patient and you are no longer under professional therapy. ..Maurice.
Hi again Dr. Bernstein...
I primarily sought him as a 'life coach', I guess I could say. I am also receiving treatment from a psychiatrist for Bipolar Disorder (II), as well as anxiety. I have been medicated and on a path of improvement for the past five years. (even though I was diagnosed way back in 1991.)
When I say that our 'banter' has become more lighthearted, it just seems to me that he has changed the course of conversations at times, discussing topics that seem 'offbeat', and not actually having to do with my present situations. We seem to be laughing ALOT in sessions, (not neccessarily about my issues), and I leave in a really good mood...but is my mood reflective of him, per se or am I reading more into this than I should be?
I'm so very conflicted.
Abby
Thanks for the added information. Have you thought about talking to your psychiatrist about your concerns regarding the relationship with your psychologist? Since your psychiatrist knows you and may even knows your psychologist, he or she may provide you with the appropriate choices and support that evidently you need. By the way, I am feeling very good about your ethical outlook since being "conflicted" in this situation is exactly what is necessary. If you had no concern for the professional boundaries as set for your psychologist and did not really care what would be the impact on his work and professional standing by him ignoring those boundaries but you were only interested in, perhaps, furthering your own emotional desires, there would be no conflict! I think you are a thoughtful and ethical person. ..Maurice.
An ethical issue nearly every psychologist and others who provide similar services encounters fairly frequently. Some thoughts: If Abby is making objective progress such as having a more fulfilling life, fewer mood swings, being able to maintain employment or doing better in school, fewer or no thoughts of self harm, etc. then she is clearly benefiting. Stopping what works is usually not recommended. Second, I suspect that the therapist has encountered this situation before. Abby may want to discuss with him how the feelings are affecting her therapeutically, and ask for changes to the the treatment approach (like less banter, etc.). If it is just transference, he should let her know that, and then help her work through it. As I have said elsewhere, it is the therapist's responsibility to maintain appropriate boundaries. If she feels her boundaries are being violated, a discussion with the psychiatrist if he or she does more than a 10 minute med review may help. Was the ability to be lighthearted and to joke and banter more freely a therapeutic goal? The ability to interact informally is an important social skill. A final consideration, is this a change in the Bipolar Disorder? Are all the clinical signs and symptoms unchanged - sleep, impulsivity, irritability, etc.? Abby said she has Bipolar II which has much more subtle changes than does Bipolar I.
I am pleased that she has the insight to see what is happening, and to ask questions. I wish Abby good luck in finding the answers.
I find my dads surgeon and i are attracted to each other, I asked him out he said yes, but not until after he has completed treatment with my dad, which is wrapping up,in the interim we do not have any contact other than the follow up visits. I can't wait, wonder if he'll remember.
Please read my posting of September 30, 2005 which includes the AMA codes of ethics..and read about what is stated concerning 3rd party involvement with the patient's physician. From a professional point of view, I would tend to discourage any personal non-professional involvement with the physician even if it doesn't turn sexual at the beginning. ..Maurice.
I'm attracted to my obstetrician. Like the other woman said it seems, although he's definitely within his professional boundaries, the "banter" between us seems uncommon also. He's asked if I was staying in town & we're always joking - but it's always been that way with him. We have great interaction & I'm very confused as the other woman. Another example, I was breastfeeding when he came into the room & although he folded his hands in front of him, he came very close to my side & said, "aw, let's look at this." He just stood there silent until I put the baby down. I know his father's a doctor who married his nurse - this interaction is also forbidden isn't it? I don't know if I should come right out & say I'm attracted to him & cease the doctor client relationship or what. One last question: is there any code language between a doctor / nurse to say, let each other know one of them is in an uncomfortable situation? I made a forward remark & quickly said I was joking because he looked frightened or shocked. Later he told the nurse "my wife & I..." The nurse said "your wife?" He said "yeah my wife" & she said "oh, your wife" & they continued talking personal stuff, which I thought is forbidden. I'm wondering if he was clueing her in that I made a personal comment that made him uncomfortable - is there any code talk you all do when you need help out of a situation?
hi doctor,
how about marrying my patient who is also my colleague. we are both doctors and started the relationship six years after she stopped being my patient.
thank you.
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