Mrs. S sat up straight and made excellent eye contact. Her tone was pleasant. She wore a colorful yellow shirt and dark green pants, and was accompanied by her husband; her gilded rings and earrings added flair to her outfit. Her neutral expression, however, stood out to me. She had seen a doctor several weeks ago regarding her first vaginal bleeding since menopause, and a uterine biopsy showing a precancerous lesion was subsequently performed. Surely by this point she had a sense of what must be wrong: the gynecology ONCOLOGY clinic is not subtly named.
As my resident explained the treatment of endometrial hyperplasia, Mrs. S listened thoughtfully, but explained that she could not schedule the surgery because she and her husband were travelling to their home country of Ghana in a couple of weeks. The resident explained that this was a time-sensitive matter and urged the patient to schedule her hysterectomy, then urged again when the patient reiterated her travel plans. The resident grew quiet and turned toward the computer.
An interval passed, filled only with the sound of typing. In this silence I decided to engage Mrs. S. Her face lit up when I told her I had spent the summer in Ghana doing research at the largest teaching hospital in Accra. It was her first smile of the visit. We talked about where I had lived, where she was from, and then spent a couple of minutes swapping stories about Ghana while the resident wrote her note. Mrs. S told us she would have the surgery when she returned from her trip. I still remember the warmth she expressed when thanking us at the conclusion of the visit.
I realize that I share information about myself with patients more readily than most. Certainly my young age and level of training invite questions about school, my background, and the like. But I find myself sharing details about my life readily, even without being specifically asked. Recently I saw a patient with a repetitive stress injury from playing percussion, and when I mentioned to her that I play the trumpet, it opened a conversational opportunity.
Self-disclosure is a reflexive behavior engrained through years of social interaction. After all, sharing of oneself makes up the very fabric of normal dialogue. The physician-patient relationship, however, is not ordinary conversation or interaction. Patients entrust us with their health, freely sharing personal and bodily details they may not have told anyone else. Because of this, it is up to us to guide and shape the clinical encounter.
There are many times when it would be unwelcome to self-disclose. A patient complaining of fatigue likely has little interest in hearing about how a busy clinic schedule and academic demands have left me tired as well. When serious moments arise, sometimes simply listening for a period is the best way to communicate.
Several researchers have examined this issue with varying results. In a retrospective qualitative analysis of 1,265 audio-recorded office visits, physicians self-disclosed in a minority of encounters (15.4%) and these statements were mostly used for reassurance, rapport building, and counseling. Another study using the same data found that patients reported greater visit satisfaction when surgeons self-disclosed as opposed to primary care doctors, correlating instead with lower patient satisfaction. A different group of researchers examined 113 primary care clinic visits by incognito standardized patients and found no positive effect of physician self-disclosure. Given this mixed evidence, a review was conducted in 2015 to analyze the literature for trends, but researchers could only conclude that physician self-disclosure is common and that further research is needed to clarify its effect in different situations.
Our interactions with patients are complex. There are clinical scenarios that can be improved by a physician sharing personal information, and others that can be hindered. Part of the challenge of clinical medicine is molding one’s style to each individual patient encounter. I hope that my instances of self-disclosure have served to enhance communication and build rapport, rather than coming off as self-centered. I’d like to think I’ve at least broken even.
Several months after our initial encounter, I ran into Mrs. S in the hospital hallway. We passed each other at first, but both did a simultaneous double take and walked back to talk. She told me her trip had been successful and that she had scheduled the surgery upon returning to New York. We only spoke for a minute, the two of us transiently stopped in the busy hallway, each being pulled onward toward the rest of our day. For a brief moment though, it was a natural continuation of the rapport we had built months ago in just one clinic visit. She made a point to thank me again for my help, and warmly wished me the best of luck going forward. Her smile told me she was grateful not only for the medical care, but for the personal connection we had made in spite of the clinical setting.
Commentary by Dr. Tanner
Like young Dr. Soiefer, I take all appropriate opportunities to share information about myself. If I’m trying to convince a patient to take atorvastatin, I mention that I’ve been taking it for years. If my patient has hepatitis, I mention my 1975 trip to Morocco. The power differential inherent in the doctor-patient relationship sometimes needs to be amplified, as with patients who are self-destructively ignoring their health. More commonly, the therapeutic bond can be strengthened by revealing that you are just a person too.
Leland Soiefer is a 4th year medical student at NYU Langone Health
Peer reviewed by Michael Tanner, MD, associate editor, Clinical Correlations
Image courtesy of Wikimedia Commons
- Beach MC, Roter D, Larson S, Levinson W, Ford DE, Frankel R. What do physicians tell patients about themselves? A qualitative analysis of physician self-disclosure. J Gen Intern Med. 2004:19(9):911-916. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1492523
- Beach MC, Roter D, Rubin H, Frankel R, Levinson W, Ford DE. Is physician self-disclosure related to patient evaluation of office visits? J Gen Intern Med. 2004:19(9):905-910. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1492510/?report=reader
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- Arroll B, Allen EC. To self-disclose or not self-disclose? A systematic review of clinical self-disclosure in primary care. Br J Gen Pract. 2015:65(638):609-616. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4540401