How Much Self-Disclosure is Too Much?
Early and late career collaboration #4
By Hans Duvefelt, MD
Doctors are people, not robots. And so far, robots (as in AI) aren’t doctors. We need to build relationships with our patients in order for them to trust us with their sometimes embarrassing symptoms, fears or circumstances.
If we never share anything about our own lives or experiences, it can be very hard to build the necessary therapeutic relationships we need in order to be effective guides on our patients journeys through disease or just life’s stages. This is especially important in primary care, and may not even be necessary for an orthopedic surgeon to handle a simple fracture.
But how much self-disclosure is too much in family medicine?
Like many things in my work, I see self-disclosure as something that evolves over time. Most people wouldn’t tell someone they just met a whole lot of things about their poor health or troubled marriage, for example. So, with a new patient, I stick with the basics. I try to find common ground by talking about pets or hobbies (mine aren’t ostentatious) or places we have lived.
I am fairly quick to share a couple of health issues I have, because they are very common and because they don’t make me look less trustworthy or competent. These include ringing in the ears (tinnitus) and acid reflux (in my case a large hiatal hernia). I am quick to share that I have a wedge pillow and that I avoid tomato sauce. I sometimes share that I take a medication for my blood pressure, especially in a discussion about side effects, for example.
If a patient I know better is going through a divorce or loss of a loved one to illness, I am not concerned about saying that I have been through the same thing. But I avoid sharing details about my experience. I just want the patient to know that what I say next isn’t just something I read about in a textbook.
I would not share anything that could hurt or embarrass me if my patient told anybody else about it. But I sometimes use myself in theoretical examples, rather than describing scenarios happening to an unnamed person. A typical example is how I describe cognitive behavioral therapy (CBT) for anxiety in an exaggerated way:
“For example, if I get a flat tire on my way to work in an area with no cell phone reception, I automatically expect the worst. In my mind, I’ll get fired and go bankrupt, my wife will divorce me and my children will call me a loser. But my therapist will stop my rambling thoughts and ask me to do some reality checking. Do I really think I’d get fired over something like that? Even if I did, couldn’t I find another job? What wife would drop her husband like a hot potato if he lost his job? Are my children that fickle? AND, couldn’t I just flag down a motorist, ask them to call the office, tell them I’ll be late and will work through lunch to make it up?”
By putting myself in a theoretical scenario like this, I believe I show that I can put myself in someone else’s shoes, that I can vividly imagine what it can be like to have anxiety disorder with catastrophic thinking, even though that is far from what I am really like.
When it comes to experiences very far back in time, I sometimes share more “private” things with patients I know well, especially if those things are common things people go through in their youth. I might give examples of being jealous of a friend, which I never am now, or how I hurt my mother’s feelings on purpose once in my early teens. None of this would be random revelations, but things said in a context when I can show understanding and sympathy for someone processing old or new feelings or events. It would be rare for me to share any current or recent regrets, that would violate my own professional boundaries.
When treating a friend as a patient, all of this gets a little more difficult. And often physicians friends want them for a doctor. But I seldom fret about it. Typically I would ask myself, would I tell them this if it hadn’t come up in a clinical encounter and would telling them be of any value from a therapeutic point of view? If not, I don’t disclose it. My friends trust me enough as a clinician, so I probably don’t need to go any extra miles to show them I can relate to what’s going on with them.
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By Lilian White, MD
“This app really helped my mine to unwind before bed. During residency, it was sometimes difficult to stop thinking about what I had seen or done that day, so this app was great for easing that transition to sleep for my mind.”
I had decided to self-disclose a little bit about my own struggles with sleep in residency with the hope of helping my patient with her own sleep difficulties. She had commented several times in our conversation about how her own situation in training was not as bad as a medical residency, so I hoped that by sharing my experience, it would show her how helpful the intervention could be.
As a person, I tend to be more shy and hesitant towards self disclosure even among friends and family. So as a physician, this trait probably informs my self-disclosure to be on the lighter side. It’s not my default to readily share information about myself. Probably a combination of nature and nurture.
In medical school, I even had a comment from one of my clerkship reviews that said “Lilian is slightly reserved in nature, but has an open aura about her.” I’m not sure what this had to do with my medical skills, so I found it a little odd and funny at the time that someone chose to comment on my personality; however, I thought the observation was interesting and accurate. I am pretty reserved as a general way of being, but if asked a question about myself, I would likely answer it openly.
The patient-physician relationship is unique in that I think part of the benefit for patients is that they can just “complain”, as some of my patients like to say, with the benefit a nonjudgemental ear and promised confidentiality. They also know as their physician that I won’t dump or share my baggage with them in return (as we might in a conversation with a close friend). I think this last point is a unique part of the patient-physician relationship and informs physician disclosure.
My rule of thumb tends to be: am I sharing this because I think it would be helpful for the patient or because it’s helpful for me? While sometimes the answer is both, I tend to only self-disclose if I think it will be helpful for the patient in front of me. If it would only be helpful to me to self-disclose (as might be the case when talking with a friend), I wouldn’t share it.
In some ways, this part of the patient-physician relationship is what makes it similar to that of a pastor, therapist or other more intimate professional relationship. If the focus moves from taking care of the client or human in front of them to the professional themselves by way of self-disclosure, part of the benefit of that relationship seems unrealized in my mind. Not that self-disclosure can’t be helpful - pastors self-disclose all the time. But the focus of the self-disclosure is for the benefit of the other.
Now, with all that being said, I self-disclosed my car had broken down the other day when I had to reschedule a patient. When I saw her later that day, she asked me how my car was doing. It was just a nice, almost mundane moment of human connection. This experience made me appreciate a little more of the shared benefit self-disclosure can have in the right setting.
I’d be curious to hear: what are your thoughts on self-disclosure in the patient-physician relationship?