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FACING a distressed teenage patient crying “You don’t understand!”, paediatrician Dr Kelly Curran was tempted to prove otherwise by sharing her own medical history.
The 14-year-old girl had just been told her colonoscopy results were abnormal after enduring months of bloody diarrhoea. Dr Curran was postoperative and waiting on the results of a biopsy to determine whether she had Crohn’s disease.
In the end, Dr Curran chose to hold back, deciding, as she explains in the New England Journal of Medicine, that the risks of such a disclosure were too great.
“My motives at this time aren’t completely altruistic”, she writes. “For several months, I have been swallowing down this painful, intensely personal secret, and here it is, burning to be spoken.”
She craves a confidante, she realises, “and even if it’s only a small part of my motivation, wanting that recognition from a patient — and one I’ve only just met — is inappropriate and selfish”.
At first glance, the idea of sharing personal information to create a bond between doctor and patient might seem appealing, but research suggests Dr Curran may have been right to be cautious.
One study used actors presenting as patients to US family physicians (the doctors had consented to be part of the study but did not know which patients were actors).
Personal disclosures by the doctors were relatively common — happening in about a third of consultations — and around 40% of them were unrelated to the supposed patient’s symptoms or feelings.
There was no evidence of benefit from the disclosures, the researchers concluded, and in some cases they were actually disruptive.
Another US study found an intriguing difference in patients’ responses depending on the specialty of the doctor revealing the personal information.
When a surgeon shared information, patients were more likely to feel reassured afterwards (60% v 45% with no surgeon disclosure) and to be very satisfied with the consultation (88% v 75%).
But when a family physician did the sharing, the opposite was true: only 42% of patients felt reassured (v 55% of those who didn’t receive a disclosure) and 74% were very satisfied with the consultation (v 83%).
There’s no doubt a doctor sharing a personal story can sometimes aid a consultation — I’ve experienced it myself — but, as Dr Curran noted, the urge to disclose may not always be an entirely altruistic one.
We humans have a powerful desire to talk about ourselves: it’s been estimated 30%˗40% of our everyday speech is devoted to the absorbing topic of ME.
Recent research from Harvard University suggests such sharing may stimulate pleasurable feelings not unlike those we obtain from food and sex.
Functional magnetic resonance imaging showed self-disclosure was strongly associated with increased activation in the brain’s mesolimbic dopamine system, otherwise known as the “reward centres” of the brain.
In fact, self-disclosure was so rewarding that participants in this study chose it over hard cash.
Offered a choice between talking about themselves, talking about other people or answering factual questions, participants tended to opt for self-disclosure even when there was a financial incentive to choose one of the other options.
“Just as monkeys are willing to forgo juice rewards to view dominant group mates and college students are willing to give up money to view attractive members of the opposite sex, our participants were willing to forgo money to think and talk about themselves”, the researchers wrote.
It’s a finding that might help to explain our willingness to divulge private information in relatively public forums such as Facebook and Twitter.
Perhaps it’s time to consider choosing to drink the juice instead.
Jane McCredie is a Sydney-based science and medicine writer.
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A consultation is a communication. It may be appropriate to share experience with a patient if it will communicate an empathetic approach to the patient. Care must always be taken not to divulge confidential experience and common sense should dictate limits to disclosure.
I agree Franno that worldview atheistic worldview (AW) provides a very different account of morality and ethics than theism (TW). The gist of the argument is the ontology of objective moral values (OMV) and duties. Objective means that moral values are universally and unchangeably binding and valid regardless of history, tradition, social trends or personal beliefs. OMV includes virtues (e.g. the golden rule, compassion and empathy) and transgressions (e.g. child abuse, paedophilia, rape, torture). Both atheists and theists agree that AW accounts for OMV by invoking evolutionary biological determinism as you have. They also agree that AW logically leads to a denial of libertarian free-will and OMV. On AW these are illusionary, they don’t really exist but merely subserves the impersonal and amoral process of natural selection to promote survival of the fittest and/or the species. This has been affirmed by atheists in a variety of disciplines that include science, ethics and philosophy.
Summary of my argument is this:
1. If atheism is true, objective moral values do not exist
2. Objective moral values exist
3. Therefore, atheism is false
If we substitute ‘atheism is true’ in premise 1 with ‘God does not exist’, the conclusion is that God exists. TW thus provides a more plausible ontological account of the golden rule than AW. TW grounds the golden rule in God as an objective moral value. AW affirms the golden rule as subserving natural selection and hence the golden rule is not necessarily valid and binding in all scenarios or possible worlds.
James hits the nail ironically on the head with his Rule Number 4: “The patient is the one with the disease.”, by (deliberately?) missing the point that doctors, too, are human (noted elsewhere) and thus also prone to illness, be it physical or emotional.
Doctors get sick, no argument. But how their illnesses affect their work and professional relationships is precisely the point of the NEJM article and Jane’s piece.
The elephant in the room is the frank admission by Dr Kelly A. Curran MD that she “craves a confidante”, suggesting that she, herself, has significant unmet emotional needs related to the delayed diagnosis. Indeed….“For several months, I have been swallowing down this painful, intensely personal secret, and here it is, burning to be spoken.” But fortunately not to a 14 year-old girl sitting opposite her in the surgery!
Dr Curran should be congratulated on her insight and self-control but perhaps this was not a good example to illustrate a common situation requiring judgement and self-awareness, truly a grey area in many instances.
Rapport between doctors and their patients evolves over time and a modest degree of self disclosure will often add to the therapeutic relationship. In anaesthetic practice there is rarely the opportunity to do this, but I push the boundaries on occasion when I sense it will put my patients at ease and enhance the relationship.
James’ point is still well made though – the patient’s needs are paramount, whatever is going on inside the doctor’s head (or body). This is not to ignore the practitioner’s wellbeing, but emphasises the need for doctors to seek appropriate help for their own and, indirectly, their patients’ benefit.
Sorry, Ethos, I agree with all of your assertions, except for the inaccurate statement that the ethos of “loving others as yourself” in a sacrificial way has its ontological basis in Christian theism. These traits, and the profound benefits that flow from such evolutionary behaviours, considerably predate the rise of the Christian faiths. Most other religious beliefs will contain an element of “for the greater good” amongst their edicts, and socialised/altruistic behaviours are present in numerous forms, even in species outside our own. Empathy is likely to be DNA coded, but variably expressed – our job being to recognise its immense power for improvement for all life, and to continually improve our practice of it. To imply that Chritian theism holds some kind of ownership of such altruism is not only inaccurate, but also a little insulting to those people who chose not to subscribe to such doctrine, but who do practice acts of selfless kindness on a regular basis.
I certainly agree that disclosure of personal experience should be consciously vetted for utility in the doctor-patient relationship, before being used in the appropriate context.
Most patients assume that the doctor they trust with their lives is competent with a combination of sound knowledge, technical expertise and adequate clinical experience. With this as a given, patients often make appraisals of whether their doctor is “good” on how perceptive and responsive their doctor is, and whether the doctor has important human qualities of empathy and compassion when called for.
I agree that an important question in self-disclosure is whether this is primarily self-serving or primarily in the best interests of the patient. It is important to avoid the extremes of either lacking compassion and empathy or using the patient as a sounding board for our own personal problems. We share important qualities with our patients: we are human, morally imperfect, we can be self-serving, have basic legitimate human needs of being valued and loved, and we are susceptible to physical and mental ailments. However, the duty of care that patients entrust to us means that we are there as providers not as consumers.
The golden rule of loving others as yourself has broad general consensus. Love is ultimately sacrificial, i.e. an attitude that leads to conduct which is in the best interest of the other, even at one’s own expense. This ethos has an objective ontological basis in Christian theism. The ethos of self-disclosure cannot be reduced to a simple mindless rule but will require a case-by-case assessment of whether this is in the best interests of our patient. We need to be honest in recognising that our motives are not always purely altruistic. In some instances, self-disclosure may be mutually beneficial but the primary focus and intent must be in the best interests the other person, our patient in this instance.
A doctor is not a foreign object. Clearly, something personal can be about what happened to the person or about a relationship. Something said can also be in reply or spontaneous or intended to help or manipulate or control. Did the researchers quoted delve into these, asking both the provider and the receiver, in addition to treater class. Without knowing the circumstances and answers to the above, we are not any the wiser. In fact, we may even be worse off as without critical appraisal of the methodology, literal interpretation of complex scenarios provide a junk base of nonsense that Medical Boards and bureaucrats could rely on, beyond their own biases, to make decrees regarding professionalism and misconduct. Spare us from the effects of such ambiguity and nonsense. A critical appraisal of the evidence and methodology is required rather than quotes that are superficial and meaningless, because this is an important subject.
It is very interesting observing things from the other side. Having retired (due to ill health) after 43 years and moving to a new location I sought a new GP. I always told them that I had been a doctor & on most occasions I was presented with a long consultation during which they complained about their problems… Medicare, Government regulations, too much administration, QA & CE, increased patient violence, problems with practice managers. Never any sharing of their medical problems but then that was inappropriate as they were young fit men & I was a gnarled old woman (who had obviously not lost her listening & counselling skills). I found it slightly exasperating when asked, “Why aren’t you still working?” No empathy there! There are times when a doctor can share with a patient. I believe it should only be to validate and give them hope rather than to unburdan yourself. Boundries get crossed a lot when you are colleagues and know each other. We are all human afterall.
Rule Number 4. “The patient is the one with the disease.”