The Corpus Callosum

A
recent study in the Archives of Internal Medicine caught my attention,
because it has significant implications for stress management by
physicians.  The study also generated a bit of
attention in the popular media.  For example, this article in
NYT:

title="NYT permanent link via RSS"
href="http://www.nytimes.com/2007/06/26/health/26doctors.html?ex=1340510400&en=f56fa2071d6a6fa7&ei=5090&partner=rssuserland&emc=rss">Study
Says Chatty Doctors Forget Patients
By GINA KOLATA
Published: June 26, 2007

…To their surprise, the researchers discovered that doctors talked
about themselves in a third of the audio recordings and that there was
no evidence that any of the doctors’ disclosures about
themselves helped patients or established rapport…


The original study is this (subscription/academic access required for
full text):

rev="review"
href="http://archinte.ama-assn.org/cgi/content/full/167/12/1321">Physician
Self-disclosure in Primary Care Visits

Enough About You, What About Me?
Arch Intern Med. 2007;167:1321-1326.

Susan H. McDaniel, PhD; Howard B. Beckman, MD; Diane
S. Morse, MD; Jordan Silberman, MAPP; David B. Seaburn, PhD; Ronald M.
Epstein, MD

ABSTRACT

Background  The value of physician
self-disclosure (MD-SD) in creating successful patient-physician
partnerships has not been demonstrated.

Methods  To describe antecedents,
delivery, and effects of MD-SD in primary care visits, we conducted a
descriptive study using sequence analysis of transcripts of 113
unannounced, undetected, standardized patient visits to primary care
physicians. Our main outcome measures were the number of MD-SDs per
visit; number of visits with MD-SDs; word count; antecedents, timing,
and effect of MD-SD on subsequent physician and patient communication;
content and focus of MD-SD.

Results  The MD-SDs included discussion
of personal emotions and experiences, families and/or relationships,
professional descriptions, and personal experiences with the
patient’s diagnosis. Seventy-three MD-SDs were identified in
38 (34%) of 113 visits. Ten MD-SDs (14%) were a response to a patient
question. Forty-four (60%) followed patient symptoms, family, or
feelings; 29 (40%) were unrelated. Only 29 encounters (21%) returned to
the patient topic preceding the disclosure. Most MD-SDs (n = 62; 85%)
were not considered useful to the patient by the research team. Eight
MD-SDs (11%) were coded as disruptive.

Conclusions  Practicing primary care
physicians disclosed information about themselves or their families in
34% of new visits with unannounced, undetected, standardized patients.
There was no evidence of positive effect of MD-SDs; some appeared
disruptive. Primary care physicians should consider when
self-disclosing whether other behaviors such as empathy might
accomplish their goals more effectively.


In a way, this is a bit surprising, as the authors appear to be unaware
of the fact that the topic of self-disclosure has been extensively
researched in the psychotherapeutic literature.  Although the
treatment context is different, many of the concepts are the same.
 Some of the authors have appointments in their department of
psychiatry, which makes this disconnect seemingly inexplicable.
 None of their 31 references pertains to the literature that I
would think would be most pertinent.  

That aside, the authors conclude:

…Our
analysis suggests that title="Medical Doctor self-disclosure">MD-SD
usually is of little value and, occasionally, can actually impair the
physician-patient relationship. Primary care physicians may wish to
make explicit decisions about any use of self-disclosure and consider
using empathy and other ways of demonstrating support and building
relationships.


Certainly it is true that the decision to engage in self-disclosure
should be considered thoughtfully.  It can be a useful tool,
but only in very limited circumstances.

What is more important, in my opinion, is the question of what
motivates the physicians to engage in self-disclosure.
 Admittedly, this is something that is hard to study
objectively; it would require an entirely different methodology.
 

This is important for two reasons.  One, the authors found
that 11% of the instances of self-disclosure appeared to be disruptive
to the doctor-patient interaction.  Thus, it would be good to
prevent this, to the extent possible.  Understanding the
motivation could help prevent these disruptions.

Second, and this is somewhat speculative on my part, self-disclosure by
physicians could be a sign of stress affecting the physician, diverting
attention from the mission of patient care.  While it is not
humanly possible for anyone to maintain mission focus 100% of the time,
it obviously is a good idea for physicians to set this as a goal.
 Deviation from this goal (particularly if it is systematic)
should lead to introspection in an effort to understand the motivation.

The authors provide some insight of their own:

…To
the extent that practitioners are disclosing to receive support, there
are more helpful venues that would not risk diverting the focus of the
medical encounter. Physician self-awareness and well-being are critical
to shaping successful practices and can be accomplished in many
ways.  Examples are professional support groups, mindfulness
training, or conversations with friends and family. Although it is
understandable that practitioners who spend considerable time each week
caring for patients might find themselves wanting to share thoughts and
feelings with patients, we hope that our findings encourage
practitioners to explicitly consider whether self-disclosure is in the
patient’s best interest and the best use of visit time…

 
The possible interventions they mention (support groups, mindfulness
training, or conversations with friends and family) all are valid means
of managing stress.  But in order to manage stress optimally,
it first is necessary to recognize it, and to acknowledge the problem.
 If unhelpful self-disclosure is a sign of physician stress,
it could be a clue that additional attention to stress management is
needed.

Comments

  1. #1 js
    June 29, 2007

    This is interesting. As a patient, I generally feel put at my ease by a certain amount of MD-SD, but I guess I can’t say that it positively affects health outcomes.

    This study has also reminded me of how much I love the term “standardized patient.”

  2. #2 Ruth Beazer
    July 3, 2007

    My own primary care physician is very clinical in his style of being an MD. For the most part that is just fine by me.
    However, there are times I am less likely to confide in him because he is so clinical.
    Also sometimes I am not able to make follow-up questions or comments because he is so quick, even though I write everything down before I see him.
    So there are times it would be better if he were more chatty.
    Ruth Beazer