Case Scenario

I have a chronic illness that I am able to keep from most of my patients. I think that when patients go to a physician for help, they generally don't want to hear about someone else's problems. Some of my long-time patients expressed disappointment when I reduced my office hours, so I let them know why I was doing that. I hope that knowing about my illness might be therapeutic for these patients. However, I think that other patients might resent it if I told them about my illness. When is it helpful to tell a patient that I am having symptoms and pain similar to theirs? When does revealing information about my situation become an imposition on my patients?

Commentary

This physician's questions fall under the broad category of what physicians should tell about themselves to patients and, in this case, what physicians should tell patients about their own illnesses. The answer here, as with so many questions about physician-patient relationships, is “it depends.” The proscription against physicians talking about themselves with patients comes from several different traditions. When we consider the practice of medicine as a scientific project, a physician's position as a “neutral observer” leads us to try to avoid muddying the waters of diagnosis and treatment with our own concerns.

Part of the legacy of Freudian psychoanalysis to medical practice is the concept of identifying and scrutinizing countertransference—a physician's reaction to the patient's situation—with the goal of keeping the therapeutic frame as blank and neutral as possible. According to the theory, within this open space patients can work out their issues through transference—the reenactment of their basic problems in relation to the analyst.

From the perspective of humanistic medicine, we have a more contemporary concern that physicians should dedicate the clinical space to attending to the patients' problems and not burden them with the physician's troubles. As the physician in the case scenario points out, patients go to their physician to get help, not to help the physician.

Despite the strength of the traditional position against physician self-disclosure to patients, it is clear that, in the course of physician-patient relationships, physicians do talk about themselves with their patients.^1,2 In my work in this area, I found that physician disclosure can serve several purposes. Most commonly, physicians share personal experiences to serve as a model. Particularly with life-cycle issues, physicians may reveal how they have personally handled some event in their family's life. Just as teachers and parents often do, physicians may use positive or negative examples from their past. At other times, physicians may talk about their experiences to lend authority to their recommendations: I know, I tried it and this is what it's like. Sharing in this way shows reciprocity and reveals the physician to be as human as the patient. In general, these are the most common and acceptable themes for self-disclosure.

Physicians may also share information about themselves with patients to advance the physician-patient relationship. By disclosing personal experiences, physicians can show empathy for patients' current experiences and enhance a spirit of mutuality. Such disclosures may range from experiences with childbirth, breast-feeding and parenting³ to depression, back pain and chronic illness.^4,5 On rare occasions, disclosures about potentially stigmatizing information such as a history of psychiatric treatment, family alcoholism or sexual abuse can demonstrate deep joining with patients' suffering. Because the patient is entrusted with personal knowledge about the physician, the relationship may be advanced. The sharing of this type of information on the part of the physician demonstrates a high degree of mutuality in the relationship.

Most physicians acknowledge that these types of disclosures are rare and occur in the specially chosen context of the long-term physician-patient relationship. As the physician in the case scenario points out, physicians are most comfortable making personal disclosures to patients whom they have treated for many years.

The gender of the physician can be important in the discussion of self-disclosure. Men and women are socialized differently about the issue of self-disclosure and, therefore, male and female physicians face different challenges when deciding in what circumstances it is suitable to reveal personal information to patients. Female physicians, who are perhaps more comfortable with self-disclosure, may need to carefully scrutinize the situations in which they talk about their own experiences, whereas male physicians, who may be reticent in making self-revelations, may benefit from rethinking their initial tendency not to share with patients.

Why might patients be concerned when a physician reduces office hours? Some, of course, may be primarily concerned about the inconvenience, or they may feel threatened by any change. Other patients may be concerned that the change in hours implies the imminent possibility of their physician's retirement. Some patients may require reassurance and affirmation of the physician's commitment. Long-term patients may, however, be genuinely concerned about their physician's well-being. Many patients do come to care deeply for their physicians and have a genuine desire to give back to the person who has helped them, listened to them and been with them over the years. Patients commonly feel free to show reciprocity at visible points in the physician's life cycle (e.g., the birth of a child or death of a parent) when patients see the physician revealed as a “real person” who has legitimate needs and experiences life's triumphs and losses.

The physician with the chronic illness provides an example of such a legitimate need. Disclosure to some long-term patients will be appropriate because it will enable the patients to understand the physician as a person with needs—in this case, the need to limit office hours. Disclosures to a few patients with the same or similar chronic illnesses may be useful in that revealing the physician's vulnerability may enhance the relationship. Such disclosures may alleviate the loneliness, isolation and despair that can afflict people with chronic diseases and allow patients to feel that they are truly understood. Patients to whom physicians make personal disclosures may feel particularly valued to be entrusted with personal information. On a few occasions, patients in whom the physician confides can provide reciprocal support for a physician living with an illness. Nonetheless, the ethical commitment underlying self-disclosure must be to the enhancement and empowerment of the patient.

When personal life changes or illness affect the organization of a practice, sending a letter to established patients may be a personal way to inform them of the reason for changes. A letter can provide practical and personal information while allowing patients time to think about their reactions. A sample letter might read like this:

“I am writing to let you know that I have reduced my office hours to four hours a day, four days a week. I intend to remain in practice, but I will be reducing my hospital commitments and taking fewer new patients.

The reason for these changes is that I have recently learned that I have (state the illness), and I have found that I feel much better when

I work for shorter periods and get more rest and exercise. I expect to continue practicing for years, and I do not intend to leave my practice or retire in the near future. I have learned a great deal from all of you over the years, and I am now finding that illness is an important teacher as well. I hope I can use what I am learning from my illness to help my patients in the future.

I hope that the changes in my office hours do not pose a serious inconvenience to you. If you find that you are unable to get an appointment to see me within a reasonable time, my partners, Drs. X and Y are willing to see my patients for acute problems or to provide ongoing care if necessary.”

Providing information to patients can help them understand why the physician has made a change in the practice and give patients who wish to do so an opportunity to convey their concern. Patients with similar illnesses may be particularly affected, and they may also have good suggestions for the physician. When physicians learn from patients, they are showing the capacity for mutuality that allows for growth in both parties. Open communication is an important element of relationship-centered care—one of the ideal elements of long-term family medicine practices.