Physician Self-Disclosure: Helpful or Harmful?

How much should doctors reveal about themselves to patients? 
Whether or not “self-disclosure” is an effective communication strategy in the doctor-patient relationship has been debated.  In fact, some studies have demonstrated that doctors who talk about themselves more are rated more poorly by patients than those who are more private. This topic has been of interest to me and I have written about it in my blog:  Doctor, Patient, Friend:  Blurring the Boundaries,  and explored it further in a recent book chapter in Social Media in Medicine.   

In the case of teachers and students, communication strategies that promote “immediacy” have been found to have positive results in terms of promoting learning by creating a more open classroom environment.  Humor and self-disclosure are two strategies that promote immediacy. But, are these communication strategies effective in medicine also? I hypothesize that they are.

Recently a patient visited me to follow up after an E.R. visit. While she was in the office I recounted to her a personal tidbit that related to her day in the E.R.  While she and I were on the phone and as I was advising her the preceding Saturday afternoon, I had walked outside of a local sub-shop, Dave’s Cosmic Subs, seeking out private place to talk. On doing so, I had stepped beneath a tree into a pile of fire ants and was bitten all over my feet, which caused a degree of distraction.   For this reason I ended the phone call somewhat abruptly and later called her back. Was this self-disclosure helpful? She found it amusing, but we didn’t lose much time over the conversation.   A few days later she made mention of it again as we chuckled together about life's annoyances.

In another recent conversation with a patient who was considering various hormonal options for peri-menopausal symptoms I revealed my personal experience with using a Mirena IUD.  Several weeks later she decided this might be a good option for her as well.

Were these personal self-disclosures to my patients helpful or harmful? In the role of patient, I’ve been to see physicians who recount personal stories during an office visit that seem to take time away from my talk-time.   In a dentist's office this can provide pleasant distraction as one is held captive with her mouth open, but in a doctor's office it can be annoying to a patient when one knows that time is limited.   Nonetheless, physicians, with their expert knowledge of medicine, process medical information in the context of their own lives in ways that are sometimes helpful to patients to learn about by way of example. 

I have, on more than one occasion, shared the story: when I turned forty I was diagnosed with hypertension.  Three months after stopping oral contraceptive pills my blood pressure normalized.  I suspect that I will eventually need blood pressure medication, in light of my strong family history and current readings (130s/80s), and also despite my normal BMI and daily exercise. However, I will try to stave it off for a few more years. Are these tidbits of personal experience helpful for me to share with my patients?

As physicians increasingly engage in social media the question of appropriate self-disclosures becomes more relevant.  Should a doctor “friend” a patient on Facebook? How should a physician conduct his or herself on Twitter?  Self-disclosure is the norm for much participation in social media. The AMA has published guidelines for social media use by medical professionals.  My own theory is that physician self-disclosure can help promote intimacy and trust between doctor and patient—qualities that are increasingly lacking in the patient-physician relationship.  I might point out that in the case of social media, self- disclosures do not occur in the context of office visits, and as such are extra communications that don’t take time away from a patient’s precious appointment time.

Recently I was interested to read about a series of studies published in the Proceedings of the National Academy of Science. The studies, led by Harvard psychology researchers Diana I. Tamir and Jason P. Mitchell, made the relatively intuitive discovery: humans get a biochemical buzz from self-disclosure.  By inference, perhaps doctors who share more with their patients are happier with their patient interactions than those who are more reserved, and perhaps those positive feelings translate into a more effective health care experience.   No one knows, and more study is needed to uncover exactly what forms of physician self-disclosure are helpful to patients and what forms are more self-serving, or “narcissistic,” detracting from the patient-physician relationship.

Are Annual Physical Exams Necessary

Recently a physician reporter for the New York Times, Elisabeth Rosenthal, argued in the cover article of the Sunday Review that routine physicals are in many ways pointless, and perhaps even dangerous.  In the article, entitled “Let’s Not Get Physicals,” Dr. Rosenthal goes on to point out that many routine tests performed during physicals --EKG’s, pap smears and blood work, are unnecessary. In my opinion, Dr. Rosenthal’s front page skepticism of the utility of the annual ritual misses the key point and sets a dangerous tone.  As every good primary care physician knows, the key benefit of an annual check-up (aka “physical”) is not the litany of tests ordered, but the opportunity it provides to do a complete review of a patient’s medical history and risk factors.  The “annual physical” also provides an opportunity for healthy people to get to know their physicians and vice versa, so that when illness arises, as it always will, the physician will understand a patient’s personality and healthy baseline.  

After years of criticism by proponents of prevention Medicare recently started to cover an annual exam, which is referred to as a “Wellness Exam.”  The Medicare preventive exam, which became a covered benefit in 2011, emphasizes history-taking as opposed to testing, which in my view is appropriate.   The Affordable Care Act also regulates the provision of preventive care by health plans requiring that plans provide a core set of preventive services without requiring a co-pay, co-insurance, or deductible.

While the physician author of the New York Times piece surely understands many of her own personal risk factors for disease and also the signs and symptoms of potentially serious underlying conditions, the general public does not have this expert knowledge. Why shun a once a year, hour-long (or, as is more often the case these days, 20 minute-long) visit to a medical expert to review one’s personal health profile, risk factors and family history?  I suppose that Dr. Rosenthal’s point is to de-emphasize the testing component.  In my view, if anything many individuals could benefit from more frequent (biannual or quarterly) preventive checks to keep them on track with their health goals and risk factors—perhaps this would keep more folks out of the ER and hospital.  As to the “testing” component of the annual physical, the visit provides an opportunity for patient and physician to discuss the state of the art, information that the patient might be reading online, and the evidence for and against screening for particular conditions. Which screening tests health insurance should pay for is a separate question. The issue here may be semantic—should it be called a "physical,"  a "wellness visit," or a "preventive check-up--" but, let’s not get rid of the annual visit.

Two Conversations About Health Care

Last weekend I was struck by two conversations that I had with acquaintances about recent experiences that they had had with their primary care physicians.  The first occurred at my local pool. A fellow swimmer asked me if I took new Medicare patients.  She bemoaned that she was abandoned--her beloved physician of over 20 years had sent out a letter announcing that she would no longer accept Medicare patients. My friend had recently gone on Medicare.  She speculated about her physician’s  motives, but felt personally rejected, or “fired.”   After she explained her situation, I affirmed, “I do take new Medicare patients,” but qualified my response with a description of my concierge model primary care practice, which requires an annual retainer fee from members in exchange for improved access to me and other amenities, including my guaranteed smaller patient panel size. 

I started a retainer fee primary care practice after having been in a traditional fee for service practice for 12 years and then after taking a year’s leave of absence from clinical medicine. Many of my old patients sought me out, though currently most patients enrolling in my practice are new patients looking for a better primary care experience.  My swimming friend nodded that she understood and that her mother had a concierge physician--she was familiar with the concept and could see its value, though was going to have to decided whether she could afford it. 

My second conversation was at a friend’s 59^th birthday party the following evening. The party was held at the upscale home of a middle-aged, gay male couple—friends of my friend. As I chatted with one of the hosts, a self-employed professional, he asked what kind of medicine I practiced. I explained that I was an internist, or a primary care physician for adults, and that I was in solo practice in Atlanta after practicing at the Emory Clinic for 12 years.  As I spoke he announced that he was in need of a new primary care physician. He went on to explain that his physician, who he was very fond of, had converted his practice last year to a concierge model practice—requiring patients to pay a membership fee in order to remain in his care.  He had made the decision not to enroll in the new practice model, in part because he was already paying a high deductible for care under his insurance and he was unsure how the annual fee would impact his out of pocket cost.  Before the host of the party said more (not wanting him to feel awkward with me), I explained that my practice was a similar model. He and I spoke for about twenty minutes about the problems in primary care and the reasons that primary care doctors were seeking out new practice models.  The man with whom I chatted pulled over his partner, who had been cared for by the same physician.  His partner reacted to our discussion—“but this is not a solution for our country’s health care problems.” I agreed, and we talked about cost and discussed new models of health care, including the Medical Home and Accountable Care Organizations, both of which have yet to materialize as answers for doctors like me.  He went on to assert that he felt that one solution to the problems in medicine would be to produce more doctors, while at the same time to lower the cost of educating them.  Personally, I doubt that producing more doctors in general, will improve primary care, nor will it reduce cost; though, better incentivizing primary care career choices would be helpful.

These conversations illustrate that for the American populous the main problems in health care today are access and affordability.   For primary care physicians the problem is not so simple.  The "system" has failed to support our work in a manner that is conducive to providing the care that we feel patients deserve. Patients may or may not be aware of the impact of this failure on our practice of medicine.

Most Americans equate spending money on health insurance with spending money on their physicians. Primary care physicians see relatively little of the money that consumers put toward their health insurance premiums. Our fees and reimbursement rates are relatively low in comparison to the exorbitant fees for tests, procedures, E.R. visits, and hospitals stays. As our overhead expense has increased, in part because of the administrative hassle involved in getting money from health insurance companies, we have responded by increasing the number of patients seen per day and our panel sizes to the point where many (including myself) feel that quality of care and the patient-physician relationship is compromised.

“Concierge medicine” and the abandonment of Medicaid, and now Medicare, by primary care practices are a reaction to these pressures, which have changed the nature of general practice and offer solutions to protect the personal aspects of the physician-patient relationship.  However, clearly these motives remain poorly understood by the average American consumer, who is faced with rising out of pocket medical costs to pay for health insurance, and increasingly feels burdened with excessive health care expense.

The disconnect leaves doctors like me in a conundrum. Do we continue to work within the confines of a system that has failed to protect primary care as an honored specialty? Do we compromise the care that we deliver in order to preserve access?  Or, do we jump ship and force change by creating new models of care—models of care that patients are increasingly seeking out as they recognize their value? It can be a difficult position to be in.