Too Much Information

By PAULINE W. CHEN, M.D.
21 nov2008--During medical school, I went to see a doctor who came highly recommended from a classmate. This doctor had not only found the cause of my friend’s pain, but she had also offered insight on how to juggle a successful medical career with a busy family life. My friend was rapturous with praise about how human this doctor was — “She’s so real” were the words I remember my friend using — and she urged me to give the doctor a try.

But my visit was not how I had imagined it would be. The doctor did help me medically, but along the way I learned about her training, her kids and her health problems. I even learned about a brewing personal issue when she let me in on some of the details before leaving the exam room to take a personal phone call. While she might have let her guard down more than usual because I was a budding physician, I wasn’t so sure she had focused on me during the exam and I felt overwhelmed by all the information she had shared.

It was, as they say, “T.M.I.,” too much information.

How much should doctors tell their patients?

Up until recently there has been little systematic research regarding physician self-disclosure and patient satisfaction. Historically, doctors erred on the side of saying little or nothing about themselves, positioning themselves as a “blank slate” against which patients could freely discuss concerns.

By the time I was in medical school in the late 1980s, those boundaries between doctors and patients had become more porous. Lecturers now told us that it was impossible to be a truly blank slate, as doctors and patients unconsciously pick up on one another’s personal cues. Eeven the most discreet doctors unintentionally reveal something during their interactions with patients. Patients might notice the kinds of shoes their doctor wears, the presence or absence of a wedding ring, and even the photographs or trinkets on his or her desk.

Some of my classmates took the idea of “no blank slates” one step further. They believed that by sharing more, by acting more “human,” doctors could strengthen the bonds with their patients.

But whatever our individual leanings were in practice, there was also very little research or evidence for young doctors to fall upon for guidance. The doctor-patient interaction was firmly part of the “art” and not the “science” of our work, so we based our ideas on anecdotal evidence, usually our own experiences. For me, the singular experience with my friend’s doctor made me less enthusiastic about disclosing my personal life to patients. And after a few more years of training, I found that I rarely brought my own life into the clinic or hospital room except when a patient specifically asked.

Over the last four years, there have been several studies on the effects of physician self-disclosure on patient satisfaction. It turns out that patients don’t always want to know about their doctors’ personal experiences. And doctors don’t always do a great job when they do choose to share their personal information.

Susan H. McDaniel and her colleagues at the University of Rochester School of Medicine and Dentistry found that doctors made self-disclosure statements in approximately a third of patient visits, but almost 40 percent of these statements were unrelated to the patient’s symptoms, family or feelings. In addition, in the vast majority of cases, doctors never returned to the topic that inspired the personal reference in the first place.

Interestingly enough, there is also a difference in how patients react to doctors from different specialties. Dr. Mary Catherine Beach and her colleagues at the Johns Hopkins School of Medicine in Baltimore found that when surgeons revealed something personal, patients were significantly more satisfied with their quality of care than when surgeons kept mum. But when primary care doctors disclosed a fact from their own lives, their patients were significantly less satisfied.

I was intrigued by these findings and called Dr. Beach.

“No, I did not expect those results,” Dr. Beach responded. “And we didn’t see a difference in what the surgeons were saying to their patients versus what the primary care doctors were saying.”

Dr. Beach offered a few possible explanations for the difference. Patients may not expect surgeons to share such personal information or may feel more vulnerable and anxious as they face the possibility of an operation. With primary care physicians, on the other hand, patients might interpret a personal disclosure like, “Don’t worry about the pain in your knee; I get that all the time, too,” not as reassuring but as dismissive or as an attempt to invalidate concerns.

As a doctor, I have often wondered if those of us who disclose little seem less “real” to our patients. At the same time, as Dr. Beach notes, there may be “a little bit of narcissism and self-centeredness going on in physician self-disclosure.” I may feel a better sense of rapport with a patient after inserting a personal note into the conversation. But at that point the focus of the discussion begins to center on me, or how I am like the patient, rather than on the patient.

When I consider my experiences as a patient, I find that my favorite doctors rarely offer their own information in the exam room. Nonetheless, I do feel a deep personal connection with them and can even reel off a few facts about their lives. But I have learned about my gynecologist and my children’s pediatrician because I have asked them specific questions during our office visits on terms that I, the patient, have set.

“Doctors should think about it before they make a self-disclosure statement,” Dr. Beach said, “because most of the time these statements occur reflexively and without much thought. Doctors should make sure the statement has some purpose in the conversation and that it is either helpful to the patient or is about empathy. And they must transfer the focus of the conversation quickly back to the patient, so they don’t run on and on about themselves.”

I asked Dr. Beach how her research affected her practice.

“I don’t spontaneously disclose as much anymore,” she answered. “As I was writing the study, I began to pay attention to my own behavior. I found that self-disclosure wasn’t really as useful as I believed it might have been.”

“Having people see your emotional commitment is not a bad thing, but self-disclosure in practice is not as effective as people think it might be in building rapport,” she said.