Personal Comments By Physicians Distract From Patient Needs

While such disclosures seem an important way to build a personal connection, a University of Rochester School of Medicine and Dentistry investigation of secretly-recorded first-time patient visits to experienced primary care physicians has found these personal disclosures have no demonstrable benefits and may even disrupt the flow of important patient information.

The journal Archives of Internal Medicine publishes the surprising results of the investigation in the June 25 issue. The investigators found physician self-disclosures in about a third of patient visits. The disclosures "were often non sequiturs, unattached to any discussion in the visit and focused more on the physician's needs than the patient's needs." The disclosures "interrupted the flow of information exchange and valuable patient time in the typically time-pressured primary care visit." Investigators found no examples of a physician making a statement that led back from the self-disclosure to the patient's concern.

"Most doctors think self-disclosure is a good idea for building relationships," said Susan H. McDaniel, Ph.D., lead author of the article and a professor of psychiatry and family medicine at the University of Rochester School of Medicine and Dentistry. "The health care system now requires doctors to see many patients. Visits to the doctor often are short and anything that is a waste of time takes away from getting to what the patient needs."

The psychologists and physicians who conducted the investigation began the research believing that self-disclosure was an effective way to encourage patients to say more about what really troubled them.

"We were hoping to find that physician disclosure would be a part of patient-centered care, encouraging the patient to open up and offer additional valuable information," said Howard B. Beckman, M.D., a co-author of the article and a clinical professor of medicine and family medicine at the School of Medicine and Dentistry. "Instead we found these disclosures to be doctor-centered and to benefit the doctor, not the patient. As a discloser myself, I was really devastated."

The investigation is part of a larger study of patient communication and health outcomes funded by the Agency for Healthcare Research and Quality. One hundred primary care physicians in the Rochester region agreed to participate, consenting to two unannounced and secretly recorded visits by people trained to portray specific patient roles.

The project produced 193 recorded first-time patient visits to primary care physicians. For the self-disclosure investigation, four recordings were eliminated for poor technical quality and 76 were excluded because the physician suspected the patient was not a true patient before the end of the visit. Self-disclosures were defined as physician statements about his or her own personal or professional experience.

Each investigator independently reviewed and analyzed 113 transcripts of patient visits, rating the content for self-disclosure and its effect on the patient. Thirty-four percent of the visits contained at least one self-disclosure. None of the self-disclosures were patient focused, while 60 percent were physician focused, the investigators concluded. Eighty-five percent of the disclosures were considered not useful and 11 percent were viewed as disruptive.

Here is an example of one brief exchange:

Physician: No partners recently?

Patient: I was dating for a while and that one just didn't work out . . . about a year ago.

Physician: So you're single now.

Patient: Yeah. It's all right.

Physician: (laughing): It gets tough. I'm single as well. I don't know. We're not the right age to be dating, I guess. So let's see. No trouble urinating or anything like that"

Although occasionally it might be useful for physicians to answers inquiries from patients about their personal life or to comment on a specific topic raised by a patient, such discussions generally should be very short and clearly tie into a patient's concerns, the authors of the article concluded.

Those involved in the investigation said the findings have affected how they conduct their practice. McDaniel, for example, now takes breaks between patient visits to discuss the day's news or vent about problems, eliminating those kinds of self-disclosures from patient sessions. Beckman, who is medical director of the Rochester Individual Practice Association, has stopped telling his elderly patients about his mother, who was very active and healthy through her 80s.

"I would tell people their expectations could be higher and use my mother as an example," Beckman said. "In subsequent visits, they asked about my mother. That was great until her health began to decline then I had to tell them she was not well. That frightened them. If I couldn't help my own mother, how could I help them" My disclosure did not work as well as I had hoped."

"Patients want their needs met. Doctors want to meet the needs of their patients and they want to have human contact," said McDaniel, who is director of the Wynne Center for Family Research at the University of Rochester Medical Center. "But self-disclosure ultimately is misguided. Patient visits should be focused on the patient. They are not about me."

While a physician's self-disclosures usually develop from positive intentions, the investigators said that empathy, understanding and compassion toward the patient are more reliable and helpful for the patient.

"If I tell my patients about my problems or how I feel, they are taking care of me," Beckman said. "Is taking care of me the only way to deepen the relationship" There are other ways. We can have empathy. We can encourage our patients. We can praise them -- things that make a person feel valued."

McDaniel hopes physicians use the article to examine the way they conduct their practice and consider whether self-disclosures are in the best interest of their patients. She wants medical schools to include more discussions of methods of communication with patients in their curriculum.

"Doctors need support groups, self-awareness groups and mindfulness groups to meet their needs," McDaniel said. "They should not use self-disclosure. If they want to complain about their rent or the stress of the work, they should complain to their colleagues, not their patients."

In addition to McDaniel and Beckman, authors of the article from the University of Rochester School of Medicine and Dentistry are: Diane Morse, M.D., clinical associate professor of medicine; David Seaburn, Ph.D., clinical assistant professor of psychiatry; and Ronald M. Epstein, M.D., professor of family medicine and psychiatry and associate dean for educational evaluation and research. Jordan Silberman, M.A.P.P., is a research assistant at Children's Hospital of Philadelphia.