Is Self-disclosure a Boundary Violation?

In the first of two articles in this issue of Journal of General Internal Medicine, Beach et al. report that physician self-disclosure occurred in 15.4% of the 1,246 audiotaped routine office visits they studied.¹ They conclude: “Physician self-disclosure encompasses complex and varied communication behaviours.…[I]t is important for researchers to be more specific about the types of statements physicians should or should not make.” This editorial explores that specificity.

In the second article, the research group looked for a possible relationship between physician self-disclosure and patients’ satisfaction and concluded: “Physician self-disclosure is significantly associated with higher patient satisfaction ratings for surgical visits and lower patient satisfaction ratings for primary care visits.”²

The authors speculate about possible reasons for the difference across the two physician groups. Surgeons generally recommend more dramatic interventions than primary care physicians. In such frightening situations, patients respond more positively to self-disclosing paternalistic statements such as, “My brother had this surgery last year and has done very well; if I had your condition, I'd have no hesitation” than the dry, balanced style of information disclosure that is now regarded as optimal, both clinically and legally.

The law on information disclosure has changed dramatically over the last half-century. The famous English jurist, Lord Denning, in Hatcher v Black³ (1954), strongly supported the paternalistic model of medicine. Mrs. Hatcher suffered recurrent laryngeal nerve damage as a result of surgery for thyrotoxicosis and was unable to return to work as a broadcaster. She sued, asserting disclosure negligence. Lord Denning said, in his judgment: “On the evening before the operation, [the surgeon] told the Plaintiff that there was no risk to her voice, when he knew that there was some slight risk, but that he did for her own good because it was of vital importance that she should not worry. In short he told a lie.… No one of the doctors that have been called before you have suggested that Mr. Tuckwell did wrong. All agree that it was a matter for his own judgment. They did not condemn him; nor should we.”

Since then, support for medical paternalism has disappeared. Doctors have reacted by adopting the other extreme—the doctor as a technician who provides data, but not advice. That may be thought to be safer, legally, but it is not surprising that doctors who care about their patients still seek to influence their decisions. Self-disclosure, from such a powerful figure as “The Doctor,” may have a beneficent intent. But does that justify a boundary violation?

It is a truism to say that the most powerful “drug” we use is ourselves. We all know that at the end of a detailed “informed consent” discussion, many patients will ask, “But if it was you, doctor, what would you do?” Do you commit a boundary violation if you answer that question?

Self-disclosure through empathic validation (“I'm sure I'd feel just the same if that happened to me”) is not a boundary violation, but establishes rapport and builds stronger doctor-patient relationships. “Self-protective” self-disclosure can only be condemned—for example, “When I saw your latest cervical smear report I felt bad that you hadn't taken my advice and returned earlier for a repeat smear.”

It is also a boundary violation to turn the doctor-patient relationship around, and invite the patient to become your therapist. “I know; I have the same problem myself. What are you doing for it?” Also, a statement such as, “I really understand how you feel—I've also been very lonely since my divorce” can rapidly progress to an extreme boundary violation.

Physician self-disclosure can substantially reduce patient anxiety. When I was in family practice in suburban Melbourne, Australia, a single mother came in with a 1-week-old baby who clearly had what we were then allowed to call “colic.” The young mother was beside herself with anxiety. I had photos of my own children on the desk. I pointed to one of my daughters, then aged in her mid-teens, and said, “I know how distressing this is for you—she had colic for the first four weeks of her life.” The young mother's relief was almost palpable. I could see her thinking, “If The Doctor and his wife had trouble coping with their baby's colic, then maybe I'm not a bad mother.”

A fast food chain recently started selling items labeled “97% fat free.” Would you buy a muffin labeled “3% fat”? We live in a world in which the Spin Meister is king. Physician self-disclosure can be used both positively and negatively in the doctor-patient relationship. Like any “drug,” it should be used carefully, consciously, and always transparently in the patient's best interest, not the physician's self-interest.