Ehical Question

[Chevalier]

I'm a general physician working at a psych only hospital. 15 inpatient unit, we also attend emergencies.
I was diagnosed with Bipolar Disorder some years ago.

Is it ok to disclose my diagnosis with patients that might feel better off knowing that I know what they're going though? I'm 24 and I have a 20 year old patient with the same diagnosis and I believe that sharing my experience might create better rapport between us. I honestly don't care if others are aware of my Dx, I think of mental illness just like any other disease (DM, hypertension, renal disease etc etc).

I'm unsure if it will be a positive thing to do, if it will hamper our therapeutical relationship or if it'll have a neutral efect. Also if it would lower my "prestige" or will colleagues and patiens see me as inferior or unfit for my job if people start finding out. My ultimate goal is to apply to a psych residency in the US (I'm an American IMG that hasn't done any USMLE step, working on it)

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[Crayola227]

No, you should NOT do this.

Just, no.

 

[deleted480308]

Hard pass

 

[Crayola227]

As a rule. Others might say there's a time and a place, and I don't say this because of prestige, or paternalism, or image.

You just get into really weird territory with transference, countertransference, projection, all sorts of things.

I don't even like to talk to patients about having a significant other and details like if we are married, live together, etc. If we were married I might feel less weird.

You don't want the patient to make it about you. You don't want you to make it about you.

Usually if anything beyond my marital status, where I am from, if I have siblings, parents, where I went to school, what part of town I live in, the weather, traffic, or healthy eating habits comes up, I don't do self-disclosure.

 

[Crayola227]

People who know me from other parts of the site might find that shocking because of how I am here.

Thing is, if you have a personal life that likely heavily influences how you practice medicine, then it's all the more important to leave it at home.

If you think you might have issues with boundaries, and I feared this for myself, then the best thing *I* think you can do is to maintain very strong ones.

I think you need a helluva a reason or rapport for self disclosure of the type you're describing.

I had a treating provider for over a year who specialized in treating physicians, after getting me to a 12 Step program (not for substances, but Adult Children of Alcoholics/Dysfunctional Families), confide in me that they had a 40 year chip.

I can think of several reasons why they thought that might be OK.

Even then, I don't think think you should mention any of your personal mental health issues.

 

[Crayola227]

To be fair, the one bit I am open about is that I was a former smoker. I use that to show that I truly empathize how difficult it is, but that change is really possible.

Also that I did not come from a family of doctors, my family had health issues and I cared for them so that's why medicine. That's often because it's something patients will ask, of course they wonder, and in broad strokes I think it's appropriate to have some appropriate answer for them.

You just have to really really really ask yourself if disclosure is best for the patient. Are you sure you're not just trying to feel closer to them for yourself?

 

[Crayola227]

I'm a general physician working at a psych only hospital. 15 inpatient unit, we also attend emergencies.
I was diagnosed with Bipolar Disorder some years ago.

Is it ok to disclose my diagnosis with patients that might feel better off knowing that I know what they're going though? I'm 24 and I have a 20 year old patient with the same diagnosis and I believe that sharing my experience might create better rapport between us. I honestly don't care if others are aware of my Dx, I think of mental illness just like any other disease (DM, hypertension, renal disease etc etc).

I'm unsure if it will be a positive thing to do, if it will hamper our therapeutical relationship or if it'll have a neutral efect. Also if it would lower my "prestige" or will colleagues and patiens see me as inferior or unfit for my job if people start finding out. My ultimate goal is to apply to a psych residency in the US (I'm an American IMG that hasn't done any USMLE step, working on it)

Also, there is definitely the sort of stigma for BPAD for a physician that you should generally treat it as potentially career ending information in the wrong hands. Need to know basis only in the workplace. I don't care that so many physicians these days have come around. Not everyone has and you can suffer greatly.

Also, the closeness in age I think makes it even weirder. The example I gave of a provider confiding in me, it was doctor to doctor, and they have like 50 years in age on me.

Also, consider, do you really think you need to do this to generate rapport with the patient? I would encourage you to explore and expand all other techniques, there's lots and most of them are less risk of harm to you and the patient.

 

[Chevalier]

Thanks for all the quick replies!

It's just that I only did 15 days of my psych clerkship back in medschool (spring break) and I wasn't thaught much about these subjects. I understand the concepts of transference and countertransference and will look more into it. I also didn't realize that by doing that I could turn the interactions with the patient into being self-centric and about myself.

I've been faced with similar dilemas due to the nature of my job. We have a head psych only during work hours and I do 24 hour shifts. At nighttime and during weekends it's just me and 2 nurses for the whole hospital (And we have on call psychs PRN).

Last time I had a patient that started crying because his auditory hallucinations told him he was going to die that day. He approached me in such a way that I interpreted of needing a hug, so I gave him one. He was very appretiative of this. However I've read that hugging a patient is controversial. So it's these small details that I'm trying to learn about.

Thanks for the input

 

[Iris42]

Sorry for derailing the conversation, but just out of curiosity, how did you get a hospital job as a general physician without doing a residency ?
Can you get a licence without passing the USMLEs
Wish you best of luck with your career gaols !

 

[Crayola227]

Thanks for all the quick replies!

It's just that I only did 15 days of my psych clerkship back in medschool (spring break) and I wasn't thaught much about these subjects. I understand the concepts of transference and countertransference and will look more into it. I also didn't realize that by doing that I could turn the interactions with the patient into being self-centric and about myself.

I've been faced with similar dilemas due to the nature of my job. We have a head psych only during work hours and I do 24 hour shifts. At nighttime and during weekends it's just me and 2 nurses for the whole hospital (And we have on call psychs PRN).

Last time I had a patient that started crying because his auditory hallucinations told him he was going to die that day. He approached me in such a way that I interpreted of needing a hug, so I gave him one. He was very appretiative of this. However I've read that hugging a patient is controversial. So it's these small details that I'm trying to learn about.

Thanks for the input

No problem, there's definitely a lot of resources out there to learn about this.

Also, this is partly specific to the culture you're in. In South America, it was common for the physicians to hug and even kiss their patients on the cheek.

I'm not sure where you are but it sounds like outside the US.

It's not just that you might make it about you, I get *your* intentions. The issue is that you are dealing with mentally ill people, who may have all kinds of abuse/trauma/neglect/boundaries issues you don't even know about. They need you to set boundaries to establish trust because many of them don't know how to do this. Many loved ones in their lives didn't know how to set boundaries and also violated your patients' boundaries.

You don't know how your patients will take your good intentioned overtures.

Some patients are looking for any reason to focus on you, not them for all kinds of reasons. They may not want to face their issues, they may want an excuse to dismiss your advice (What do you know? You're not bipolar. Then you tell them. What do you know? You're just as crazy as me! See how you can't win?), the list goes on and on.

 

[Chevalier]

Sorry for derailing the conversation, but just out of curiosity, how did you get a hospital job as a general physician without doing a residency ?
Can you get a licence without passing the USMLEs
Wish you best of luck with your career gaols !

I do't live in the US. I´m from Guatemala.
Here you're licenced as soon as you graduate from medschool. The reason behind this is that Family Medicine isn't even a specialty here. So general physicians that just graduated tend to gravitate towards these spots (specially in underserved rural areas) and maybe half of them continue on to residency.

Between finishing medschool and being able to apply to residency you have to wait an avarage of a year, so newly graduated physicians apply and work at various hospitals and clinics around the country; they usually work that year in the specialty that they're interested in. I have friends working in ENT clinics, pediatric emergency departments, ICUs, etc. In my case I'm working at a psych only hospital

My case is even more special. There's a legal status here where you can practice medicine (psychology, dentistry and other professions alike too) without having a licence. I just recently finished my medschool curriculum (17 days ago) but my thesis is still pending for me to be able to graduate (I'm working on it). So I'm allowed to work as a GP under the supervision of a licenced physician. It's more somewhat like a paid internship (with extra responsabilities and perks) and I'm subject to legal repercussions if anything happens under my responsability (I even have to sign everything I order or progress notes, and they can be legally used against me. Not sure how it is in the US). I'm like a PA at the moment (comparing to the US system)

 

[splik]

This is not an ethical question (nor an ehical question). But the question of self-disclosure is a great one. Here are my thoughts:

1. medical students are often taught to be dispassionate, maintain boundaries, and not share things with patients. This is even more extreme in psychiatry. Well, the reality is one can share whatever you feel comfortable sharing and that is how to decide what to self-disclose. but there is a time and place for everything. I would argue that an inpatient psychiatry unit is not the place to be telling patients you have bipolar disorder.
2. It is your inexperience and difficulty knowing how to connect with patients in the horrifically traumatic environment of an inpatient unit that is making you ask these questions. If you have bipolar disorder yourself, it may be even harder still for you to work in this environment. But if you can't figure out how to establish rapport with patients than telling them "I'm one of you", well then that is what you need to work on. Telling patients you have bipolar is a lazy way of trying to build rapport and has the chance of spectacularly backfiring.
3. Just because you have bipolar does not mean that you know what it is like to be in the patient's position. You do not. Their experience is not your experience and you can never know their experience, all you can know is your experience of their experience. It is dangerous to make assumptions that you do.
4. There is a power dynamic set up in the hospital setting that is even more stark than in an outpatient setting. You have the keys to the asylum. Your patients do not.
5. You telling patients you have bipolar disorder could elicit a number of reactions: maybe it could offer some hope to patients; but for others still will react with feelings of shame, and believe they aren't doing well enough, or feel you are chiding them or criticizing them for being ill. Others still may react with anger or hostility projecting their own rage for their illness upon you "why is this mentally unstable lunatic my doctor?! I'll report him/her to the medical board!" etc.
6. It is not about you. When you start talking about your experiences, you unavoidably make it about you. We are here to focus on our patient, and their experiences, and not your need to reconcile this unbearable feeling of straddling the line between being a mental patient and being a physician (imposter) in a looney bin.
7. When patients are very manic, very psychotic, decompensating from their personality disorders it is not possible to establish rapport. There is no therapeutic alliance. It makes it so much easier when you accept that fact.
8. Therapeutic alliances are even more tenuous on an inpatient psych unit if a patient is involuntary.
9. Sometimes patients do need touch. Hugging patients is sometimes okay. I used to hug patients all the time on medical units when I worked in internal medicine. In psychiatry, I almost never hug patients (in fact I only hug them if they initiate and we have the chance to talk about what that is about). It is rarely appropriate to hug patients on an inpatient psychiatric unit. You must be very careful about being incorporated into the delusional system of patients, of being accused of sexual assault etc. How much did you need to hug the patient because you had no idea how else to respond to the distress of this suffering patient? What happens if a patient repeatedly expects to be hugged? What if a patient wants more than a hug? This is why it is important to understand some of the aspects of this. At the very least there must be another member of staff present to protect you and your patients.
10. Mental illnesses are not just like physical illnesses. They just aren't and no one believes otherwise despite lots of campaigns to try and medicalize misery. Mental illnesses impact the experience of the self - your thoughts, feelings, perceptions, behavior - (put simply your soul) in a way that other illnesses to not. They are also not diseases (and btw hypertension is not a disease, it is a risk factor). This is one of the reasons there are all sorts of other considerations that you would not have to consider with diabetes etc.

 

[Doc1401]

Addiction psychiatrists who had issues with substance abuse themselves, and who may have got a DUI in the past often disclose this to their patients in detox/recovery. If it benefits the patient it can be helpful in select situations, as it can be motivating. Linehan also disclosed that she has borderline personality disorder to her audience.

 

[Crayola227]

Addiction psychiatrists who had issues with substance abuse themselves, and who may have got a DUI in the past often disclose this to their patients in detox/recovery. If it benefits the patient it can be helpful in select situations, as it can be motivating. Linehan also disclosed that she has borderline personality disorder to her audience.

I still think it is important for a physician to first learn how to maintain boundaries and keep strong focus on the patient not themselves, and once they feel comfortable with that and other therapeutic techniques for building an alliance, they might have the experience and judgement how and when to disclose, as well as manage the change in interaction between provider and patient that might result.

Thinking about recovery, boundaries is one of the first lessons they teach you. It's a big deal in BPD. My hope is that in your examples those providers disclosed being fully cognizant of these issues and able to maintain excellent boundaries and manage issues that come up around being open with their diagnosis.

 

[Crayola227]

I think my comment above is my only rebuttal to @splik 's great advice.

In med school they teach you to be conservative, to be dispassionate more in the way of learning to control your emotions, your reactions, and to maintain your boundaries. I think that's very appropriate at that level. I think they are necessary skills even if they don't need to be universally applied in all situations, and a lot of those skills people don't have mastered in clinical application going into medical school, or graduating from it.

I think it's easier to learn to keep your mouth shut, and then learn when to open it, basically.

First do no harm. I was definitely tighter lipped with patients until I got to be more comfortable, and I started small when it came to "deviating from the med school party line" on non-disclosure, so that I could learn from the practice. It is the practice of medicine, after all.

Sometimes you put your foot in it. Sometimes you make the patient a little uncomfortable. Sometimes you end up uncomfortable, and didn't even see that coming from the interaction. You learn what works, what doesn't. Start small.

I think it's easier to not be on the side of disclosure, and as your career and experience grows, continue to re-evaluate .

I wasn't so much taught never to disclose. I was taught:
Always think before you disclose about consequences.
Always do it asking yourself if this benefits the patient and what harm could be done.

It's that "easy."

I think we all agree in this instance, there is more harm than good that might be expected in this scenario.

 

[clausewitz2]

Addiction psychiatrists who had issues with substance abuse themselves, and who may have got a DUI in the past often disclose this to their patients in detox/recovery. If it benefits the patient it can be helpful in select situations, as it can be motivating. Linehan also disclosed that she has borderline personality disorder to her audience.

Worth bearing in mind that Linehan first did this literally decades after she established herself in the field. It was not anything she led with.

 

[Merely]

This is not an ethical question (nor an ehical question). But the question of self-disclosure is a great one. Here are my thoughts:

1. medical students are often taught to be dispassionate, maintain boundaries, and not share things with patients. This is even more extreme in psychiatry. Well, the reality is one can share whatever you feel comfortable sharing and that is how to decide what to self-disclose. but there is a time and place for everything. I would argue that an inpatient psychiatry unit is not the place to be telling patients you have bipolar disorder.
2. It is your inexperience and difficulty knowing how to connect with patients in the horrifically traumatic environment of an inpatient unit that is making you ask these questions. If you have bipolar disorder yourself, it may be even harder still for you to work in this environment. But if you can't figure out how to establish rapport with patients than telling them "I'm one of you", well then that is what you need to work on. Telling patients you have bipolar is a lazy way of trying to build rapport and has the chance of spectacularly backfiring.
3. Just because you have bipolar does not mean that you know what it is like to be in the patient's position. You do not. Their experience is not your experience and you can never know their experience, all you can know is your experience of their experience. It is dangerous to make assumptions that you do.
4. There is a power dynamic set up in the hospital setting that is even more stark than in an outpatient setting. You have the keys to the asylum. Your patients do not.
5. You telling patients you have bipolar disorder could elicit a number of reactions: maybe it could offer some hope to patients; but for others still will react with feelings of shame, and believe they aren't doing well enough, or feel you are chiding them or criticizing them for being ill. Others still may react with anger or hostility projecting their own rage for their illness upon you "why is this mentally unstable lunatic my doctor?! I'll report him/her to the medical board!" etc.
6. It is not about you. When you start talking about your experiences, you unavoidably make it about you. We are here to focus on our patient, and their experiences, and not your need to reconcile this unbearable feeling of straddling the line between being a mental patient and being a physician (imposter) in a looney bin.
7. When patients are very manic, very psychotic, decompensating from their personality disorders it is not possible to establish rapport. There is no therapeutic alliance. It makes it so much easier when you accept that fact.
8. Therapeutic alliances are even more tenuous on an inpatient psych unit if a patient is involuntary.
9. Sometimes patients do need touch. Hugging patients is sometimes okay. I used to hug patients all the time on medical units when I worked in internal medicine. In psychiatry, I almost never hug patients (in fact I only hug them if they initiate and we have the chance to talk about what that is about). It is rarely appropriate to hug patients on an inpatient psychiatric unit. You must be very careful about being incorporated into the delusional system of patients, of being accused of sexual assault etc. How much did you need to hug the patient because you had no idea how else to respond to the distress of this suffering patient? What happens if a patient repeatedly expects to be hugged? What if a patient wants more than a hug? This is why it is important to understand some of the aspects of this. At the very least there must be another member of staff present to protect you and your patients.
10. Mental illnesses are not just like physical illnesses. They just aren't and no one believes otherwise despite lots of campaigns to try and medicalize misery. Mental illnesses impact the experience of the self - your thoughts, feelings, perceptions, behavior - (put simply your soul) in a way that other illnesses to not. They are also not diseases (and btw hypertension is not a disease, it is a risk factor). This is one of the reasons there are all sorts of other considerations that you would not have to consider with diabetes etc.

Your posts are always insightful af we are appreciative

 

[Chevalier]

I now understand that although my idea was intended to help it actually doesn't (atleast in this setting and moment).

Somehow I find it hard to create a theurapeutic bond with psych patients (To be fair I've only been here for 2 weeks + my 2 week exposure back in medschool). I've only read about specific topics: Mental Examination, Emergencies, Agitated Patients, Neuropharm, Suicide and some of the main pathologies these 2 weeks. I'm also slowly learning how to approach a psych patient (I've shadowed some psychotherapy sessions).

I still get nervous when interrogating and chatting with the patients, mainly because I'm not 100% sure what's the correct way to lead the conversation depending on the individual pathology. I understand that what you say to them and the way you do it (even if it's not formal psychotherapy) affects them a lot and can help or hinder their progress. That's why I wanted to share my experience, somehow I thought it would benefit the setting.

Seeing that I have difficulties in this area, does anybody have any recommendations on literature about the doctor/patient relationship, boundaries, transference/countertransference, etc in a psych setting?

I really love the field and my patients, but it's such a unique field regarding these questions and I'm struggling with them.

Thanks again for taking the time to answer in such a constructive way!

 

[AcronymAllergy]

Try not to think of it as "interrogating" patients so much as interviewing them (in the "walking alongside" sense). In general, when forming rapport, exhibiting empathy, respect, and some aspect of positive regard goes a long way. Throw in some active listening and reflection, and you'll probably be ok with most folks.

As was mentioned above, by self-disclosing to a patient (particularly very early in the professional/therapeutic relationship), you can cause a great deal of boundary blurring. Once this happens, it can be difficult to then return to a predominantly non-disclosing relationship and interaction style without damaging rapport. You can always share or disclose later, but you can never un-disclose or un-share information that's out there. And whenever you're wondering if you should do something, stop and ask yourself why and for whom you're doing this. Who benefits? Is it truly for the patient, or is it you (e.g., to alleviate one's conscience, reduce one's own discomfort in an emotionally-charged situation, etc.).