Vol.3, No.3, 179-185 (2011) Health
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Exploring the subjective burden of confidentiality
among physicians in norway
Løvseth Lise Tevik1*, Leiulfsrud Håkon2
1Department of Research and Development, St Olavs University Hospital, Trondheim and Institute of Neuroscience, Norwegian
University of Science and Technology, Trondheim, Norway; *Co rreponding Author: lise.lovseth@ntnu.no
2Department of Sociology and Political Science, Norwegian University of Science and Technology, Trondheim, Norway.
Received 25 January 2011; revised 7 February 2011; accepted 23 February 2011.
Background: Concern about protecting patient
privacy is proposed to be a barrier for physic-
cians to talk about emotional distress from their
professional experiences. This makes it difficult
for many physicians to utilize and fully benefit
from different network of social support. The
subjective burden of confidentiality is reported
to be associated with physician’s health and
wellbeing. Aims: To gain knowledge about fac-
tors in the in personal and professional sphere
that can be associated with the subjective bur-
den of confidentialit y. Methods: Qualitative semi-
structured interviews with 14 general practi-
tioners and hospital physicians in Norway. Ex-
amination of transcribed verbatim interviews
using qualitative content analysis. Results: The
subjective burden of confidentiality is likely
linked with factors such as perception of pro-
fessional role, social support from colleagues,
partners and friends; size of patient population,
organizational factors and work environment,
and the overlap between personal and profess-
sional relationships. Conclusions: Addressing
the interaction of emotional demands and pa-
tient confidentiality is important to study suc-
cessful coping with distress from physician’s
professional experiences.
Keywords: Professional secrecy; doctors; ethics;
work stress; social support; work en vir onment
Although physicians are educated and trained to be
capable and mentally prepared to handle patient’s mis-
fortune, it is inevitable that they can be emotionally af-
fected by their patients. Situations that can cause emo-
tional distress can range from one major traumatic event
to several critical incidents over a short period of time
[1,2], including everyday routine situations [3-5]. As
exposure to emotional job stressors usually cannot be
reduced, the physician’s ability to cope with emotional
demands is i m po rt ant in orde r to prevent stress [6,7] . The
most common method physicians apply to cope with
emotional distress involve turning to others for support
[8]. Previous research has confirmed that support from
others is a critical resource to foster adjustment to dis-
tressing events, and of considerable significance for
people’s health and wellbeing [9].
A key assumption in research on stress and coping is
that people centralize their own needs. However , in m any
situations people must prioritize other people’s needs or
other important personal and professional values and
goals. Competing priorities in coping, such as concerns
about own confidentiality [10,11] or the need to maintain
or protect ones own or their in-group professional integ-
rity [12,13], can act as a barrier to seek support from
others. In addition, the concern about protecting other
people’s privacy in terms of discretion and client confi-
dentiality is also an important barrier for supp ort seeking
in emergency- and human service professionals [14]. A
recent cross-cultural study showed that about 30% of
hospital physicians regarded patient confidentiality as a
considerable barrier to seeking emotional support from
their professio nal and person al network [1 5]. In this st udy,
the interaction between emotional demands, patient con-
fidentiality and coping was clearly associated with phy-
sician’s health and wellbeing [15].
As concerns about patient’s privacy seem to be relevant
for physicians coping with emotional distress from their
professional experiences, it is interesting to gain knowl-
edge how confidentiality mediates coping with emotional
distress, and factors in their personal and professional
sphere, which can be associated with the subjective bur-
den of confidentiality. This includes an explicit focus
upon physician’s coping with emotional distress from
their professional experiences, and how they resolve
L. L. Tevik et al. / Health 3 (2011) 179-185
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
these possible challenges in light of the norms and rules
of patient confidentiality. We are here primary interested
to reveal examples an d patterns in how patient confid en-
tiality is practiced, which explain the current research
design based upon in depth interviews of Norwegian
physicians, rather than a quantitative approach. The quail-
tative study supplements and supports more quantitative
driven research on the role of patient confidentiality for
professionals in emergency and human services [14,15].
In-depth interviews were carried out in a sample of 14
practicing physicians working in two Norwegian health
regions. Nine were general practitioners (GP), four were
oncologist from a hospital with patients from the whole
country, and one senior consultant was specialized in
treatment of physicians with health problems. Partici-
pants were recruited based on recommendations from
their colleagues and superiors. Our concern was to ex-
plore contrasting experiences among the ones inter-
viewed. In order to do so it was important to have a mixed
sample in terms of experience and ty p e o f me d i ca l p r a c-
tice (Table 1).
The interviews were conducted as semi structured in-
dividual interviews with open-ended questions, and held
in the physician’s office. The interviews lasted from 45
minutes to 3 hours, on aver age taking 1 – 1.5 hours. Par-
ticipants were asked open-ended questions. Core con-
cepts were pursued flexibly in the individual interviews,
according to the topics that appeared most adequate
during the conversation. The participants were asked to
give a short summary o f their curren t position, edu cation
and career as physician. The interview covered topics of
emotional distress from their professional experiences,
coping with distress and the ways in which confidentiality
affected them in various situations at work and outside
Phys icians were encouraged to speak freely and raise
issues concerning confidentiality that were important to
them, and to support their responses with examples. We
avoided a focus on judgments of individual decisions as
right or wrong practice of confidentiality [16].
The interviews were taped and transcribed, and then
the interviewer and co-workers verified the transcriptions.
In the analysis and coding of data, this study followed
Miles and Huberman’s [17] qualitative research method.
Two researchers separately coded the data, and the codes
were later compared in order to reconcile discrepancies
and reach consensus to ensure the validity of the inter-
pretations made. Qualitative conten t analysis of text was
conducted on several levels. Initially, we looked in detail
at the transcript of each interview, starting with particular
Table 1. Characteristics of int e rviewees.
No. Gender Age Hospital Position* Location Patient
Head of dept/
med. office Partner’s occupation
1 M 50 No CMMO District 1’- 10’ Yes Psychologist
2 M 44 No CMMO District 1’- 10’ Yes Unknown
3 M 54 No GP City 10’- 200’ No Teacher
4 F 29 No GP City 1’- 10’ No Unknown
5 F 49 No GP City 1’- 10’ No Physician
6 M 48 No CMMO District 1’- 10’ Yes Physician
7 M 40 No GP District 10’- 200’ No Housewife
8 M 44 Yes SSC District 10’- 200’ Yes Nurse
9 M 52 No GP City 1’- 10’ No Nurse
10 M 50 Yes SSC City >4 500’ Yes Not physician
11 M 48 Yes SC City >4 500’ No Physician
12 M 54 Yes SC City >4 500’ Yes Physiotherapist
13 F 45 Yes SC City >4 500’ No Physician
14 M 40 No CMMO District < 1000 Yes Single
*GP = General practiti oner/(S)SC = (Se ction) senior consultant/CMMO = Chief Munici pal medical officer. **numbers in thousand.
L. L. Tevik et al. / Health 3 (2011) 179-185
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
examples, and worked our way up to more general cate-
gorizations. Each interview was read several times,
searching for respondent meanings [18]. During this
process, all the interviews were carefully read and key
words and notes were gleaned from each document, in
order to illuminate the research questions. Then we looked
for clusters of themes. A set of codes was related to a
single interview and then compared to all interviews for
differences and similarities. At the end, the text was
condensed into themes and coherently organized.
The responses from the Norwegian physicians’ illu-
minates that concerns about protecting patient’s privacy
can be a source of stress for physicians (Box 1) .
The subjective burden of confidentiality was primarily
associated with factors such as; 1) perception of profess-
sional role, 2) social support, 3) partner’s occupation, 4)
size of patient po pulat ion 5) work envi ronm ent a nd 6 ) the
overlap between personal and professional relationships.
We were not able to identify any diversity of situations or
themes based on gender.
3.1. Perception of Professional Role
The subjective burden of confidentiality increased as
a result of incongruity between personal needs and the
desire to display a certain professional image. In line
with this confidentiality fortifies th e image patients have
of the “perfect physician”: responsible and devoted.
Upholding a professional image of competence, confi-
dentiality, and emotional capability comes with a price
tag, and at the expense of the personal need to deal with
emotional demanding part s of their work (Box 2.1).
3.2. Social Support
A general coping strategy, confirmed by most of our
physicians, was to confide in other people by without
revealing patient names or other personal features. They
were particular about who they shared emotional work
experiences with and where they did this. The physicians
saw the necessity to vent feeling with people they felt
particularly close to, often rooted in a longstanding rela-
tionship with mutual respect and trust, such as an ex-
Box 1. The subjective burden of confide ntiality
If I think about it as a professional, then confidential- ity works
just fine. It is as it should be and confidentiality functions well.
That’s the official version. Yet at the same time, I know as a per-
son, that if it didn’t exist I could have managed some situations
better. I b e l ie v e s o
Patient confidentiality like a straightjacket and stops you from
airing the difficult t hi ngs th at trouble you.
perienced colleague, partner, family member or a close
friend. As such, the provision of social support for them
was not only a matter of confidentiality, but also the
quality of interpersonal relationships. Man y par t i c i pa n t s
reported that confidentiality became a barrier for using
non-physicians as a source of su pport. This was a sour ce
of distress, because it limited the physician’s network of
possible confidants, and could have a negative effect on
their personal rel at i onships (Box 2.2).
3.3. Partner’s Occupation
In addition to trusted colleagues, partner was one of
the most important s ource of comfort and eas e o f dist re ss
from work. Physicians whose partner was a physician
saw this as an extra advantage as both the clinical and
emotional part of their work could be discussed more
openly in an ethically safe framework of confidentiality
(Box 2.3 ). Howeve r , p hysicians who ha d partner s in othe r
occupations did not express that they felt it “irresponsi-
ble” to confide in their partner or that partner’s occupa-
tion was a disadvantage. Those who preferred to share
emotional distress from their work experiences with their
partner vindicated this through their “internal confiden-
tiality” regardless of partner’s occupation, where confes-
sion is based on mutual trust that the information is in a
safe place (Box 2.3).
3.4. Size of Patient Population
The roles of colleagues varied according to what kind
of work context and pat i ent relations the physicians were
involved in. An encouraging and interdisciplinary work
environment was often a positive supplement to the lack
of physician colleagu es for physicians working as a solo
practitioner or in a thinly populated district. Small un its,
although having only one physician, have other health
care employees who are involved with the same patient.
In this respect the physician could discuss issues of con-
cern with someone at work, especially with nurses. This
was justified by the internal confid entiality presen t at the
health care centre, ward or organization. A common pat-
tern was that turning to non-physician colleagues at work
was more common for physicians mainly working alone,
the co-worker had co nsiderable senio rit y an d a hi g h level
of empathy, or when the work environment between phy-
sicians was competitive and unsupportive.
3.5. Work Environment
Confidentiality and graded information could make
in-group relations stronger among physicians and con-
tribute to a divisio n of pro fession al groups, sp ecialties or
units of physicians within the ho spital or medical office.
In light of this, the confidentiality code may both work as
L. L. Tevik et al. / Health 3 (2011) 179-185
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
a factor to maintain professional integrity, as well as a
stressor and barrier for seeking social support with
non-physicians. This was particularly evident among the
physicians work ing in hospitals. Even though the climate
between physician co-workers was not good (Box 2.4),
many felt they could not go beyond professional “bor-
ders” and talk to non-physician c o-workers.
The realization that graded information might create
a hierarchy and different in-group relations at the work
place was compensated by creating alternative and less
hierarchical modes of collaboration between physicians
and non-physicians (Box 2.4). The extended network of
possible confidants appears to have made it easier to
share demanding work experiences with co-workers they
valued and relied on regardless of the co-workers pro-
fession. An important issue related to coping with emo-
tional distress and confidentiality was the absence or
presence of forums debriefing at the workplace. Such
forums were according to those interviewed important for
managing stressful situation s in an eth ically safe manner.
These forums, informal and formal, were typically a
result of the combination of work environment, organ-
izational structure and personal initiative from seniors at
the ward or health care centre. Although a formal forum
existed in the quality system of the organization, most
often physicians or co-workers used informal forums,
such as Monday morning coffee breaks, staff meetings
and lunch or private conversations between two physic-
cians. These forums were not regarded as loose talk about
patients, b ut describe d as an adv ice seeki ng sit uation held
with respect for patients and confidentiality (Box 2.4).
3.6. The Overlap between Personal and
Professional Relationships
Privacy may be compromised when professional rel-
tionships are interwoven with personal ones (Box 2.5).
Physicians that worked and live within a small commu-
nity faced situations where they had to be aware of con-
fidentiality in interpersonal relationships. The GP’ s in the
small rural practice said that having friends and col-
leagues as patients was almost a weekly occurrence.
Though, also physicians working in larger communities
and hospitals faced these situations when treating col-
leagues or members of a social group they belonged to.
Younger physicians had not yet worked up a pool of
patients that made confidentiality as challenging in in-
terpersonal relationships in this regard. As a “newcomer”
they did not know many people in their community. This
was perceived as an advantage in order to avoid emo-
tional connection with patients or distress by identifica-
tion with patient’s life status. The need to keep profess-
sional and personal relationships separate was also the
reason why many physicians preferred to live in their
neighbor municipal or district than the one they worked
The amount of personal information the physician
found comfortable and appropriate to know about
people they knew set the premise for these kinds of
consultations and encounters. Some physicians pre-
ferred to completely separa ting the roles by refusing to
treat people they knew well. Others did not have this
strict division between the private and professional.
However, the extent in which they treated people was
limited. Some chose to only write out prescriptions,
treat minor illness, perform superficial examinations
and refer people to proper treatment/skilled clinicians.
Some physicians drew the line between physical and
psychological/psychiatric issues, and did not assist
people with issues that had great emotional impact
such as sexual issues, family crisis, suicide attempts
and such. Still others had no separation between
someone they knew a nd a ny oth er pat ie nt; they treated
them equally regardless of the patient’s problem.
When communication in social situations became a
clinical encounter or addressed medical concerns, the
physicians often used confidentiality as a tool to ac-
tively force the encounter into a professional rela-
tionship or setting. In these situations, confidentiality
became a buffer of potential relationship stress; it
regulated how the professional role came forward in a
private setting in a manner that protected the integrity
of both parties an d their relationship in the future. They
always ensured that the consultation was conducted in
their medical office. Or they explicitly specified that
they are in the role of physician during the consul tation
(Box 2.5).
This study may extend our understanding on the
relationship between protection of patient’s privacy
and physicians coping with work related emotional
distress. The results from the interviews with physic-
cians suggest that organizational, professional and
personal factors, which reinforce one another, may
contribute to the subjective burden of confidentiality.
For example, a hospital ward with a hierarchic struc-
ture and unsupportive climate might have a different
impact on this matter than a supportive work envi-
ronment with a network of consistent boundaries re-
garding the psychosocial work climate. This is in line
with previous research where physicians are shown to
have different attitudes to and practice of confidenti-
ality [19,20], their professional rol e [21,22] and c oping
strategies used to deal with ethical [23,24] and emo-
tional [25] discomfort in their work. Based on the
current results, these factors are likely to be associated
with how physician manages emotionally-char ged work
situations and confi de nt iality.
L. L. Tevik et al. / Health 3 (2011) 179-185
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Box 2. Factors associated with the subjective burden of patient confidentiality.
2.1 Professional role
Confidentiality causes one to become an individualist. One must give the impression of being present and complete
secrecy of all information- and because of this, it is important to maintain an im pression that information is not easily
exchange between us doctors [No.1]
Confidentiality is the problem; it is so strong and important that it hinders debriefing because of fear of showing
weakness in a profession that is supposed to be “elite” [No. 6]
One also has professional pride in that information should be kept to oneself [No. 8]
2.2 Social support
Because of confidentiality, I primarily rely on my colleagues, perhaps more so than my partner [No. 5].
I don’t usually discuss concrete situations from work at home. One main reason for this is confidentialit y. My partner
has said that it puts distance between us. But there is something about confidentiality…it happens quite fast that
you’ve suddenly said a little something. It’s much easier to say nothing at all about your professional experiences
[No. 10].
Most often you have a few people you feel particularly close to. And I have mine. It does not have to be a physician.
It is more personal, and is a ma tte r of trust and personal chemistry [No. 10]
2.3 Partners occupation
My wife is a nurse, and I do not believe that I violate confidentiality when I talk to her [No 9].
Confidentiality limits the kind of issues you bring at home. However, my partner works in the health care system.
This makes it easier [No. 9]
Though I can speak with my colleagues, I be lieve it is common to speak with your part ner. At least if yo ur par tner is
a physician. We have an internal confidentiality, were I can share confidential information about patients, and know
that it is in a safe place. It is probably not legal at all [No.11]
2.4 Work e nvironment
It is a bit problematic to use other co-workers as confidants. We have some of the traditional separation between
physicians and nurses. I feel that to a certain extent I have to maintain loyalty to the physicians and not take the nurses
into confidence in regard to how much information I give. That’ s the way it is, it’ s like an unwritten rule her e [No. 10]
Of course the medical meetings between doctors are important. However , because the house staff is a l arge part of the
medical centre, it should not be a difference between us. They perform many clinical functions and have much
knowledge about the patients. Often it is th e same patients that are challenging for us doctor s, as it is for them [No.5]
It is more important to emphasize the ward and that those who work here is a unit. Particularly because we are
exposed to the type of cases we have here. I mean, it becomes wrong if I constantl y emphasize [a hierar chy] that I am
a senior consultant, and you a resident, next a poor intern, after that a nurse and then an enrolled nurse. Of course I
have the main responsibility, but it is not necessary to demonstrate a visible power in the ward through confidentiality
and rank. Everyone know their tasks, and all serve the same pur pose; working together with in the best interest for the
patient. And the enjo yment and challenges we experience are som ething that we are going to share [No. 12]
I think it’s important to have a place where you can be together and laugh about the frustration you have about
patients. I don’t feel that confidentiality is a barrier to that. When I go to a colleague and talk about little things that
happen, it’s between us. That is a freedom we take [No.6]
2.5 Personal and
professional relationships
Confidentiality complicates my life. In social situations it complicates my life. In professional situations I think it is
easier to handle [No.3]
As we have a more personal relationship with patients as general practitioners we place a major importance to ensure
confidentiality [No. 1]
In contrast to hospital physicians who focus more on “cases” that lays along the hospital beds. I think this personal
relationship facilitates increased awareness on confidentiality among general practitioners than hospital physicians
Confidentiality regarding family and friends is difficult - incredibly difficult. Close friends who have problems.
There I sit at a party with them and maybe before I sat and spoke with them about their worst life trauma [No. 3]
When they [friends] come to my office, they see me more as a physician. If they visit my home and we are chatting at
the kitchen table, then in this situation I am talking with them as a friend. I think this makes them feel safe as well.
There is something to learning how to separate the private and the professional realms, you know. You will come into
some problems regarding confidentiality if everything gets mixed together [No.5]
There isn’t as much leeway for how to build a friendship. Because I have information that I don’t want to have
between us, but it is there anyway [No.1]
The present results indicate that a positive work
environment alleviated the subjective burden of con-
fidentiality. In addition, multidisciplinary teams with
good, open c omm unicat ion provide a f orum for shared
experience as well as shared knowledge and informa-
tion. Interestingly, participation in meetings to discuss
stressful work situations seemed to be helping to vent
feelings both in a personal, and ethical, suitable man-
ner. To b u il d a c om m o n ex pe r ie nc e b as e m ay el im i na te
the need for detailed information in daily communica-
tion with fellow workers as the emotional reaction be-
comes readily recognizable without it [26]. This might
L. L. Tevik et al. / Health 3 (2011) 179-185
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counteract the subjective burden of confidentiality.
Confidentiality was also perceived as a tool that pro-
tects the physicians from possible relationship distress.
Interweave bet ween personal and professiona l spheres for
physicians have received increased attention the last
decade [27,28]. Rourke and his associates have focused
on boundary issues that may evolve due to treating own
family members and friends [29]. All physicians, re-
gardless of specialization, face such situations from time
to time; though being a physician in a small community
pose more frequent and proximal interpersonal chal-
lenges in this regard. Miedema, Easley, Fortin, Hamilton
and Tatemichi’s [30] study on how the trespassing of
patients onto the physicians’ pe rsonal live in small towns
and rural communities, illustrate this issue. Our study
shows that the physicians used confidentiality as a tool to
force such personal encounters into a professional setting
in order to protect both parties integrity.
The participants in this study represent a selected
sample which might have been more reflective than the
average physician and more willing to expose personal
demanding situations and/ or situations where confiden-
tiality as a norm of behavior has been compromised. The
point of situations and themes that came up in the inter-
views with the GPs,’ corresponded with the hospital
physicians’. We have no reason to believe that the basis
for the experiences of those who participated in this study
to differ from those of their colleagues. Tough their
willingness to make these experiences explicit may be a
deviation fr om the general populat ion of physicians. M ost
of the interviewed had a long work experience and in
depth thoughts about the topics addressed. The disad-
vantage of this kind of sample is of course that we might
have missed out interesting dilemmas among junior phy-
sicians. This said, when the physicians were asked to
recall particular matters as inexperienced physicians,
none did mention any previous experiences were the role
as a subordinate was a problem in this regard. They rather
focused on the importance of finding a trusted friend,
preferably a fellow colleague to share stressful work
experiences with, regardless of position or experience.
The sample is over-representative for men. This reflects
the proportion of GPs and oncologists in Norway where
the majority is male (Statistics, The Norwegian Medical
association, 2009). Interestingly we have not been able to
track any systematic gender differences in the topic ad-
dressed by the participants. Some of the male physician
believed that female colleagues would find confidential-
ity more c hallengi ng under t he ass umpt ion that wom en i n
general prefer to share their emotions and seeks support
more than m en. We ha ve not found any s upport f or this i n
the current study or in correspondent research [14 ,15].
When the respondents in our study report that inter-
professional relationships and confidentiality are crucial
factors for inhibition and seeking emotional support, it is
important that the organization facilitate a communica-
tion atmosphere that address both the technical and emo-
tional parts of medicine. In addition, that experienced
physicians t ake the lead in promoting pr ofessional cha nge
on this matter. An advisory service from skilled seniors
might create a competence beyond the medical and tech-
nical aspects of the medical profession.
We are grateful to the physicians who participated in this study. An
extended and special thanks to Olaf Gjerløw Aasland, head of the
Research Institute, Norwegian Medical Association for contribution to
the conceptual model. We also greatly appreciate constructive com-
ments of the manuscripts done by pr ofessor/head of dep artme nt Olav M
Linaker and associate professors Ismail Cüneyt Güzey at AFFU and
Valentina Cabrol Iversen at St Olavs Hospital.
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