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Physician Self-Disclosure About Illness

I recently struggled with an interesting patient care issue related to my illness. I had to cancel several weeks of clinical sessions, which I realize is a hardship for my patients.

A few weeks ago, when seeing a long-time patient of mine—a warm woman with several chronic conditions—I apologized that we had cancelled her previously scheduled appointment on short notice. I paused a beat and quietly said that I had been hospitalized. She was genuinely concerned. She was anxious to know more information and if I was going to be okay. I waved it off and said that I was getting better. But as I attended to her needs I could not help thinking whether I should share more information with her.

There is a growing literature about physicians sharing personal information with their patients, something known as “physician self-disclosure” or “physician personal disclosure.” In one study, investigators examining audio recordings of patient visits found that when general internists self-disclose patients report lower satisfaction, but when surgeons self-disclose patients report higher satisfaction. An accompanying editorial suggested that some forms of self-disclosure may be useful while others may violate patient-provider boundaries. Another paper in which investigators observed physicians interacting with standardized patients concluded that there was no evidence of a positive effect of physician self-disclosure, that it could be disruptive, and that physicians should consider avoiding it. Physicians Danielle Ofri and Juliet Mavromatis explored their experiences with personal disclosures to patients in their recent blog posts.

I considered the pros and cons of disclosing details of my illness to my patient. On the one hand, I didn’t wish to violate boundaries or to have my patient worry about me. On the other hand I did not believe that boundaries were absolute and impermeable, and I was comfortable being seen as human and subject to the same frailties as all human beings. I even have patients with whom I’ve shared meals and some with whom I connect on social media. So I’m comfortable selectively breaching what some would consider to be inviolable boundaries. After all, if I practiced and lived in a small town it’s likely my patients would know almost as much about my life as I knew about theirs. It’s only the big city in which I practice that makes it less likely I will accidentally connect with patients in a non-clinical context.

As we often do in primary care, I asked myself what was the worse thing that could happen if I disclosed? After all, I had already made a conscious decision to disclose my condition to the world through my blog post. And I knew this patient for so many years—what was I afraid of?

Just before I left, I scrawled the link to my story on a pad of paper in the exam room and handed it to the patient. Later that night, I found that she left a nice comment.

Would I have done this for all my patients? I doubt it. Did I do the right thing? I think so. But I suspect my views on this will continue to evolve over time.

Let me know your thoughts.

54 thoughts on “Physician Self-Disclosure About Illness

  1. Wow- Danny- I didn’t realize you had gone through all this but am so glad to see you are back to your good ways!
    While a bit of a different animal, self-disclosure for dentists is pretty common and helpful, though I have to be careful to do it at the end of the appointment when their mouth is not stuffed with cotton roles!
    Seriously, glad you are healthy and hope we can get together in Boston before long.

  2. You are a physician second, a human first. Humans relate to one another through personal stories. Let’s nurture kindness, caring and support both ways in the doctor-patient relationship.

  3. Danny… I agree with Joe – We are human beings above all. In addition, as I’m sure you have noticed, your long term patients who you know well — also know YOU well 🙂 They will pick up on the fact that something is wrong. More so, I believe it would likely change our “relationship” if they weren’t informed to some degree about what had transpired.

    Glad you’re doing well.

  4. I don’t know if you’ve read Peter Ubel’s “Critical Decisions” yet – if you haven’t, I strongly recommend it. Much of it deals with the emotional component of medical decision making, both for the patient and for the doctor.

    There’s a wide swath of content all over ever’where from the patient side of this conundrum, and way too little from the doctor’s perspective. I think that any doctor’s decision to share personal information with patients is entirely up to that MD. However, all of us are made up of our experiences, and the emotional impact of them, as well as the cognitive effects of learning-by-doing.

    All that you’ve proven here is something that anyone who knows you already knew: you’re a deeply human doc, in the best way. It’s your self-awareness, combined with your intellect, that drives your emotional intelligence.

    We need to figure out how to help clinicians stay in touch with their humanity. It’s a difficult path to navigate, because healthcare pros see so much in the way of human suffering, it requires them to built filters to keep themselves from being emotionally flayed every day of their lives …

    1. Yes, there is something important (and therapeutic) about physicians keeping in touch with their humanity and not worrying so much about what’s the most right thing to do. Go where your humanity and heart lead you.

      Thanks, Casey.

  5. Danny, you should have a chat with Gordy Schiff who has recently written about boundaries in a somewhat different sense then physician self-disclosure. I’d love to be a fly on the wall for that conversation. (Schiff GD: Piece of My Mind: Crossing Boundaries—Violation or Obligation? JAMA September 25, 2013 Volume 310, Number 12 1233-4)

  6. Hi Danny,

    As a patient, not only would this disclosure “humanize” (such a sterile word for such a fantastic concept) you would also demonstrate that you valued me as more than simply a patient. As I say about my therapist, more than an acquaintance but less than a friend, perhaps?

  7. There’s not much in the way of published research on the subject of physician self disclosure.. Anecdotally, I saw my Internist a while back – he and I are the same age – and I casually mentioned that I had fallen off a ladder and broken several ribs. He laughed and said that the same thing happened to him…a fall off a ladder and broken ribs. That was one of the first time in 15 years he ever shared anything personal about himself. I appreciated it because it made him suddenly seem human and a bit more empathetic.

    I would suggest that physicians worry less about engaging in harmless self disclosure and more about patient’s perception that they are cold, calculating and generally uncaring.

  8. Judicious self-disclosure, being fully present, and active listening is part of empathic, therapeutic communication between sender and receiver in a caring health care encounter. This is what teach and practice as an NP in college health in Boston.

  9. You and your family certainly experienced a harrowing and frightening ordeal on so many levels. Wonderful that you are well on the road to a full and successful recovery. Yay to all who are supporting you in this process and for your being a brave soul !
    You still have so much to experience on this beautiful planet!

      1. I practice at the Simmons College Health Center with Kay, part time too, so, we have the same colleague just across Brookline Ave. 🙂
        I also teach full time in the Master’s and Doctoral programs at the Simmons College School of Nursing and Health Sciences.

  10. People always feel physicians are some sorta hero and can never fall ill or let alone have any medical related issues or even share our personal medical problems with anyone else…Well, I guess we ma be heros in our profession! Physician personal disclosure is inappropriate profession-wise,,,,but nevertheless we are human as well and would most definately feel like sharing personal thoughts, healthwise or not…So my dear, you did well talking about it and from all indication, it made u feel better I guess.

    1. Agbo, I didn’t disclose this to my patient to make me feel better. I did it because she wanted to know and I felt it was okay to let her see me as human and subject to illness just like all people.

      Are you saying that from the perspective of a healthcare provider or as a patient?

    2. I’m really curious what made this seem to be for *his* benefit, and what in the post leads you to say “it made u feel better I guess”!

      Is there literature (or even widespread rumors) about clinicians talking about their own illness that suggests it’s unethical or unwise?

  11. Facebook makes me yearn for a Like button on comments. The Disqus comment system has that, but I hate it for other reasons. (It gave me much heartburn conflicting with other logins.)

  12. > On the one hand, I didn’t wish to violate boundaries
    > or to have my patient worry about me. On the other hand
    > I did not believe that boundaries were absolute and impermeable …

    It’s becoming apparent that your “essays” on this site give valuable insight into your thought processes, your considerations. (For that reason, I call them essays, not just blog posts.) It’s not limited to these posts related to your illness – you guide the reader through how you face issues and decisions. It builds empathy and understanding.

    In your words here I see a powerful argument for sustained relationships between a patient and a provider – that powerful connection. I’m sure you wouldn’t have been as personal with a stranger; the judgment call you made in that moment was based on your years of relatedness, I expect, and what you know about how she takes things and what concerns weigh on her.

    This is a heck of a good discussion here.

  13. I suffer with nerve pain as a result of repeat surgeries. My pain was treated by clinicians who had no idea what or how I was actually feeling. People get cuts and bruises, but not many have nerve damage. I always sensed that my pain was not taken totally seriously…it could not be THAT bad. Then on one of my visits to my PC physician, it was revealed to me that they had suffered an injury that caused constant nerve pain. They said to me, “All I could think of was you”. I have never had such a connection with a clinician. It was a defining moment in how I handled my comdition moving forward. It was so empowering to know I was taken seriously and with empathy. A moment that formed my views as an empowered patient. Someone, my physician, knows what I am going through… really knows. This is the relationship I wish for every patient.

    1. Thanks for the comment, Pam. It sounds like that was a turning point for you and suggests another way that physician self-disclosure of illness can be helpful.

      But I think you’d agree that good physicians can show empathy even without having experienced the patient’s condition.

  14. As a physical therapist working with cancer patients, some who have poor outcomes, I’ve been asked what training I’ve had in dealing with loss. The answer is “No formal training”. I decided about 15 years ago to connect with my patients on a personal level, and to be sure that I’m not the only one “giving” in the relationship. That way I look at a new patient and wonder what I’m going to learn from that person in my human experience. And that approach seems to be working for me!

    Thank you for sharing your story, Danny. I couldn’t stop once I started reading. So glad you’re back in the game!

    Amy deB Kinder (Dave’s sister….) in Annapolis

    1. Amy, patient care benefits from that human connection. Just because the role of the clinician is to treat and that of the patient to be treated, doesn’t mean they can’t both learn from each other and both grow from the relationship.

      Thanks for your contribution, Amy.

  15. Totally great discussion. Thanks for presenting it Danny – and such thoughtful comments. Knowing the studies, and being a primary care doc, I have to say: it depends. This is the Art of Medicine. Like many things about ‘the art’ – it’s difficult to measure, to test, to replicate.

    The studies with internists and surgeons – were done to look at associations between physician communication styles and malpractice. Funny thing – there was an association for internists, not surgeons (Do people have lower expectations about surgeons’ bedside manner? But I digress…).

    Some disclosure statements (in the studies) seem odd, and perhaps done for the wrong reasons. To convince a patient to do something, because the doc did? To give examples? In that case, self-disclosure shouldn’t be done. I think it should be uncommon but is appropriate in particular circumstances. Long-term partnerships, when patients are curious. If patients ask me, I answer, but keep it real brief. It’s their time, not mine. It can be distracting, may make a patient uncomfortable. But again, it’s an art. In the case of an absence (like Danny’s), the patient is already wondering what’s going on – before the doc gets in the room. So looking for cues, offering a prompt…paying attention..I think that’s the key.

    Mostly, genuine empathy is best – like Danielle Ofri’s blog about a patient answering the call from her kid’s teacher during their visit; Danielle thought about disclosure but chose ‘I know’ instead.

    Sharing with patients isn’t only about one’s experience; it can be about sharing beliefs. I will always remember a Veteran patient (now passed) who wouldn’t let me out of the room until we talked politics. Now this is never, ever, a good idea (and I get emails about how it’s against federal employer policy). But I made one exception, in my whole career. Because we’d both end up laughing – belly laughing. And have plenty of time to talk about blood pressure, blood sugars, diet, exercise, sleep and other activities of daily living. And he said he liked seeing me and the rest of the team. When he died, I cried. A lot.

    It really is about Connecting. Hey, what a great name for a blog 🙂

  16. As a patient advocate who constantly finds herself reminding people that our doctors are human beings first and doctors second… Thank you for self-disclosing. You included your patient in the circle of who you are as a person. I think that is something we’ve lost over the last 100 years when our doctors were our friends first, and someone who took care of us in a health care partnership, second.

    1. Ellen, that historical perspective is interesting. On the other hand, a century ago your doctor didn’t have much to offer you in the way of effective treatments.

      Thanks for your comment.

      1. Dr Danny,

        I think we all appreciate the leaps that health care has made, not only in diagnosis, but treatment options for patients. 100 years ago I would have died, which for me would certainly be bad :). I wasn’t suggesting going back in time. But I do wonder – is there a reason why our doctors can’t open themselves to their patients and still be effective in the health care team the two should create to maximize care? I think the idea of distancing the physician from the patient results in a lesser experience in every way for the patient, and many would argue, the doctor as well.

        When I placed your post on my Facebook page, I received some interesting interactions with patients including:

        “My Doctor did this for the first time just yesterday! He explained that once he had the same condition and was scared at first, how he dealt with it, knew what not to do and did it anyway. I felt blessed that he chose to share personal health information with me and made me feel a lot more confident in his skills and humanity.”

        ” Dear Dr., I believe that when a Doctor shares things with patients it is always a positive experience. I have had one or two Doctors like this over the years, they were my favorites, these men shared serious and child rearing stories with me. It was flattering to me that they liked me enough on a personal level to share a part of their lives. They are both retired now, I miss them both, the sharing kind of put us on an even field, it was generous of them and made for a wonderful Dr./ patient experience.”

        ” Absolutely wonderful…. He is human… Doesn’t everyone want a physician who is precise…speaks to you in a way you could understand him…and you could feel comfortable telling him with is wrong with you…I don’t know one person who wants to have a doctor that treats you like a piece of furniture…who knows, a doctor might need your advice someday….God bless all our physcians, nurses, surgeons, advocates… Etc…”

        ” A couple of mine have and I really appreciate their being open with me. We work as a team to solve my health issues and their disclosure makes me feel as if they are vested in improving my health.”

        I’ve never met a patient yet who prefers a doctor who doesn’t share, over one who does.

      2. Great comments, Amy. I personally have concluded, partially through this experience and the discussion on my blog, that I should be able to share this kind of personal information. But I do think it depends on the patient and the situation. A few readers stated that they would never want that kind of disclosure fro their physicians, and I have had some patients to whom I would never feel comfortable disclosing certain aspects of my personal life, illness or otherwise.

        One more point: self-disclosure is not necessary to be an empathetic provider.

    2. Something about this whole discussion was just weird to me, and I realized what it is: the word “disclose,” particularly “self-disclose.” To me it connotes revealing something that you were keeping secret. I wonder how the word got into this topic – it must have been long ago.

      My sister Amy’s comment above seems to be about … about … what do they call this blog? Connecting?

      If that’s the word, it would explain why there’s no single answer to whether or how to do it – because connecting to each different person is different, no?

      1. I think it became known as disclosure because these are things that we usually keep private, even from acquaintances who aren’t close friends.

        And I agree with you about different approaches to different types of patients/people.

      2. Self disclose is a term used in the literature and research to refer to the exchange of personal details by both the patient and physician. No moral connotations should be connected to the use of the term.

        If truth be told patients are often just as relectant as physicians to engage in “self disclosure” ,, i.e., telling doc about seeing s chiropractor, stopping medications, etc.

      3. Interesting observation, Steve … it seems to me that when patients withhold something (as you suggested) it’s because they fear disapproval. (I appreciate everyone’s thoughts on “disclose” here btw.) Another cause is embarrassment – “I don’t want to show this lesion on my privates,” etc.

        Is “withhold” the opposite of “disclose,” in this context? In any case it all seems to come down to being socially appropriate or not, eh? Hence the “not black and white.”

      4. e-Patient Dave,

        I understand why the word *disclose* however certainly prefer the thought of connecting, and agree with your assessment. In my very humble opinion, I feel like this will eventually become more the norm, however feel sad that we find the need to analyze how to have a human relationship between human beings. I guess that’s the part that seems a bit strange to me.

  17. I am a medical social worker. Boundaries are a chronic consideration with patients in this role. Each patient situation is different. I have a chronic potentially life threatening condition and work with people with chronic potentially life threatening conditions. I have disclosed to some patients who appear to have a fear I will not understand some of their uncomfortable feelings. There must be a clear benefit to the patient. Some patients will feel you can better understand but some will be afraid you can’t meet their needs if you have limits. My condition has made me a better social worker. I was empathetic before but had some difficulty being present – there was always a time crunch. Now , I lose track of time because I am present. More quality vs quantity.

    1. Susan, thanks for your comment and insights. It really brings a new dimension to the discussion, an extension of the issue that has already been raised about parents only wanting their kids to see pediatricians who have kids of their own. I agree with you about the empathy issue.

      I wish you strength in coping with and battling your illness.

    2. Great contribution to the discussion, Susan. I particularly like “There must be a clear benefit to the patient.” That may not always be clearly possible, but I like it as the *intention* of any disclosure.

      How have you dealt with the time crunch? Do you just disregard it, and bust the schedule sometimes? Or do you find it actually doesn’t bust the schedule?

  18. Danny, I’m a patient advocate who’s rubbed virtual elbows a fair amount, and literal elbows briefly, with your patient Dave. FWIW I’d find the kind of sharing you write about highly valuable in a patient-doctor relationship. Assuming that the baseline two-person gestalt led to an inclination to share in the first place, I’d welcome the connection. I’m the kind of guy who’d chew up your apt. time with a batch of questions probing along the lines of how your experiences affected your assessment of all things medical and your practice of medicine going forward. I think we need more transparency, not less. As a lay person who’s become active in end of life reform, my antennae are always up about this issue. For me, trust is enhanced with “disclosure” and diminished with opacity.

    1. Bart, it is interesting how many feel that the “human” connection outweighs everything else, and others felt that we must be cognizant of rules that force us to distance ourselves. But I agree we need more of the human touch in medicine.

  19. I have had a great deal of interaction with doctors for the past 18 years, due to a number of conditions, including cancer, severe bronchial asthma, and a finger loss due to catching my ring on something, which pulled a tendon out of my arm and caused permanent damage.

    The cancer caused me to become very involved in the e-health movement, with ACOR and other organizations, although more recent events have made me re-focus my attention on my other health issues.

    Seeing doctors for these conditions… I had a doctor tell me the bronchitis was all in my head and I should just buck up and go back to work – I changed doctors and was out of work for weeks, unable to breathe, totally fatigued. I had a hand surgeon tell me I was a Vicodin addict because I needed medication for pain 2 weeks after the traumatic finger amputation. The difference between that doctor and the one I immediately replaced him with, who asked how my pain levels were… night and day.

    I applaud your decision to disclose what happened to you – when appropriate. It makes you human. If I were your patient, it would make you more personal, more accessible. I have experienced both kinds of physician, from internist to specialist. It makes all the difference in the world, to me, when the physician reveals him or her self as human.

    I do think you have to assess what the individual patient wants to know, to some degree. And – considering what you’ve been through, take it easy! Life is short, Maybe having had this awful, terrifying, traumatic experience will add to your appreciation of each day. I know it has for me. Congratulations on posting all this, and on your recovery.

    1. > I do think you have to assess what the
      > individual patient wants to know, to some degree.

      And ain’t that true of any healthy relationship! I don’t know if there are formal measures for a good health relationship, but I imagine it doesn’t include flat-out not believing the other party when there’s no evidence for disbelief.

      I keep returning to something I heard 2 years ago from Richard Rockefeller MD, one of “Doc Tom” Ferguson’s friends: “If you have a collegial relationship, you can talk about it.” The “collegial” bit made such an impact I wrote about it last year, in both business and medical contexts.

    2. On a related note, Deborah – during my near-fatal illness in 2007, the nurse who was managing my case pointed out that some patients have more appetite for information than others. She’d learned to assess that silently while working in pediatric oncology.

      1. People vary significantly in their interest in having information. Those of us who participate in this kind of discussion tend to be “information-seeking” patients – but some still want the “doctor knows all and don’t ask questions” style.

  20. Something that no one has mentioned (I think) is the possibility of loss of employment following disclosure of illness. Oh, it’s illegal, etc., but it happens. I am now retired and I find the freedom to never consider that aspect very liberating.

    1. One other thing related to disclosure of illness on a public blog (not specifically related to disclosure to patients) is the concern that in the US this could make it difficult for the discloser to obtain health insurance. But thank goodness the ACA has made this irrelevant, which similarly is quite liberating.

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text:
修真世界 World of Cultivation Chapter Seven Hundred and Ninety One “The Power of Gluttons”

This chapter has been brought to you by me, and WanderingGummiOfDoom.

Chapter Seven Hundred and Ninety One – The Power of Gluttons

The mist ball suddenly exploded!

Howling waves enveloped everyone, countless tiny white figures leaping at the group.

Zuo Mo’s scalp pricked, the green strand in his hand vibrating relentlessly. When the white shadows were struck by the green strand, they immediately exploded.

Bam bam bam!

With every explosion, a strange power would pass to Zuo Mo’s wrist from the green strand. The frequent and eerie power battered at Zuo Mo like waves.

Zuo Mo’s heart shook. His physical body was so strong yet he felt as though he couldn’t keep a grip on the green strand!

These white shadows were the size of a thumb and shaped like tadpoles with unusually large heads. When they opened their mouths, they revealed two dense rows of scary teeth.

There were tens of thousands of them that furiously charged at the group.

Tenth Grade’s expression turned cold. The crescent blade around him suddenly attacked!

The flash from before was absent, but an indescribable bloodthirst replaced it!

[Hundred Sacrifice Soul Killing Sword]!

The sword scripture known to be the most vicious in the world lived up to the name. With this attack, a vicious and bloodthirsty energy formed as the sword moved! The little crescent blade suddenly lit up with a dark red color.

The crescent moon attacked!

After turning dark red, the crescent seemed to be a bloody shadow, that  moved relentlessly. These grey shadows changed constantly as though they were moving about, forming and dissipating. Each shadow was filled with great killing energy.

As the shadows formed and dissipated, the vicious energy of the dark red crescent blade reached a peak.

Woo woo woo!

Like the cries of hundreds of ghosts, like the howls of tens of thousands of beasts!

In front of Tenth Grade the white shadows seemed to be frightened by such vicious energy. They screamed even more frequently, so sharp and high pitched it almost ruptured eardrums as they furiously fled in all directions.

The dark red crescent blade easily passed through the layers of white shadow as though they were intangible.

The silky blood shadow would turn the white figures into a water droplets upon contact, so quickly the white shadow didn’t even have time to shout.

In a flash, all the white shadows in front of Tenth Grade were swept clean, and only droplets of water fell down.

Lil’ Pagoda stretched out its head from behind Tenth Grade. It sucked in all the raindrops into its body.

Zuo Mo finally cleared out the white figures in front of him. His wrist gave off pangs of soreness and his heart was intimidated.

The white mist in the surroundings were still the same as though what had happened just now was just a dream.

Yet before Zuo Mo would sigh in relief, dozens of white arrows suddenly shot out of the white mist. Zuo Mo’s wrist instinctively shook, and the green strand shot towards the white arrows.

The green strand accurately hit the white arrows yet the explosions that Zuo Mo predicted did not occur. The straight arrows suddenly opened their mouths and bit the green strand!

Zuo Mo discovered that these were not white arrows but snakes!

The mist snakes held onto the green strands and would not let go.

At this time, the tails of the snake suddenly exploded. Starting from the tail, the snake exploded inch by inch! When the snake head exploded, an astounding power passed to Zuo Mo through the green strand.

Zuo Mo’s entire hand turned numb!

Such strong power!

Zuo Mo’s expression turned grave. Following this power, the green strand shook lightly. Woosh woosh, dozens of crescent energies immediately shot towards the other white snakes.

Half of the crescent energies hit a target. Seven white snakes nimbly dodged and then exploded in unison!

Zuo Mo’s expression changed dramatically.

The explosion of one white snake had been so strong just now. The power of these seven snakes would release when they exploded in unison, the power … …

He reacted quickly, his shen power rippling and gathering in his right hand.

A great power smashed out through the green strand in a furious wave.

Zuo Mo’s body lit up with bright golden light and he couldn’t help but take a step back.

Hiss hiss hiss!

The hissing within the white mist echoed in his ears.

Zuo Mo was astounded!

The monsters inside the white mist was so strong and they seemed to be endless. The white mist still moved slowly towards them. Zuo Mo knew if the white mist completely shrouded him, their situation would worsen.

What should he do?

The monsters made from the white mist seemed to be unable to go too far from the white mist. At most, they would fly two zhang from the white mist.

Zuo Mo thought of how he had used the magnetic bottles before to carve out this zone of safety. If he could expand the area….

He hurriedly searched in his ring. He had used most of the bottles already, and the remaining few were futile.

No, there had to be a way!

Zuo Mo turned his face and saw the Black Gold Seal Soldier. He couldn’t help but slap his forehead. How did he forget this guy?

Zuo Mo pulled over the Black Gold Seal Soldier and said emotionally, “Blacky, look, our situation is not very good!”

Hearing this, the Black Gold Seal Soldier excitedly made a fist and patted his chest. “Big Brother, should I go? No problem! Watch me beat them to pieces!”

“Beat them to pieces?” Zuo Mo shook his head and said mysteriously. “There is a way that you can easily defeat them!”

“What way?” The Black Gold Seal Soldier asked with a curious expression.

Zuo Mo patted the Black Gold Seal Soldier’s stomach. “Hei, eat them! Just like how you usually eat food. If you eat all of the white mist, wouldn’t they be defeated?”

The Black Gold Seal Soldier had a dumbstruck gaze. A moment later, he stammered out, “Big Brother, the white mist isn’t tasty … …”

“Blacky! Look, this is the best time for you to display our talents. As long as you show your talents, we will all look at you differently. Your A Gui sister will bring you good things to eat. Didn’t you want to eat some cloud steeds? If you suck dry all of the white mist, this might be considered … …” Zuo Mo had a deep expression.

“Really?” The simple-minded Black Gold Seal Soldier immediately widened his eyes and was excited and spirited. “Alright! See how I suck them dry!”

He opened his mouth. As expected, the white mist burrowed into his mouth like a whale inhaling.

Zuo Mo’s eyes turned. Just one wasn’t enough. His eyes swept across the other little ones. The little ones retreated in fright. Zuo Mo’s gaze landed on Lil’ Pagoda and his eyes lit up.

He felt very proud. Fortunately, ge had taken along enough gluttons!

“Lil’ Pagoda, come here!”

Lil’ Pagoda came over with a timid expression.

“Good son, go suck in. This mist is a good thing! Think about it, the mist of the ancient era, with just a mouthful, you will be immune to all ills. With two mouthfuls, you will have your youth forever, with three mouthfuls … … oh. In conclusion, this is something good! Ancient era mist that could trouble even those totem warriors. At present, they would be sold in by the drop or as single strands! Good son, you cannot miss this opportunity, it will never come again!”

Zuo Mo spoke cleverly.

Lil’ Pagoda’s eyes were down, its expression hurt as it slowly moved its fleshy body forward.

The yinyang fish at its forehead started to spin. Hiss, the surrounding white mist started to stream into the yinyang fish at an even faster rate than the Black Gold Seal Soldier.

The Black Gold Seal Soldier glanced sneakily at Lil’ Pagoda and gave out a rebellious snort. His mouth widened, his eyes widening, and his inhalation rate of the white mist suddenly increased

Zuo Mo looked around in pride.

People were short-sighted and could not understand that it would always be the gluttons that would conquer the world!

With two great gluttons in his hand, he could vie for the world!

Rain Hall.

Tan Xu coldly inspected the corpses on the ground. Without raising his head, he said, “It is people from Karma Temple, they didn’t even put up a good fight.”

His tone was filled with dismissiveness. He had enough cause for this. From the moment he discovered them to killing them, he had only used two moves. He felt slightly disappointed. In his view, Karma Temple’s shen power was not acceptable. This kind of shen power was actually able to become the cornerstone of a big sect.

Tan Xu had been full of anticipation towards the mission. Other than the importance of the mission itself, he was excited about the opponents he would encounter.

Tan Xu was outstanding among the Kun Lun disciples. Otherwise, he would not have been chosen to become a Child of Kun Lun. There were other disciples in Kun Lun that were about the same as him in strength. For example, Nie Chen and Zhen Meng Ling were not weaker than he was. However, sect competitions could not compare to true fighting outside.

However, up until now, he had not encountered an opponent that could last for three moves. He felt bored by this.

Nie Chen held an exquisite disk in his hand. If experts saw this, they would exclaim—[Determination Compass]!

[Determination Compass] was one of the most famous Kun Lun talismans. It was ninth-grade, and it had been high up on the treasure rankings for a long time.

While shen devices were stronger and better treasures now, ninth-grade talismans were still rare and had wondrous abilities.

Nie Chen raised his head. “Left side, three people.”

Tan Xu’s expression became murderous. Snap snap, he cracked his joints. “Don’t interfere!”

Nie Chen ignored him and said directly, “Ling Meng, attack as well. Finish as fast as possible, we do not have much time.” He raised his head to look at the endless rain coming down the sky. He murmured to himself, “Totem Coliseum, interesting.”

Tan Xu’s expression became displeased but he did not make a sound. It was alright that he spoke towards Nie Chen in an defiant manner on a daily basis, but this time, Nie Chen was the leader for this mission. Tan Xu was a rebellious person but he cared about discipline. This was the conduct of Kun Lun at present. As Lin Qian continued to govern, Kun Lun’s discipline tightened. What people usually did was not controlled, but once they entered battle, they had to be disciplined.

Tan Xu only thought inside that he had to be faster in attacking than last time.

The three silently hid in the curtain of the rain without any presence.

Their understanding of this ruin far surpassed everyone else. People had to admit defeat to Kun Lun’s great wealth. Kun Lun had quickly found the previous incarnation of the ruins from its ocean of records, the Totem Coliseum.

Kun Lun truly had too many records. Their dominant status for thousands of years allowed them to collect innumerable precious records. The number of secrets unknown to people could not be counted.

They found many details concerning the Totem Coliseum and prepared well. They knew each obstacle, they had taken along talismans to counter each obstacle. For example, the [Rain Disguise Cape] that could hide them in the curtain of rain.

Adding on three strong Children of Kun Lun, it was clear how much Kun Lun wanted the shen device nucleus.

In the curtain of rain, the three figures appeared. They were careful yet they did not detect that there were people hiding in the rain already.

Translator Ramblings: The Power of Gluttony should be the title of this story, not World of Cultivation.

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27 thoughts on “修真世界 World of Cultivation Chapter Seven Hundred and Ninety One “The Power of Gluttons””

  1. I wonder if it’s the power of gluttony, or the power of greed.
    Both seem to fit him extremely well.
    Thanks for the chapter.

      1. actually if i remember correctly, Pride is considered the most dangerous since Pride Is considered to be “The Sin from where other sins come from” Which is why Pride is usually considered the leader

    1. Pride : Lil’Miss Gongsun Cha
      Wrath : Wei Sheng Xishiong
      Greed : of course Ge!
      Gluttony : Lil’Ones
      Envy : Luo Li (he was once jealous of Wei Shen, until he found his path)
      Sloth : Cheng Lian’er (she just want to drink her tea leisurely)
      Lust : Chun shidi (his love to -ahem- animals is abnormal)

  2. Not really, I would expect a different kind of novel if it were named The Power of Gluttony xD

  3. Then Zuo Mo should have used Pu Yao’s Wasteland Sacrificial Arts to consume the mist to be the third glutton!

  4. Why is Tenth Grade so strong when he cultivates ling power?

    “this might be considered ” if Blacky were smarter he’d realize that his meant “never gonna happen” 😉

    He really sounds like a snake oil salesman…

  5. thanks for the chapter!

    Gluttony ~ 7 deadly sins

    hmmm… Zou Mo and his group has them all 😀

  6. Thanks for the chapter WYHCWE and WanderingGummiOfDoom! Those three better pray they don’t run into Wei Sheng. He’s the worst thing that can happen to anyone from Kun Lun.

    1. Nah, Wei Sheng would at least give them clean and quick deaths. Ge on the on the other hand could infuriate them to death with just his words. To say nothing of all his other methods.

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Practice requests and requires various personal data to understand your needs and provide you with better service. In addition, we may gather such information for the following reasons: (1) internal record keeping, (2) to keep records of customer purchases, (3) to improve our Website, programs, products, or services (4) to periodically send promotions about new programs, products or services, or other special offers from which you may unsubscribe at any time, (5) for aggregate, non-identifiable data for market research purposes, and/or (6) to customize the respective program, product, or service you purchase or use according to your interests. You will be given the opportunity to opt-out of having your email address used for commercial emails from Practice at the time you receive any marketing email message from us. In any case, if you wish to be removed from any such Practice emails, you can send an email with “Unsubscribe” in the subject line to Info@drgabriellelyon.com. You can also contact this email address if you would like to:

• See what information we have about you, if any.

• Change and correct any information we have about you.

• Have us delete any information we have about you.

• Express any concern you have about our use of your information.

Information Storage.

All information is stored through a data management system. Practice takes precautions to protect Personal Information. When customers submit Personal Information via the Website, it is protected both online and offline. Whenever Practice collects sensitive Personal Information (such as credit card data), that information is encrypted and transmitted to Practice in a secure way. Customers can verify this by looking for a closed lock icon at the bottom of their web browser, or looking for “https” at the beginning of the address of the web page.

While Practice uses encryption to protect sensitive information transmitted online, we also protect your information offline. Only employees who need the information to perform a specific job (for example, customer service) are granted access to Personal Information. The computers and servers in which we store Personal Information are kept in a secure environment.

However, unfortunately, please note that no data transmission over the Internet or any wireless network can be guaranteed to be 100% secure. As a result, while we strive to protect your Personal Information, you acknowledge that (a) there are security and privacy limitations of the Internet which are beyond our control; (b) the security, integrity, and privacy of any and all information and data exchanged

between you and us through this Website cannot be guaranteed; and (c) any such information and data may be viewed or tampered within transit by a third party.

Confidential Information.

All Personal Information collected by Practice will be held in confidentiality and will not be disclosed to third parties, except that we may disclose Personal Information: (1) pursuant to the Terms and Conditions and this Privacy Policy, (2) if we are required to do so by law, (3) in the good-faith belief that such action is necessary to conform to the edicts of the law, (4) to comply with legal process served on us, our partners, sponsors, investors, or affiliates, (5) to protect and defend our rights or property or those of our users and/or (6) to act as immediately necessary in order to protect the personal safety of our users or the public. Practice will not sell, distribute or lease your Personal Information to third parties unless we have your permission or are required by law to do so.

Access by Third Parties.

Note that whenever you make your Personal Information available for access or viewing by third parties through our Website, programs, products, or services, and social media, the information you share also can be seen, collected and used by third parties and, therefore, we cannot be responsible for any unauthorized third party use of such information that you voluntarily share online or in any other manner. Practice also is not responsible for the privacy statements or other content on the websites outside of our Website.

Use of Cookies.

A cookie is a piece of data stored on a site visitor’s hard drive by a web page server to help Practice improve customers’ access to our Website and identify repeat visitors to our Website. Cookies allow web applications to respond to you as an individual. The web application can tailor its operations to your needs, likes and dislikes by gathering and remembering information about your preferences. Like most companies, this Website may use cookies to identify which pages are being used. This helps us analyze data about webpage traffic and improve our Website in order to tailor it to customer needs. We only use this information for statistical analysis purposes and then the data is removed from the system. Overall, cookies help us provide you with a better Website, by enabling us to monitor which pages you find useful and which you do not. A cookie in no way gives us access to your computer or any information about you, other than the data you choose to share with us. You can choose to accept or decline cookies. Most web browsers automatically accept cookies, but you can usually modify your browser setting to decline cookies

if you prefer. This may prevent you from taking full advantage of our Website, programs, products, or services.

Use by Children.

This Website is not designed for, nor do we believe it is appealing to, children under the age of 13. We do not knowingly collect Personal Information from children under the age of 13. We encourage children to consult with their parents before providing Personal Information.

If you have any questions about any of the terms of this Privacy Policy, please contact Practice at Info@drgabriellelyon.com.


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We Need Our Sleep

Sleep, sleeping positions, posture, Dr Beverley Marr

Unfortunately, most of us do not get enough sleep. There is nothing new about that statement. But did you know our sleeping positions do have an impact on us and can be even harmful? Sleep is as important as taking a breath, drinking water and eating. Without it, humans experience intolerable psychological effects like severe …

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Zombie Combat Simulator on PC / Windows 7.8.10 & MAC

Zombie Combat Simulator – kill zombies by playing alone with friends through local multiplayer or online. This is a third-party quality action game in which the player has four different cards, four modes: checkpoint, survival, infection and sandbox, as well as three levels of difficulty: easy, difficult and nightmare. In the sandbox mode, you can freely create new units anywhere and set up parameters such as weapons, health, movement speed, types of behavior for AI, etc. If you have a little single mode, then clean the cards from the dead with your friends via Wi-Fi multiplayer or play with other people online. In the settings of this action there is a choice of the quality of graphics detailing, the ability to disable auto-shots and bloody effects.

Zombie Combat Simulator

How to run Zombie Combat Simulator on your PC

To install the mobile version of Zombie Combat Simulator on your computer, you will need to install the BlueStacks emulator first. To download the emulator, use the link, after downloading the BlueStacks, run its installation.

Download games from Google Play. Open the application store in the main window of the emulator, enter the name of the application in the search engine.

To download it to your computer, you will need to use a Google Account. To do this, confirm the account with a login and password, after which the will be available for download and installation.

Zombie Combat Simulator
Zombie Combat Simulator
Developer: Airblade Studio
Price: Free+

Install Zombie Combat Simulator on PC Using Bluestacks

  1. Download and Install BlueStacks
  2. Open and run BlueStacks
  3. Choose the Market from where you want to Install it, Choose Play Store.
  4. If asked for ID, put it.
  5. Now in Google Play Store Click the Search button.
  6. Enter the Zombie Combat Simulator in it.
  7. Install The .
  8. Go To Drawer and Open the from Main Menu and Enjoy.

Recommended: Evo Explores on PC / Windows 7.8.10 & MAC.
That’s all for Zombie Combat Simulator on PC / Windows 7.8.10 & MAC, if you want to learn more about Apps and Games on PC please follow our Blog DroidWhiz and get all the latest feeds about Apps and Games on PC.

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29th Oct, 2020

'Stay at home to save lives and stop COVID-19 spread' warns Worcestershire Director of Public Health

WORCESTERSHIRE’S Director of Public Health is urging everyone to stay at home to prevent the spread of COVID-19.

Dr Kathryn Cobain issued the plea yesterday, saying it would preserve life – everyone, even the healthy, should avoid contact with others, stay away from social groups and stop visiting family,

She added the highest level of social distancing was vital to keep everyone safe and protect the most vulnerable.

The following advice was issue –

Everyone should be taking part in social distancing. Even if you are feeling well, follow the advice.

Avoid contact with other people. Keep two metres away from everyone else at all times.

Change your behaviour. Don’t go anywhere to join groups of people. Don’t have visitors to your house. Work from home if you possibly can.

Social distancing doesn’t mean you need to lock yourself away. Fresh air and exercise are still vitally important but enjoy these alone. Do not meet up with family and friends who do not live with you.

Critical workers of course have to be in work and Worcestershire County Council said it recognised the enormously important role they have in providing care and support.

“We will do what we can to help and to ensure they are able to do their job whilst their children are kept safe.”

Schools an education settings in Worcestershire have a key role to play in meeting priorities to preserve life and prevent COVID-19 spreading, along with keeping critical services going.

The county council said it was committed to enabling those workers, critical to the response to coronavirus, to attend their workplace over the coming weeks and months.

Any of those workers who could not keep their children at home have been guaranteed a safe place for them, while they work on the frontline.

“We can only do this if everyone uses this provision only when you really need it.

“Please consider this as an option of last resort.

“Children who cannot be safely looked after at home, are vulnerable, or need specialist support will be provided for,” added the county council’s statement.

Dr Cobain said: “It is extremely important that we all stay at home. By avoiding social contact with others, we are saving lives. It may feel difficult and isolating to be avoiding other people, but this measure is essential if we are to prevent the spread of the virus.

“I’d encourage everyone to stay at home, work from home if possible, and keep children at home.

“Critical workers are of course an essential part of our response to the virus, and we will support them.

“The safest place for their children is also at home. I’d encourage our critical workers only to send their children to school if absolutely necessary.

“This is to keep us all safe.”

Visit GOV.UK for more on the latest social distancing guidelines and go to worcestershire.gov.uk/coronavirus for more advice on COVID-19.

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The anti-borreliae efficacy of phytochemicals and micronutrients: an update

Anna Goc and Matthias Rath

Therapeutic Advances in Infectious Disease 2016, 3(3-4): 75-82

Abstract: Naturally occurring substances have been used for centuries to fight against various pathogens. They serve as a source for new chemical entities or provide options to already existing therapeutics. While there is an increasing interest in studying antimicrobial properties of naturally derived agents, little is known about their effects against Borrelia burgdorferi sensu lato, the causative pathogens of Lyme disease.

A better understanding of this aspect could advance knowledge about pathophysiology of these bacteria and help improve the efficacy of current approaches against Lyme disease. Here, we review all naturally occurring substances scientifically evaluated to date, including plant extracts, their metabolites, and micronutrients, against vegetative (spirochetes) and latent (rounded bodies, biofilm) forms of Borrelia sp. This summary reveals the potent anti-borreliae activity of several of these natural compounds indicating their potential in enhancing the efficacy of current treatments for Lyme disease, and offering new options to already existing therapeutic regiments.

This article is protected by copyright. All rights reserved.

Key Words:
biofilm, Borrelia sp., cysts, micronutrients, phytochemicals, spirochetes

Full Study:

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I want to implement a nomination process. Users should be able to

  1. Nominate existing Nodes of type 'course'.
  2. Nominate new content that should later be of type 'course'.

All nominations should be listed somewhere.

What's the best way to do this?

For 1. I thought about using the Flag module and then just make a view where all nodes with nomination flag are listed.

For 2. I'm not sure, maybe I use webforms and the admin has to transfer it into a node of type 'course'. But how do I get a list of new AND existing nominated content?

How about using modules Node_convert, and Flag (which is obviously a must have for what you're looking for)? About Node convert (from it's project page):

adds a menu tab "Convert" on the node view page, i.e. node/1/convert, which gives the ability to convert the node from its current node type to another node type. The module provides the means to transfer all the field values of the current node type into fields on the destination node type, or discard them.

I'm using Node_convert already for long time, works great. It allows for implementing a lifecycle (or workflow?) to start from a node that is only just something like an idea (or suggestion, question, issue, abstract, etc). Those ideas that get the highest votings, are the ones that seem to make sense to handle with highest priority. Compare it to a 'Question' with a lot of votes, but with hardly any (or no) answers.

When the node's content evolves (read: the more effort/details added to it), I convert its content type to finished products like (eg) a recipe, a redbook (already from my Drupal 6 days a few years ago).

By combining it with some type of access module (related to either taxonomy or content type) I can make it more restrictive to give access to it. E.g. public to start from, then "authenticated", and in the end only for roles such as "subscribers", "students", etc.

Maybe you also want to consider Fivestar and/or Voting API (I have the impression that "Voting" is a kind of synomym of what you mean with "Nominate").

And of course: use Views as you are considering already. To continue my samples above: using some basics Views reports, you can easily massage it all in a todo list also.

| improve this answer | |
  • thanks for your input, sadly node_convert does not support all of the field types I need (e.g. paragraphs) but I keep this one in mind for another project. – scar May 18 '15 at 14:45

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√   Certified Criminal Law Specialist – Certified by the State Bar of California, Board of Legal Specialization (#202778)
√   18 years of trial experience in California’s state and federal criminal courts
√   1000’s of successful case results and courtroom victories – all real client reviews
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√   5-Star Rated on Yelp and Avvo – Client choice award winner
√   Aggressive trial attorney, creative strategist, skilled negotiator
√   Heartfelt defender
√   Honest, straightforward, reliable
√   In-house private investigator | expert defense team
CALL NOW FOR EXPERT HELP: (818) 609-1800
Initial consultations are free and confidential.
CALL NOW: (818) 609-1800
Initial consultations are free and confidential.

Cover Story in the Los Angeles Times, Sunday Edition.
Ms. White’s fascinating attempted murder case was featured on the LA Times website.
Debra has a true sense of humanity about her that is so often lacking from the legal profession; add to that her razor tact and tenacity. It only takes one conversation with her to know you have found a uniquely superior attorney.
Debra S. White is a real fighter with a very compelling life story. She has the both the impressive academic credentials and breadth of experience to make her an excellent choice to defend you.
In one meeting, Debra demonstrated more insight and knowledge than I had experienced in 12 months with my prior attorney.

San Fernando Valley Office

21112 Ventura Blvd.,
Woodland Hills, CA 91364

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515 South Flower Street, 36th Floor,
Los Angeles, CA 90071

© 2020 Law Offices of Debra S. White.  |  All rights reserved.   |  Legal Disclaimer.


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Skip to main content

Universal Credit

How making our user journey longer made things better for users

Posted by: , Posted on: - Categories: Product Owner, Service Design, Universal Credit
Map of user journey on whiteboard

Product owner Karen Gibson talks about how her team simplified the interview process for work coaches by creating a new process featuring a ten-minute evidence gather which replaces a 60-minute interview.

What we learned while improving accessibility

Here in the Department for Work and Pensions (DWP) we're building services that should be fully accessible to everyone. As a front-end developer for Universal Credit, I'm part of the team helping to make this goal a reality. Right from the time I …

Learning through prototyping: tools for Universal Credit claimants

Posted by: and , Posted on: - Categories: Universal Credit

We’ve been looking at some new ways of helping claimants and our operational staff to visualise looking for work in new ways. There are lots of variables to take into account when finding work. Things like: • understanding the type of …

Universal Credit Digital Service: building new skills

Posted by: , Posted on: - Categories: Agile development, Software Development, Technical Architecture, Universal Credit

The Universal Credit Digital Service is helping build new skills, both for the claimants using it, and for the technical team building it. Universal Credit Digital Service video transcript Rob Thompson, Universal Credit Digital Service “UC digital is a flagship project, …


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Welcome Your IET account
Bristol Spaceplanes

Space-plane developer expresses frustration at lack of UK investment

An engineer working within the space plane industry told MPs that a lack of support from major players in the aviation industry might be slowing down the development of the new disruptive space technology.

David Ashford, managing director of Bristol Spaceplanes, thinks space planes are an incredibly valuable invention, which are likely to have as much impact in the future as the steam locomotive did in the 19th century.

However, Ashford feels a lack in industry support in Britain is slowing down this process, as major aviation companies are unwilling to back the new technology.

“The main risk is just lack of investment capital,” he said. Space planes are going to revolutionise space flight eventually and if the UK wants to develop the world's first space plane, which it could do, you need the money, Ashford told the Science and Technology Select Committee.

Space planes are a new type of space vehicle that take off and land in a similar way to aircraft and can hence be re-used.

Ashford said: “It's going to revolutionise space flight like the steam locomotive revolutionised land transport. It’s that level of transformation.

For Ashford, the history of space planes dates back to the 1960s, when aviation companies were looking into the technology as the “obvious next step” after converting ballistic missiles into launch vehicles.

Yet Ashford said the race to the moon forced companies to dismantle their space plane projects and focus on what was seen as the space-related priority at the time.

Now, the engineer believes space planes have a solid chance to take off, but he is frustrated at the poor support they are receiving from big players within the aerospace industry.

“We're trying to team up with major players, and we’re having great trouble engaging in dialogue with them,” said Ashford. “It's sort of, ‘space planes arent in our strategic plan, dear boy, and thats meant to close the conversation down. Then I say no, its not in your strategic plan because it's a disruptive technology, but the first one of you guys that puts it there hits the jackpot, and theres a very long pause.”

According to the engineer, this lack of support is likely to interfere with the Government’s plans for a UK spaceport.

In fact, not all industry exponents believe that a British spaceport will be ready by 2020.

Richard Peckham, business development director at Airbus Group, said: “I would certainly say it’s close to impossible. I think it could be not too far away from 2020, but 2020’s going to be pretty nigh impossible.”

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