OBJECTIVES: Our goal was to describe how physician knowledge of and interactions with patients’ families affect the processes of patient care in family practices.
STUDY DESIGN: Using a multimethod comparative case study design, detailed field notes were recorded after direct observation of patient encounters and the office environment as part of the Prevention and Competing Demands in Primary Care study. We identified domains of outpatient visits in which patients were accompanied by a family member or in which family-oriented content was discussed.
POPULATION: Outpatient encounters with 1637 patients presenting in 18 family practices in the Midwest were analyzed using an editing style.
OUTCOMES: We developed a typology for ways in which family context affects outpatient visits.
RESULTS: Patients were accompanied during 35% of all outpatient visits, with the vast majority of these visits involving children. Family history or a family member’s problems were discussed during 35% of visits during which no family member was present. An analysis of these "family-oriented" visits resulted in a typology of 6 ways that family context informs and affects the outpatient visit: (1) using family social context to illuminate patient disease, illness, and health; (2) using family to discover the source of an illness; (3) discussing and managing the health and illness of family members; (4) family concern for a patient’s health; (5) using the family as a care resource and care collaborator; and (6) family member receives unscheduled care.
CONCLUSION: Family context is an important feature of family practice that influences the processes of patient care. Since family-oriented care is an essential feature of family practice, outcomes of this largely hidden part of care deserve further study.
KEY POINTS FOR CLINICIANS
- Family physicians have many opportunities to talk with patients and their families about family history and family context.
- Physician knowledge of family context is an important factor in medical decision making and can be classified as 1 of 6 types.
- Long-lasting physician-family relationships should be encouraged in current and future systems of primary care.
Over the past decade health care has experienced rapid and sometimes volatile change that has affected the quality of patient care.1 Changes in the structure and financing of health care have compromised family practice’s ability to maintain its core values of comprehensive, coordinated, and continuous care in the context of the family.2 For example, the Direct Observation of Primary Care (DOPC) study found that one fourth of patients in participating northeastern Ohio practices were forced to change health care providers during a 2-year period.3 These patients reported less coordination of care, decreased continuity with their new provider, and less satisfactory interpersonal communication.
Reports from the DOPC study also found, however, that the family remains an important focus in patient care despite these disruptions in continuity and coordination. Family issues were discussed in more than 70% of patient encounters, accounting for 10% of visit time.4 Patients were accompanied by family members in one third of outpatient visits, providing opportunities for family involvement and even care for 18% of these "non-patients."5 These findings were consistent with those of a recent Canadian study that looked at the role of those people who accompany patients into the medical examination6 and a qualitative study of the ways the family was integrated into routine patient care.7
Although these and other studies confirm that the family is a salient feature in family practice, it is not known how knowledge of the family context affects the process of patient care. Data from the Prevention and Competing Demands in Primary Care Study (PCDPC) were used to answer this question through observation of visits in 18 family practices in Nebraska.
Methods
We used patient encounter data from the PCDPC practice study, an in-depth observational examination of the organizational and clinical structures and process of community-based family practices. Each of the 18 purposefully selected practices was studied using a multimethod comparative case study design that involved extensive direct observation of clinical encounters and office systems by field researchers who spent 4 weeks or more in each practice. Field researchers directly observed and dictated descriptions of approximately 30 patient encounters with each of the more than 50 clinicians and audited medical records of each of these patients. Detailed descriptive field notes documented day-to-day practice operations. Individual depth interviews with each clinician, many of the office staff, and members of the community were used to obtain different perspectives on each practice. Details of the sampling and data collection are available elsewhere in this issue.8
We analyzed 1600 of the 1637 outpatient encounters to determine how the family had an influence on patient care (37 visits had insufficient data for effective analysis). Each encounter was coded by one of the co-authors (S.H.) as a family-oriented visit if: (1) the patient’s family member was present in the examination room or (2) medical or health information about the patient’s family was discussed and/or addressed during the visit. Another author (D.S.M.) read each encounter using an editing organizing style9 by writing brief jottings about each encounter that described how the family had an impact on these medical encounters. Finally, 2 authors (S.H., D.S.M.) jointly examined these jottings to identify an organizational framework and to categorize all family-oriented care visits. The frequency of family-oriented visits was determined using SPSS for Windows (SPSS, Inc; Chicago, Ill).10 Encounter field notes were used to develop case examples to illustrate the ways the family context affected the process of patient care.