A 34-year-old man with a history of heart problems and very high cholesterol recently had stopped taking his medications. The clinician wanted to explore this further. He knew that the patient’s daughter had been killed in a car accident, so he initiated a conversation about the family. The patient admitted that he had quit taking his medications when this tragedy hit. “I just sort of gave up,” he said. “I know that I’m depressed over this.” The clinician took this opportunity to acknowledge the patient’s depression, and they talked about beginning antidepressants. He decided that medications might hamper the grieving process but encouraged the patient to talk. The clinician let the patient know that he was available any time of day.
Using Family to Discover the Source of an Illness
Clinicians frequently asked questions about the family to determine the source of a patient’s illness, for example, “Who else is sick in the family?” Patients were asked about their exposure to other family members (eg, passive smoke) and were also reminded of how they could spread disease to their families. These conversations were particularly productive when clinicians knew the entire family and both patients and clinicians could use the visit to problem-solve ways of improving the health of both patients and their family members:
A mother brought her 5-month-old infant in with complaints of a cough and runny nose. The clinician diagnosed the patient with asthmatic bronchitis and asked the mom if she smoked. The mom indicated that both she and the baby sitter smoke but not around the baby. The clinician took this opportunity to educate mom on how smoke permeates both clothing and the air. She stressed to mom that her smoking will aggravate the baby’s condition and that the baby will likely have more and longer episodes if she continued to smoke.
In this encounter, the clinician took advantage of a teachable moment to educate the parent on how her smoking was affecting her child’s health but also engaged the mother as a patient by spending time counseling her on smoking cessation.
Discussing and Managing the Health and Illness of Other Family Members
Patients often talked about the health of family members. Sometimes this came up because clinicians were also caring for other members of the patient’s family, and they wanted to know how they were doing (eg, “Is everyone else in the family well?”). In other patient encounters this arose because the patient was the primary caretaker of another family member and wanted information or support. In the following case illustration, the clinician makes recommendations that involve the husband and treats the family rather than just the patient:
A 53-year-old woman is visiting for a health maintenance visit. The patient is a breast cancer survivor who recently had a mastectomy and is currently on chemotherapy. The patient asks the clinician if she has had any experiences with women having breast cancer whom have had husbands lose interest in sex. The patient then confides that her husband has never said anything, but she senses a difference in him; he has absolutely no desire to have any sexual contact with her. The clinician listens and is very sympathetic. She encourages the patient to seek counseling for both of them and talks with her about talking with her husband about this sensitive issue.
Family Concern for a Patient’s Health
Although patients visited their physicians for a variety of reasons, some came in to allay the fears or pestering of family members. The initiation of these visits took different forms. In most cases, patients made appointments as a result of concern expressed or pressure from a family member. In other cases, the visiting patient would ask the clinician to pressure a family member to seek care or would go ahead and schedule an appointment for him or her. These “reluctant patients” may not have otherwise come in. Although women family members most often encouraged these visits, there were also examples of concerned husbands and adult sons who prompted their family members to seek care. In the following illustration, the clinician had been prompted by the patient’s wife to talk about a particular health issue that the patient would not have otherwise brought up:
A 56-year-old man came in to review his medications for high blood pressure. The clinician asked the patient how he was doing and the patient responded, “Everything is fine.” The clinician responded, “That’s not what you wife says. She says you’re having problems with your legs.” They spent most of the visit talking about the patient’s leg problems.