Using the Family as Care Resource and Care Collaborator
In some encounters clinicians and patients discussed the roles of family members in helping patients improve health and health outcomes. Family members became care resources in a variety of ways. In some instances, the clinician asked about the possibility of involving other members of the family in care management; sometimes the patient suggested that a family member should take this role. Some family members who accompanied patients asserted themselves during visits. For example, many parents who accompanied their young children into visits asked questions and offered advice or suggestions. Clinicians also involved family members as care collaborators, asking questions and involving them in decision making about health and health care.
An adult daughter brought in her 90-year-old mother because her behavior was becoming more unpredictable and erratic. During her most recent visit to her mother’s nursing home she had witnessed her running around with no clothes. That incident, along with a recent series of falls, caused the daughter a great deal of concern. “I know when my mother acts like this, this is not really my mother,” she said. “This is not the person I know.” During most of the encounter the daughter and clinician talked about the dosage and side effects of each of her mother’s medications, gradually eliminating some of the drugs that seemed unnecessary. The clinician commented to the daughter, “We need to get some order in this.” The daughter agreed.
Family Member Receives Unscheduled Care
Sometimes the family member actually became a patient. This happened more frequently when family members accompanied the patient but also when the patient visited alone. Clinicians, patients, and family members all initiated this unplanned care. Clinicians would specifically ask about a family member who was also a patient - and would even give the patient a drug sample to take home to a spouse or child. Often, patients came in requesting medication refills or other advice about a family member’s health problem. Some family members who accompanied patients took advantage of these visits to ask about a particular health problem, to get a free sample, or to refill a medication. In the following example, the clinician saw both husband and wife, and the husband took advantage of the encounter to talk with the clinician about his own health issue and to schedule an appointment:
A husband accompanied his 79-year-old wife to her medical visit; she had shortness of breath and weakness. Near the end of the visit the husband asked about the results of his prostate-specific antigen test. Because the clinician kept family charts, the patient’s husband was able to get his results. The patient’s husband then asked the clinician if he needed to make an appointment. The clinician looked in the chart and responded, “Well, you need to have a complete physical. Make an appointment for that.”
Sometimes the accompanying person gets direct care during the visit as in the following illustration:
A mother brought her baby in for her 1-week check-up. The physician asked the mother how she was feeling. The mother mentioned that she felt a “burning sensation” after urination. After asking the mother a few specific questions, the clinician instructed mom to jump onto the table for a brief examination. The mother was diagnosed with a vaginal tear and was instructed on how to care for it.
Discussion
This paper presents a data-driven typology that shows the multiple ways in which patients’ families influence the outpatient visit in family practice. As found in previous research, family-oriented care frequently occurred through the collection or discussion of family history of illness.4,11 Information on family history and family context frequently led to important changes in decision making and treatment for both the patient and the family. With the renewed emphasis on family history as a method of identifying patients at increased genetic risk,12 the family history-taking skills of family physicians should become increasingly important in educating patients and their families about genetic risk.
Patients also shared important contextual information about how family relationships and family stresses were affecting their own health. They talked about the health and illness of family members that had often influenced the patient’s reason for a visit. These conversations also helped to uncover the stress-related illness, anxiety, and depression of patients and family members, sometimes representing the “real” reason for a visit. These family-oriented exchanges have been shown to positively affect the physician-patient relationship and have an impact on patient satisfaction and perceptions of quality of care.13-15