Original Research

The third person in the room: Frequency, role, and influence of companions during primary care medical encounters

Author and Disclosure Information

  • OBJECTIVE: We wanted to characterize patient accompaniment to medical encounters and to explore the rationale and influence of the companion on the primary care medical encounter.
  • STUDY DESIGN: This was a descriptive study.
  • POPULATION: Academic general internal medicine physicians, patients, and patient companions participated.
  • OUTCOMES MEASURED: We measured the frequency of waiting and examination room companions, the reasons for accompaniment, the influence on the encounter, and the overall helpfulness of the companion as assessed by patients and companions. We also determined the physician’s assessment of the companion’s influence, helpfulness, and behavior during the encounter.
  • RESULTS: Companions were in the examination room for 16% of visits; 93% were family members. The rationales for waiting and examination room companions were to help with transportation, provide emotional support, and provide company. Examination room companions helped communicate concerns to the physician, remember the physician’s advice, make decisions, and communicate their own concerns to the physician. Patients believed that examination room companions influenced 75% of medical encounters, mainly by improving communication between physician and patient. Physicians agreed that examination room companions favorably influenced physician and patient understanding (60% and 46% of encounters, respectively). Patients indicated that waiting and examination room companions were very helpful for 71% and 83% of visits, respectively.
  • CONCLUSIONS: Companions frequently accompany patients to their primary care medical encounters. They are often family members, and they assume important roles in enhancing patient and physician understanding.


 

References

KEY POINTS FOR CLINICIANS
  • Sixteen percent of adult patients have a companion present in the examination room during their ambulatory medical appointments.
  • Companions are more common with older, less well educated, and more medically or socially complex patients.
  • Companions participate actively during the encounter.
  • Companions often improve patient and physician understanding during the encounter.
Traditionally, physician training focuses on an encounter between 2 people: the patient and the physician. In practice, a third person frequently accompanies a patient to the medical encounter. The American Medical Association Council on Scientific Affairs states that primary care physicians “need a strong and effective model to guide their relationships with family caregivers” and recommends that physicians tend to the needs of individuals assisting patients and to the patients themselves.13 In family practice, family members commonly accompany one another,2 but conflict between families and health care professionals can occur.3 Interviews with hospital counsel and medical staff have identified families as the primary difficulty in end of life situations.4 Nevertheless, family members provide invaluable information about the patient’s broader psychological and sociocultural dimensions and the personal relationships that contribute to the patient’s functional autonomy.5

Although common, third party involvement in adult medical care has not been well studied. This prospective study explored the frequency of companions, the reasons for accompaniment, and the companion’s influence on the medical encounter from the perspective of the patient, the companion, and the physician.

Methods

Setting, physicians, and patients

The study was conducted at the general internal medicine practice of the University of Colorado Health Sciences Center. Fifteen full-time faculty and 42 internal medicine residents participated. A companion was defined as any person older than 18 years who accompanied a patient to a medical visit and was designated as an examination room companion if that person spent any portion of the visit in the examination room; otherwise, that person was designated as a waiting room companion. Persons employed solely to provide transportation services for patients were not considered companions.

Study design

The study consisted of 2 parts: a prospective study to document the frequency of patient accompaniment by a third person to ambulatory medicine visits, and a survey of patients, companions, and physicians to explore the rationales and influence of the companion during the medical encounter. A professional research assistant was present for an average of 8 of 10 half-day clinics per week. To accomplish the first objective, a research assistant directly observed 1294 consecutive patient visits from September 22 to October 29, 1998. To accomplish the second objective, from mid-September to mid-November, a professional research assistant attempted to enroll all consecutive patients accompanied to their appointments. Unaccompanied patients were approached for consent at the convenience of the research assistant. Patients and their companions were approached for consent in the waiting room immediately before their visits.

For inclusion, patients and companions provided consent and were literate in English. Patients, companions, and physicians independently completed self-administered questionnaires immediately after their visits. All were informed that responses were confidential and would not be disclosed to one another. This study was reviewed and approved by the Colorado Multiple Institutional Review Board.

Questionnaire development

The survey instruments were developed after a thorough review of existing research1,6-10and refined by pilot testing and review with a professional survey consultant. Patients and companions completed demographic questions (Table 1). Patients rated their overall health, stated their relationship to the companion, and indicated the reasons for companion accompaniment (Table 2). Patients and companions indicated from a list of 7 items (Table 2) how the companion influenced the visit and rated the companion’s helpfulness during the encounter (5-point Likert scale: 1 = very unhelpful to 5 = very helpful).

TABLE 1

Patient demographics and characteristics*

Companion in examination room (A)Patient alone (B)P, A vs BCompanion in waiting room (C)P, A vs C
Total115121 85
Female57 (54)76 (73).1958 (71).022
Age (y)
  18–4421 (20)39 (33)<.001>16 (20).06
45–6434 (33)55 (46) 39 (49)
≥6549 (47)26 (22) 25 (31)
Race
White73 (72)79 (66).0956 (73).73
Black/African American7 (7)22 (18) 8 (10)
Hispanic/Latino16 (16)14 (12) 11 (14)
Other5 (5)5 (5) 2 (3)
Education ≤ high school57 (56)40 (33)<.001>48 (61).56
Income (US dollars/y)
47 (51)61 (54).8239 (53).50
15,000–35,00023 (25)29 (25) 22 (30)
>35,00023 (25)24 (21) 13 (18)
Self-noted health
Poor/fair58 (53)53 (44).3740 (48).13
Good28 (25)34 (28) 32 (38)
Very good/excellent24 (22)34 (28) 12 (14)
Medical and social complexity (MD rating)
Simple/straightforward6 (5)27 (24)<.001>11 (13)<.001>
Average24 (21)36 (32) 32 (39)
Somewhat/very complex83 (73)51 (45) 39 (48)
Patient visit type
Return with primary provider85 (75)73 (64).1651 (62).07
New with primary provider18 (16)28 (25) 15 (18)
Episodic with provider other than primary10 (9)13 (12) 16 (20)
Physician
Faculty68 (62)55 (45).0144 (52).19
Resident42 (38)66 (55) 40 (48)
Some categories are missing data, so the columns do not equal n. Percentages were computed based on available data, and some columns equal 101% because of round-off error.
*Values are number (percentage) unless otherwise indicated.

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