The third person in the room: Frequency, role, and influence of companions during primary care medical encounters
- 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.
TABLE 2
Patients’ and companions’ reports of companion’s reasons for accompaniment and influence on the medical encounter*
| Patient’s report | Companion’s report | ||||||
|---|---|---|---|---|---|---|---|
| Companion in waiting room | Companion in examination room | P † waiting room | Companion in waiting room | Companion in examination room | P † waiting room | ||
| Companion’s reasons for accompaniment | |||||||
| Help with transportation | 58 (69) | 61 (55) | .05 | 64 (79) | 66 (58) | .003 | |
| Provide company | 39 (46) | 58 (53) | .39 | 43 (53) | 55 (49) | .59 | |
| Help communicate concerns to the doctor | 6 (7) | 56 (51) | .001> | 5 (6) | 60 (53) | .001> | |
| Help remember physician’s advice and instructions | 4 (5) | 51 (46) | .001> | 5 (6) | 54 (48) | .001> | |
| Provide emotional support | 20 (24) | 48 (44) | .004 | 27 (33) | 60 (53) | .006 | |
| Express concerns regarding the patient to the physician | 6 (7) | 41 (37) | .001> | 9 (11) | 51 (45) | .001> | |
| Help make decisions | 5 (6) | 39 (35) | .001> | 2 (2) | 32 (28) | .001> | |
| Help with language barriers | 1 (1) | 14 (13) | .003 | 0 (0) | 12 (11) | .002> | |
| Help with insurance or payment forms | 7 (8) | 11 (10) | .69 | 7 (9) | 5 (4) | .23 | |
| Companion’s influence on medical encounter | |||||||
| No influence or don’t know | 57 (70) | 28 (25) | .001> | 58 (72) | 24 (21) | .001> | |
| Companion influenced | |||||||
| Physician understanding | 5 (6) | 63 (57) | .001> | 5 (6) | 69 (61) | .001> | |
| Patient understanding | 3 (4) | 59 (54) | .001> | 10 (12) | 68 (60) | .001> | |
| Tests ordered | 3 (4) | 13 (12) | .039 | 1 (1) | 12 (11) | .01 | |
| Prescribed treatment | 1 (1) | 26 (24) | .001> | 4 (5) | 26 (23) | .001> | |
| Number of referrals | 0 (0) | 10 (9) | .005 | 1 (1) | 6 (5) | .13 | |
| Length of visit | 7 (8) | 19 (17) | .07 | 6 (7) | 20 (18) | .04 | |
| *Values are number (percentage) unless otherwise indicated. | |||||||
| † Difference between waiting room and examination room companion. | |||||||
TABLE 3
Physician report of examination room companion’s influence on the medical encounter*
| Decreased | No influence | Increased | |
|---|---|---|---|
| Communication | |||
| Physician’s understanding | 1 (1) | 43 (39) | 66 (60 |
| Patient’s understanding | 0 (0) | 59 (54) | 51 (46) |
| Resource use | |||
| Time spent explaining/ counseling | 9 (8) | 66 (60) | 35 (32) |
| Length of visit | 6 (7) | 75 (68) | 28 (25) |
| Treatment recommended | 2 (2) | 106 (96) | 2 (2) |
| Number of referrals | 1 (1) | 106 (96) | 2 (2) |
| Number of tests ordered | 2 (2) | 106 (96) | 1 (1) |
| n = 114. | |||
| *Values are number (percentage). | |||
Physician report of examination room companion’s behaviors
| Behavior | n (%) |
|---|---|
| Active behaviors | |
| Clarified or expanded history | 71 (65) |
| Supportive/encouraging toward patient | 71 (65) |
| Asked questions/requested explanations | 53 (48) |
| Discussed concerns about patient’s symptoms/problems | 50 (45) |
| Made evaluation or treatment requests | 19 (17) |
| Took notes | 14 (13) |
| Distractive behaviors | |
| Discussed own symptoms | 16 (15) |
| Discouraging/controlling toward patient | 7 (6) |
| Passive behaviors | |
| Passive observer | 17 (15) |
| n = 114. | |
Data analysis
Data were used from each member of a set regardless of survey completion by other set members. One patient had 2 examination room companions and 2 patients had 2 waiting room companions. In each case, both companions were surveyed. In the 2 cases in which a patient had waiting and examination room companions, the examination room companion was considered more influential for the medical encounter and only that person was surveyed.
The data were analyzed with SAS version 6.12 (SAS Inc, Cary, NC) using bivariate and multivariable methods. Comparisons were made between patient categories (patient alone, patient with examination room companion, patients with waiting room companion) using the chi-square statistic for categorical variables.
Multivariable analyses were conducted to explore the effects of various independent variables on the decision to bring a companion into the examination room. The outcome variables for the regression models were defined by patient status (patient alone, patient with examination room companion, patient with waiting room companion). All significant variables (P ≤ .05) in bivariate analyses were entered into the multivariate analyses. Odds ratios (ORs) with 95% confidence intervals (CIs) were obtained for each variable in the model.
Patient and companion agreement on the reasons for accompaniment and influence on the medical encounter were measured with the kappa statistic. Kappas (κ) of 1.0 to .75 denote excellent agreement, .4 to .75 denote good agreement, and 0 to .4 denote marginal agreement.11
RESULTS
Of the 1294 patient visits, 834 (64%) were to faculty physicians and 451 (35%) were to resident physicians. Overall, companions were present for 29% (n = 374) of patient visits and accompanied the patient into the examination room for 16% (n = 212) of visits. Companions accompanied patients to 23% (n = 196) of faculty visits and 39% (n = 178) of resident visits (P P = .98).
Ninety-three percent (121/130) of unaccompanied patients and 92% (200/217) of consecutive patient–companion pairs approached for consent agreed to participate in the study. In 26 cases the patient or the companion refused to participate for 1of the following reasons: language barrier, too ill, lack of time, invasion of privacy, or uncomfortable with process of consent. Patients and physicians completed surveys for 97% of patient encounters, and companions completed surveys for 99% of patient encounters.
