The Effect of Families on the Process of Outpatient Visits in Family Practice

Results

Of the 1600 outpatient encounters that were analyzed, 923 (58%) were family-oriented in some way. In a total of 560 visits (35%), patients were accompanied into the examination room by at least one other person (usually a family member), while 363 (23% of total visits) included mention or discussion of the patient’s family in some way when the patients were by themselves. A large percentage of people who accompanied patients were family members (96%), indicating that such encounters were indeed “family visits.” Individuals accompanying patients into these family visits were much more likely to be women (73%), with this high percentage largely due to the high representation of mothers present during their children’s health care visits. For adult family visits, wives (29%), adult daughters (19%), and husbands (19%) most frequently accompanied patients into the examination room.

The family frequently came up in the medical visit when clinicians took patient health histories. Clinicians asked their adult patients about family history of heart disease, cancer, and diabetes, and sometimes use of alcohol, tobacco, and other drugs. Parents accompanying their children were frequently asked about their own history of disease, or they offered such information to help clinicians make a diagnosis or determine treatment for their children. For some patients, knowledge of their own family history led to their visit in the first place. For example, one patient came in to get a breast lump examined in part because she had a strong family history of breast cancer (her mother died of breast cancer). The clinician and patient explored her risk for breast cancer, and the patient was scheduled for a mammogram.

Although taking a patient’s health history was a routine part of patient care, some of these discussions led to visible changes in health care delivery. For example, during the history-taking for a 31-year-old man presenting with a constant dry cough that had lasted for 7 weeks, the physician discovered that the patient’s father and brother had died of lung cancer and his mother of a heart attack. The physician told the patient he wanted to treat him a little more aggressively because of this family history. Although this change in treatment may not have been necessary, it reflects how family-related concerns can affect patient management.

Among adults, women were more likely to be accompanied, often by their young children. When other family members accompanied adult men into the medical encounter, they were usually wives and sometimes mothers. Visits by adults older than 75 years were characterized by several factors: The patients were more likely to be men than any other visit type, and family involvement was greater than for any other adult category. Elderly patients were most likely to be accompanied by wives and daughters, many of whom served as primary caretakers. These visits were marked by frequent questioning and an exchange of information, and often care collaboration between providers and family members.

One of the most common patterns was for mothers and fathers to give and receive information about their children’s health, illness, and social context. Clinicians relied on parents to provide information about their child’s health condition, contextual information about family health history, or other familial, work, school or other environmental factors that may influence health and disease. These family encounters provided many opportunities for educating parents and providers about the important health issues of their children. Parental involvement progressively decreased through adolescence Figure 1

Qualitative analyses of patient visits identified categories of the different ways a family perspective made a difference in these patient encounters. Although many of the visits fell into a general category of family history of illness that did not appear to affect subsequent decision, 6 nonexclusive categories were identified in which a family-oriented perspective affected patient care: (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 patient’s health; (5) using the family as a care resource and care collaborator; and (6) family member receives unscheduled care. The following sections provide case examples of different ways the presence and/or incorporation of the family in patient visits can make a difference in the processes of care.

Using Family Context to Illuminate Patient Disease, Illness, and Health

In addition to discussions about the family and health history, the family social context provided important information for understanding and improving patient care. These discussions ranged from inquiring about or discussing the home and familial relationships as sources of support or stress, talking about the effects of a recent death or divorce on patient health and well-being, or determining family dynamics as they relate to a patients diagnosis or reason for visit. Patients and accompanying family members commonly initiated these discussions, but clinicians also asked about the patient’s social context, particularly when he or she knew the family. As illustrated in the following example, this contextual information can help to illuminate the patient’s “real” reason for the visit, guiding the clinician toward more productive discussions and effective patient care: