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How does a physician overcome the challenges and take advantage of the valuable opportunity that arrives with that third person in room?
Nitin S. Damle, MD, FACP, recently saw one of his favorite patients, an elderly woman who had always been active and independent. Yet this time, her daughter and son-in-law came to the appointment with her. They said she was forgetting things, becoming disoriented and even getting violent with her husband.
During his initial examination, he didn’t notice much of a change in her condition. She seemed to be the same highly functioning woman he’d known for years. Yet because the woman’s daughter and son-in-law had come into the office and spoken up, Damle was able to perform an exhaustive examination, get the woman admitted and then into assisted living, saving her and her husband from a dangerous situation at home.
“Clearly, without the family bringing this to my attention, it could have gone on for quite a lot longer,” says Damle, president of the American College of Physicians and a practitioner in an eight-physician group in Wakefield, Rhode Island.
Family members can be a physician’s extra eyes and ears. They can boost patient compliance. They know more about a patient than a doctor ever will. As a result, they can provide crucial information. And they can advocate for their loved ones, advising and steering them toward healing.
But having family members in the mix can also create anxiety, introduce the toxins of family dynamics, suck up a physician’s time and create privacy concerns. So how does a physician overcome the challenges and take advantage of the valuable opportunity that arrives with that third person in room? Here’s some guidance from the experts.
If a family member is present, it’s crucial for the physician to set the stage and a tone of honesty and open communication, says Bernard M. Bandman, Ph.D., executive director of the Center for Communication in Medicine in Bennington, Vermont.
“Good communication is good medicine,” he says. “It leads to more effective care. It leads to strengthening relationships between the physician, the healthcare team, the patient and the family.”
Doctors need to use that honest and open communication to see how the patient feels about having company during the appointment, Bandman adds. “It’s a delicate matter. … So it’s really incumbent upon the physicians to say, ‘You know, I see you brought some relatives. Would you like them to stay or would you like to have a little time for just the two of us to talk and then we can invite them to come in later?’”
How the patient answers, including through body language, may help the physician understand whether any problematic family issues exist. Chances are, the patient will welcome the opportunity to have the family member close by.
Even with a helpful family member in attendance, physicians should still spend some time alone with a patient, allowing the patient the opportunity to share private concerns or ask confidential questions.
“I’ll ask a family member to leave so I can properly do a physical examination,” says Damle. “During the exam, I’ll query the patient on what’s going on, how they see things and what their perspective is. Once it’s all done, I’ll bring the family member back into the room.”
Privacy concerns are essential, but HIPAA provides some flexibility when it comes to family and friends. The U.S. Department of Health & Human Services’ Office of Civil Rights says physicians are permitted to share information that is “directly relevant to the involvement” of family and friends who help provide a patient’s care or the payment of care. Information can also be shared if the patient is present and gives consent or if the patient, “when given the opportunity, does not object.”
In other words, a signature on a written release is not necessary. However, physicians should always document any verbal consent on the patient’s chart.
With patient and family member together, physicians should start a conversation about the role of the family member, says Bandman. He suggests that physicians briefly share their own experiences.
“It’s really humanizing when a doctor says, ‘You know, from my experience, I’ve seen family members play different kinds of roles in caring for their loved ones,’” says Bandman. Next, he says, physicians should ask the patient direct questions: Whom do you look to for help? What do they do for you? What would you like them to do for you?
Doctors also need to be aware that the traditional definition of “family member” no longer works.
“A ‘family member’ does not have to be somebody who is related by blood,” says Myra Glajchen, DSW, director of medical education at MJHS Institute for Innovation in Palliative Care in New York, where she educates, mentors and trains young doctors. “It is anybody who the patient identifies as helping them cope with or manage their illness. It could be a neighbor, a significant other, a friend from church, whoever the patient decides.”
And realize that these family members, if they aren’t already, will likely become the caregivers of older patients. “They play a huge role,” says Damle. “Consider them to be part of the healthcare team.”
How valuable these “teammates” can become depends largely on the physician and how well he or she can nurture the relationship. Doctors need to be proactive about their potential relationship with a family member, experts say, starting as soon as a patient walks into the office, either with a family member or without.
Even if a patient, especially an older patient, is alone in the examination room, Glajchen inquires about family, asking, “Did you come here with anyone today?” If there’s a family member in the waiting room, she’ll ask if the patient might want that person in the room, too.
“It is up to the patient,” she says. “Generally speaking, the patient will say yes because they are nervous.” A family member can help a patient absorb information, ask questions, offer emotional support and make sure a physician’s instructions are followed, she says.
If patients come alone, Glajchen asks them if there’s someone helping them with their care or someone at home they might want to be at the appointment. She then asks them to bring that person next time, or she takes advantage of today’s technology.
She says she has brought family members into appointments virtually, using GoToMeeting, Apple’s Facetime and conference calls.
“The physician doesn’t have to feel that it only works if the family member or friend is physically present,” she says.
It’s also important for the physician to query the family member. Glajchen says too many doctors assume that if someone is at an appointment, he or she is ready to take on the responsibilities of caregiving.
Family members might not feel comfortable changing a dressing or lifting a parent out of bed, says Glajchen.
“It behooves the physician to ask the family member if they are prepared and willing-and what we could do to help them feel more prepared to take on those responsibilities,” she says.
These conversations take time, and Bandman knows physicians are hesitant to put even more pressure on their tight schedules. However, an upfront investment of time “saves time down the road in terms of the planning and the execution of the care plan,” he says.
Early, honest conversations with patients and family members not only nurture trust, they give physicians clear knowledge of the patient’s resources and family support. In addition, they can help establish a point person who can communicate with the entire family, saving the physician significant time later.
With a family member engaged and welcomed, the benefits can add up. Physicians will get a deeper, more objective and more reliable family history. They’ll get better descriptions of current conditions and symptoms. They’ll have another set of ears to hear-and later share-information on diagnosis, treatment and medication.
The doctor will have a helper to ensure compliance at home. And, of course, the patient gets invaluable emotional support. “That kind of support, is key to outcomes,” says Bandman.
Promote those benefits, says Damle. He suggests creating a pamphlet for family members-and displaying it prominently in the office-that tells them how important they are, how their opinions are valued and how they are respected members of a patient’s healthcare team.
“I can’t think of any reasons not to involve a family member,” he says. “They can really enrich the conversation. We welcome them, and the more information we can get, the better job we can do.”