The Companion of the Patient in the Family Doctor's Office: Making Visible The "Guardian Angel"

Turabian JL^1* and Perez-Franco B²

¹Family and Community Medicine, Health Centre "Industrial Park", Regional Health Service of Castilla la Mancha (SESCAM), Toledo, Spain

²Family and Community Medicine, Health Centre "The Station", Talavera de la Reina, Regional Health Service of Castilla la Mancha (SESCAM), Toledo, Spain

*Corresponding Author:

José Luis Turabián
Specialist in Family and Community Medicine, Health Centre "Industrial Park"
Regional Health Service of Castilla la Mancha (SESCAM), Toledo, Spain
E-mail: jturabianf@hotmail.com

Received date: June 23, 2016; Accepted date: July 18, 2016; Published date: July 22, 2016

Citation: Turabian JL, Perez-Franco B (2016) The Companion of the Patient in the Family Doctor's Office: Making Visible The "Guardian Angel". J Community Med Health Educ 6:453. doi:10.4172/2161-0711.1000453

Copyright: © 2016 Turabian JL, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

The companion of the patient is his "guardian angel". She or he may seem to play a secondary role, but sometimes is the main actor. Each person has his "guardian angel" and so there is a high prevalence/frequency of occurrence of companion in the family medicine office, which is about 25% of patients seen, and what is most striking, the companion is in the office, without patient, in 40% of the visits. In this situation it is important that the family doctor is careful and be aware of the "guardian angel" of each patient, in order to "make the invisible, visible". This "angel" –companion- can have different shapes, and his presence can be felt more or less clearly, but is constantly giving messages in the interview, which becomes a triad, and his presence can be an aid to the diagnosis and treatment. Some cases about the presence of a companion in the primary care consultation are presented: the partner companion, the companion who comes in place of the patient (absent), the intrusive, the observer companion, and the sick one. The family members are the most frequent companions of patient in the office, and therefore we have to create a model of practice, for all patients, family oriented. A second adult, usually the husband or wife or parents who accompany the patient in the office, is always important and deserves the attention of the doctor. The presence of family members in the office visit creates opportunities to the family doctor who can talk to them about their family history and context, and this knowledge can be important for decision-making and for therapeutic measures.

Keywords

Companion; Family health; Caregivers; Family practice; Office visits; Physician-patient relations; Metaphors

Introduction

"See, I am sending an angel ahead of you to guard you along the way and to bring you to the place I have prepared”. Exodus 23, 20 [1].

Ángelos - "messengers" - is an ancient Greek word from which our modern "angel" derives. The angels are often depicted as messengers of the Almighty in the Hebrew Bible, Christian Bible and the Koran, and this has always been their first function (messengers, envoys). The traditional christian belief is that we all have a guardian angel that cares us about physical, moral and spiritual dangers, and intercedes for us when faced with the Almighty.

The patient's companion is his guardian angel. Each person can have his "guardian angel" and so there is a high prevalence/frequency of the presence during the consultation of family medicine!, which is about 25% of patients seen, and what is most striking, the companion go alone to the office, without the patient, around 40% of the time. The interview with relatives of the patient is essential in family medicine, but little is known about this process [2]. The presence of family members in the office visit creates unique opportunities and challenges for the doctor in the interview the patient [3].

Although many consultations occur on a patient only, there are often other with companions. Angels are not seen; the family doctor may not "see" the companion. But it is important that the doctor is alert and aware of the "guardian angel" of each patient. He may appear in different ways, and his presence can be felt more or less clearly, but constantly being given messages in the interview, and thus becomes a triad. It is important that when our patient passes into the office, we use a few seconds to observe the companion. He will tell us much information. Even though we do not know what he has transmitted. Thus, an important feature of family medicine is taken into account the companion. A second adult -usually parents or husband or wifeaccompanying the patient consultation is always significant and deserves the attention of the doctor [4,5].

The companion can be defined as a "minor character". But as in many classical paintings with angels, some "important people" appear in them; for example, the Virgin and Child, Saint Joseph, etc., and may be that the angel is secondary. But these angels, although they are in the dim background of the picture, are often the main character. One could generalize that the companion or the context of the patient- is the main actor. This is critical to contextualize assistance. And we have not to neglect the information that we can bring if we want working in a bio-psycho-social framework [6,7].

It is known that the guardian angels have several tasks: guide us, give us protection, inspiration, company, give advice, intercede for us, clarify our intellect, so that we can better grasp the truth, assist us in disease, etc. Similarly, the companions of patients, those guardian angels, have several functions: give information on the severity of the disease, prevent anxiety, build trust, promote the production of more information about the patient, family and context, helps family dialogue, aid to decision-making, improves satisfaction, implies a value as carers of the sick, provides support, and improves patient health outcomes. These positive effects appear to be particularly valuables for older people who are usually perceived as more vulnerable, the sickest, the oldest and those with less education [4].

Although most angels are "good", there are rebel angels that were cast out of heaven with Lucifer. Thus, the companion can be an ally if we need him, or it may be "a problem." There are aggressive companions. And there are affectionate companions. The triadic communication in medical encounters can be useful, but it is difficult [8]. With the experience the doctor can become familiar with them and can use them for the benefit of achieving a "good practice."

How the companion communicates with the doctor and patient? As the guardian angels, companions can differ greatly in their participation [9], and they can choose different ways to communicate and give messages with the family physician. It is important that the doctor be careful and be aware that each companion is seeking ways to make their presence felt, and is constantly giving messages. The companions can speak loudly with loud and powerful voice- when they believe that the doctor needs to know unequivocally something important about the patient, or have a special message to give to the doctor. The companion can talk quietly gently, like a whisper, or through non-verbal communication [10]. These messages are usually strong and clear, despite the silence in the consultation. The companion can speak through indirect messages: suddenly his eyes rest on an object, or are open when a certain word is spoken in the interview, or there is a smile at any given time; the doctor immediately feels it's a message or a reply. Also, the companion can talk to the doctor through their patterns of behaviour over time.

Case Reports

Some examples of the variants of companion of the patients in the family doctor office are shown in Boxes 1-5.

How can the “companion type” be described? The most frequent companion is the collaborative woman. But, there are many different ways to describe or represent angels. In classical paintings, the angels differ significantly in their shape, colour, tactile properties; their expressions of emotions are different and thus provoke us in various ways, etc. [11]. Some types and characteristics of the companions have been described from the point of view of the doctor (associate, passive, intrusive, ill, observer, etc.). There are different situations that may occur in the office when the patient comes with a companion. But, perhaps, a "companions type" could be described. These usually come behind the patient. They sit outside the main line of conversation. And they usually listen. Preferably are women. Often they are quiet when the patient explains, and when the doctor speaks. They know what their role is. They are not intensely involved in the interview, at least verbally. In the end, they salute to the doctor, and leave.

• As in the classifications of angels, regarding the companions of the patients, there is no consensus. Some authors suggest four variants of the "companions type" that seem to be the most important:

• The female patient that comes with male and active companion, who is involved in the interview. His presence means usually a support force. The companion gives seriousness and notoriety to the interview. It means "you must listen to me because this is important". Often this companion appears when we have a mistake in a decision either therapeutic or diagnostic. Aggressiveness is palpable. The empathy and assertiveness must be used and we have to maintain control.

• Patient young, with a middle-aged adult woman companion who is the mother. The patient (male or female), usually does not speak; the mother acts as if she were the patient, explaining with great detail the symptoms. Although you ask her to be quiet, this will be not effective. In this case, the patient does not look to the doctor; the patient gives all power to his mother, who also uses the query to count more medical problems, whether they are problems of her or of your child.

• A couple. He is a middle-aged patient with his wife. The man explains his symptoms. For each symptom, the woman explains these symptoms as more serious. She works highlighting or aggravating every sentence spoken by him. Usually it is a sign of alarm. It is typical in patients who do not often go to the office. They require a study of their condition, because otherwise we run the risk that he not to come again, and we lose the patient.

• The lone companion. She or he comes alone. The companion tells us about data or symptoms or problems that the patient does not know. So, we are alert when the patient is in the office. These companions usually are women. The patient has a pathology of which he is unaware. It can be a toxic dependence, alcohol or other drugs, or cancer, or dementia. The aim of this visit is that we know that the next query will be the companion with the patient. And in this next visit, the companion will be silent. Then the doctor "shall" conduct the interview to the patient towards the problem that has been told, even if the patient brings other else.

However, with the companion, as with the angels, there are many variants - even there are angels with only head and wings - and other classifications could be:

a) The collaborative companion: it is the most common type, assuming about 70% of companions. She or he helps the doctor spontaneously and with respect, providing relevant information about the patient and adopting a position of responsibility in the therapeutic process. Here the role of the companion is essential not only to contain emotionally, but also for listening carefully and, if necessary, take note of the doctor's instructions.

b) The passive companion: it is common in men; he does not involved or barely in development of the interview. Sometimes he remains in the waiting room without entering the office, although usually greets the doctor when the patient leaves the office.

c) The intrusive companion: he participates actively in the interview, so that often interrupts to the patient, inducing the answers or even pretending to instruct to the doctor.

d) The pathological sick companion: she or he projecting his symptoms on the patient, trying to solve his own fears, doubts or demands. The companion is the real patient, reflecting his anxieties and demands on the patient. This situation is extremely common in paediatric offices.

e) The observer companion: it is the role that the child takes accompanying his parents to the office, or the companion male adult partner.

f) Two companions for one patient or one companion with two patients: as with angels, where it is extremely rare to find a painting with two adults angels, it is rare that occurs two or more companions with the same patient or a companion for two different patients -for example, his mother and daughter-, but it happens sometimes!

Box 1

Case 1: The sick companion

Iphigenia, 91 years presents a colon cancer and liver metastases diagnosed recently. Her daughter, Siringa, 57 years, goes to the office.

-"Doctor, we do not tell her. It is for that does not affect her... She has changed the character: she is continually angry ... She makes me get up at midnight ... I can not anymore ... I hurt my arm, and neck, and head ... and this fatigue and nerves ... I do nothing but cry ...”

Iphigenia is a sick dependent that is living with her daughter. Siringa, is separated, unemployed, with a new partner, and with emotional and financial problems. The companion is actually the real sick, and she reflects her anxieties and demands on the patient.

Box 2

Case 2: The intrusive companion

Proteus, 25 years, comes to the office with his mother, Diorita, 66 years. Proteus filed a school delay and now takes an electronics course. The mother is speaking; she is the leading voice in the interview:- "He has many exams and yesterday was very nervous ... His father refused to join us and we went for a walk he and I ... but he was so nervous, so I took him to the emergency room ... And was prescribed this ..." (Sample a box of Lorazepam).

The mother asks the doctor for her son a referral to the psychologist and analysis. Mother and son are anxious, but he does not speak; looks away. The mother also shows to the doctor the results of a visit that she made to ENT... Diorita has 2 children, the oldest 35 years living alone, and Proteus staying with parents. Diorita's husband has, according her, "strange behaviours with acute sudden anger." Diorita is closely linked with Proteus.

Box 3

Case 3: The contributor companion

Malbina, 50 years, accompanies her elderly mother to the office. She presents a venous leg ulcer. Malbina is attentive to the development of the consultation, the mobile off, helps her mother to undress, she helps interpret what was said by the doctor. She asks questions of what they do not understand. She helps with documents that the patient carries in her wallet. Malbina helps to describe the situation and she is attentive to the guidelines:

- "Doctor, the ulcer has increased rapidly these days, with more pain."

- "So, what I to do to cure it at home and how monitoring will be done?"

She helps the doctor spontaneously and with respect, gives interesting information about the patient and adopts a position of responsibility in the therapeutic process. She notes the doctor's instructions. She asks questions. She explains doctor's instructions to the patient.

Box 4

Case 4: The passive companion

Adan, 20 years, accompanies his mother (who has a headache), and enters to office reading a magazine, and he is unattended or without participate in the analysis of the situation during the consultation.

- "Adan, turn off the phone", says his mother.

- "Whatever you want" (continues with the device)

To other comments of the mother or the doctor:

-"Does not matter"

- "Since you prefer"

-"Okay..."

This companion is more common in males. Sometimes he remains in the waiting room. He is not involved in the development of the clinical interview.

Box 5

Case 5: The observer companion

Mara, 40 years, with pulmonary atresia, migraines, and anxiety, and a 16 year old son with attention deficit hyperactivity disorder, is in the office because of an abdominal pain, and she is accompanied by her husband, Orion, 40 years, unemployed. Orion sitting away from Mara and the doctor, and he makes drawings during the consultation. He speaks little in the office, but is alert, and when he asks or when intervenes, proves to be very attentive to the course of the interview and very knowledgeable about the issues:

- "Yes, we know that they can be influenced by psychological factors."

- "Specialists never are agree, look for example the childhood vaccines that are different in each region."

Mara has chronic feelings of frustration, isolation, inadequacy and guilt. Also she has limitations of daily life. The Orion presence is puzzling in the interview. It seems that Orion also remains to be a distant observer about the usual feelings of Mara. Orion seems that attends to consultation only to check for proper development.

Conclusion

The companion is a metaphor of the patient and his family. Similarly that metaphor can be useful to explain the work of the family doctor [12], also may be useful to explain the meaning of companion of the patient. Metaphors enable us to understand something that is unknown in terms of its familiarity. For this reason, they are used frequently in all sciences that adopt common words to name complex realities. The metaphors are analogue devices, used to illuminate reality. Metaphors can simplify expert knowledge, not by ignoring or reducing the inherent complexity, but by providing a point of entry for its comprehension. They are a means of generating ideas, promoting creativity, and constructing concepts and theories. Thinking based on metaphors and comparisons is a way of transforming a concept into something that is so suggestive, interesting, and surprising, that it reaches people more easily.

Family doctors have to look at the companion. It is, as the painter Paul Klee said: “to make the invisible visible" [13]. The family doctor has to capture the impression of the landscape and the characters, including shaping the scene [14]. The family doctor has to contextualize to understand and improve his diagnostic and therapeutic decisions. A second adult, usually the husband or wife or parents who accompany the patient in the office, or instead of the patient, it is always important and deserve the attention of the doctor. Family members are the most frequent companions in patient consultation, and they have different roles [15], and therefore we have to create a practice model, for all patients, family oriented [4]. The companion of the patient could be an actor more in care management model in the primary health care system with the purpose of creating a strong cooperative and collaborative “team” among of physicians, care managers, specialists, patients, and companion of the patient [16].

The presence of family members in the office visit creates opportunities to the family doctor, fosr example can talk to the patient and family about their family history and context, and this knowledge can be important for decision-making and implementation of therapeutic measures [17]. Moreover, the fact of the high prevalence of companions leads us to consider the ethical aspects of consultation, mainly confidentiality when talking to family members about the disease of an adult.

Being aware of the companions of the patient, using the classification "Guardian Angel" presented here can be useful to the doctor. The accompanying affects communication between doctor and patient, and it can give us a forecast about the consultation. The companions can help the doctor to decide how to handle the interview: use more or less assertive or empathy, maintain control, avoid the appearance of a conflict, to perceive the need a study of patient pathology, etc. The companion will be an obstacle in communication between patient and doctor, or a great help for physicians to improve patient compliance [4,5].

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