The Companion of the Patient in Family Medicine: The Fable of the Painting and the Frame

Primary health care provides the first point of entry for health-care delivery [1-6], with links to higher levels of the health system and other services. Family physicians do not treat diseases but take care of people. Family medicine is the medical specialty which provides continuing, comprehensive health care for the individual and family within the context of community. Providing family-oriented primary care is one of the distinguishing features of this specialty [7-9].

Conventionally, physician training focuses on an encounter between two people: the patient and the physician. In practice, a third person (companion) frequently accompanies a patient during medical encounter [10].

A second adult-usually parents or husband or wife accompanying the patient consultation is always significant and deserves the attention of the doctor. Although many consultations occur only on a patient, others of them involve companions with the patient in the office [11].

Thus, although it is admits that the presence of companion of the patient in the medical office is something common, and he or she is often seen as a family resource to improve the quality and safety of care of the patients, and doctors often assess as positive the presence of companion of the patient, who is usually a family member, but nevertheless reports, reviews or investigations about the presence of a companion of the patient in consultation, are rather scarce in our environment [12].

Family doctors need to understand that the disease process is socially constructed within the patient's life, and they have to mediate between the subjective experience of illness of the patient and scientific explanation. This subjective experience is built in the family context and is expressed in the medical consultation, often with the presence of a companion of the patient, usually family member. But, these concepts can be difficult to understand and explain, even for experienced physicians in the specialty, and in other medical areas. Therefore, it is necessary to achieve a more meaningful representation of the fundamental concepts of Family Medicine, and facilitate the transfer of these concepts to clinical practice [13].

It can understand the presence of the companion of the patient in consultation, as a metaphor from the patient. Metaphors (which include analogies, similes and models) are cognitive tools by which something unknown is understood in terms of something known. Metaphors (models) are central in family medicine [13]. The companion of patient is perhaps his "guardian angel" [14], or he can be understood as a "listening device" [15].

In this context, we have recently had the opportunity to conduct several research studies on this issue, and we would like to present a summary, which can be especially useful to family physicians, with 2 goals:

1. To have a very brief update about the subject of companion of the patient in the consulting room: “what was known or intuited”, “the things that are going knowing”, “what remains to know”, and its “implications for the family medicine practice”

2. To show this update, with an educational approach, through a short fable. The fable is an adult education method that can serve to intuitively understand abstract concepts, by linking them to specific situations, and so to facilitate their assimilation. The fable is a brief written narrative that has a didactic purpose; this means that there is a moral or teaching, and it applies to our life. Most of his characters are animals, but also plants, etc., that think and speak like they were human beings. In the fable you can distinguish two parts: one is the story itself; and the other moral.

The fable of the painting and the frame

Once upon a time which several paintings, same of them accompanied by their framework, went to the family doctor office? That day the family doctor had to visit 30 patients.

The first painting was Mr. Landscape, and he entered to consultation accompanied with a frame that accentuated its image, increasing their colors and appearance. It was a simple, rectilinear frame, as a classic construction. It was a frame whose function was to protect the picture. This was Mrs. Classical Frame, a middle-aged adult, housewife; she was the couple of Mr. Landscape. "This patient, comes with a collaborator companion", he thought the doctor.

The second painting was Mr. Abstract Expressionist, and he came to the consultation unframed because he believed that the framework interferes with the integrity of the paint. "This patient comes unaccompanied”.

Therefore, to this patient not affect the characteristics commonly described for patients with accompanying: they are older, with more chronic diseases, take more drugs, with lower levels of social class, and generate hospital referrals", thought the doctor.

The third patient, Mrs. Portrait, was a painting which came to consultation with a frame "baroque", whose shapes were sculpted and paints, so even exceeded the painting itself. The frame was the husband of Mrs. Portrait, Mr. Frame Baroque, unemployed. "This patient has a companion that is too close to the painting so, that he can 'drown' her, as she cannot 'breathe' well. It could have family problems?” thought the doctor.

The next patient, Mr. Still Life, was a painting who came with a framework which jeopardized the integrity of the paint. "This companion feels guilty, and may jeopardize my intervention on the patient", thought the doctor.

Next patient, Miss Marina, was accompanied by a framework that had illusionistic effects, fooling the eye playing with the real or simulated by means the perspective, the shading and other optical effects, achieving a "heightened reality" or a "replacement reality". "This patient comes with a companion who is the real sick", thought the doctor.

The Next patient was a cubist painting. Mr. Cubist came with a frame complex, which emulated Gothic cathedrals. "This companion of the patient is complex; can be critical or show anger. I must be careful during the interview. This companion could be also non-collaborator. Could be this is an indicator of potential problems in the context of the patient?” thought the doctor. And up to 27 patients. The Last patient did not come. It came the companion instead the patient. The framework was presented alone in the consultation, without his painting. "This companion without the presence of the patient may indicate that I should appreciate to him regardless of his patient, like if the frame was a sculptural work by itself. The presence of companion without patient, that is to say, the companion who go to consultation instead the patient, which is usually family of patient (the likelihood that the patient is present in the consulting room is significantly higher, only when the companion is the husband or wife of the patient), but that is not present in the room, occurs with some frequency has ethical and legal implications ", thought the doctor.

And doctor kept thinking: "The frames have a humble heart. They are not protagonists of the work of art, but a complement of the paintings. Their mission is to reclaim the viewer's attention to a few meters and disappear when it is a few feet of the image. But a wellchosen frame transforms a painting or drawing into something unique, special, and adds value and makes it become a point of visual attention wherever you are. Also, the companion is the reference context or environment more next to the patient. Something likes the "framework" where the patient is. A graphic simile of the different types of companions of the patients is the different types of ‘picture frames’ that accompany the paintings”.

“The way in which the problem is exposed by the companion of patients (most of who are relatives) and who are in different positions in the family and in the social structure, have profound implications for how the family doctor makes the diagnosis (for example, a diagnosis of ‘schizophrenia’ or ‘mentally ill’)”.

“This mean that people give to events in their lives different senses, and how they talk about them is essential to understand the problem and their interactions with other persons. The "triadic" interview (doctor, patient, accompanying person) can be a "therapeutic conversation", since communication here is a wraparound process that gives meaning to the world”, concluded the doctor.

The moral of the fable: Things we know or intuit

Although to the clinicians are not surprise to hear that patients often attend outpatient medical visits with a companion, for example a family member, and it is a common phenomenon in family medicine and others medical areas, and with hospitalized adult patient, it seems to has not been, in general, a topic of interest. Previous research on the communication in medical encounters primarily has focused on dyadic interactions between physician and patient. Consequently, the presence of companion of patient in the medical office, and his implications for medical practice, has been sparsely studied [16,17].

It is unknown exactly what the meaning of consultation with companion of patient. In addition, patients who are accompanied by a family member are likely to be different than patients unaccompanied, in relation to their health problems, functional abilities, family, relationships and attitudes toward family involvement in their care.

An important feature of family medicine is taken into account the companions in attendance of individual patients. The physician-patient relationship is part of the patient's larger social system and is influenced by the patient's family. The context of the patient includes family, friends, work, religion, school, and health resources. Recognition of this context allows the doctor does not see health problems as isolated events but as a response to, or inserted in, life crises, stress, inadequate habits, or family dysfunction [12,18].

The term "companion" can be understood as "an actor on the border," and this refers to both the "place" (in the border of the patient care) and the "process" (triadic relationships doctor-patientcompanion). Also, other metaphor that can be used with the companion of the patient is the "guardian angel" of the patient. Any case, she or he may seem to play a secondary role, but sometimes is the main actor [14].

A patient's family member can be a valuable source of health information and can collaborate in making an accurate diagnosis and planning a treatment strategy during the visit to the office. Accompaniment to medical visits is associated with better self-care maintenance and management, and this effect may be mediated through satisfaction with provider communication. The companions provide company, emotional support; and they have a role in mobility and decision making of the patients. However, their participation often poses challenges [19,20].

It is recognized a forecast value in the presence of a companion: gives information on the severity of the disease: if the companion is concerned, the doctor should be concerned; if the companion pays little attention to the interview, it is normal that the medical problem is mild [21].

The new things that we are know

The visits in which one or more family members are present, are quite common, and their prevalence figures or frequency are ranging from 16% to up to 62%. We found that 24% of the interviews were with companions. This means a moderately high prevalence of the presence of companion, which is present in almost one of every 4 visits, served in Family Medicine. The companions of the patients are usually family members (93% of cases), being a woman in 73%, aged between 21-40 years, and she is the wife in 48%. Our studies reproduce these data, being the companion predominant a middle-aged adult, usually the couple and housewife. We also found that their social availability to be the companion of the patient was predominantly worker in 37%, housewife 27%, and retired 23%. Patients with greater needs are most often come accompanied, which is positive. Those more likely to have a family member present include patients with a low level of health literacy, patients with chronic diseases, older patients, and women. We find similar characteristics: the patients with companion were older women, unskilled, with poly-pharmacy, generate hospital referrals, and with lower levels of social class [22].

Doctors may differ about the most useful behaviors of companions (e.g., information or support) and can have problems during interview (for example the companion dominant or with demanding behavior). It has been reported that the most frequent companion is a collaborator (48%-68%), followed of liabilities-silent observer (29-69%) and intrusive (5%). We found that 45% of companions were "collaborators", a figure in the lower range than previously reported, and with a slight predominance of accompanying "non-collaborators" (55%). This companion "non-collaborator" is a housewife or unemployed with family problems, and accompanies a patient also with family problems. There is an important frequency of the presence of companion "non-collaborator" in Family Medicine consultation; the 50% of the companion of the patients are "non-collaborators" (this means, in short, that the companion becomes an obstacle in communication between the patient and your doctor, and could include any companion who has some of the characteristics of "liabilities", "intrusive", "fastidious", "guilty", "sick", "observer", "critical/ displeased", or "aggressive"), who are housewives or unemployed preferably, and with family problems; on the other hand, the patients who are accompanied for these companions also present family problems [23]. Family doctors may need to use special family interviewing skills for resolving problematic communications, managing conflicts or negotiating common ground during consultations with patients with companions "non-collaborators" [24].

A patient's family member can be a valuable source of health information and can collaborate in making an accurate diagnosis and planning a treatment strategy during the visit to the office. Accompaniment to medical visits is associated with better self-care maintenance and management, and this effect may be mediated through satisfaction with provider communication. Companions provide company, emotional support; and they have a role in mobility and decision making of the patients. However, their participation often poses challenges. Our research group has communicated that the presence of companion of the patient in consultation Family Medicine is associated with a 45% of familiar problems vs. the presence of unaccompanied patient (30% of family problems). The problems in familiar context of the patient were associated with the total number of chronic diseases (risk factor), and higher age is a protection factor. Thus, the presence of a companion, especially with a young patient with chronic diseases, is a sign of family problems [25].

Clinicians may also be aware that it is not uncommon the presence of a companion without the patient or instead of the patient in the consultation of family medicine [26]. It can be assumed that indicates a greater severity of the patient’s biopsychosocial fragility compares to the presence of a companion with the patient; this could have ethical and legal implications of communication with the companion when the patient is not present; and the possible bias of information obtained only from the companion in the family medicine consultation. We found a high frequency of the companions who are attended in the family medicine consultation without the presence of the patient (9% of all visits), so, this increased the ethical and legal implications. There is no relevant difference between patients or companions according to be present or not the patient at the medical office. The likelihood that the patient is present in the consulting room is greater, significantly, only when the companion is the husband/wife of the patient [27].

There is a high prevalence of the presence of companion, which is in almost one of every 4 visits served in Family Medicine (approximately, the 25% of the interviews are with companions). The family members are the most frequent companions of patient, predominating a middleaged adult, usually the couple and is a worker in 40%, housewife in 30%, and retired 20%. The patients with companion are older women, with more chronic diseases, with poly-pharmacy, they generate hospital referrals, and they have lower levels of social class.

The presence of a companion is an indicator of potential problems in the context of the patient. This is found in 45% of the cases the patients with companion vs. 30% in unaccompanied patient,

The 55% of companions are "non-collaborators", that are they predominantly housewives and unemployed persons.

There is a high frequency of the companions who attended the family medicine consultation without the presence of the patient (9% of all consultations), which has ethical and legal implications

The companion shapes the experience obtained by the patient's physician. A second adult accompanying the patient in the consultation is always significant and deserves the attention of the doctor. It is needed achieve communication skills during the interview with the different companions of the patients in family medicine consultation. The (Supplementary Table 1) shows what remains to know, and (Supplementary Table 2) shows some implications for practice. The companion of the patient is an area of family medicine which has received little attention, and their presence may go unnoticed, but their frequency deserves the attention of the physician, who must deepen its characteristics and meanings, "making the invisible visible" in the care of these patients with companions (14).