Types of Companion of the Patient in Family Medicine

The key point of the Family Medicine is that, this is the unique medical speciality that is interested in the people first and in the disease secondly. That is, understanding the patient and his disease based not only on symptoms and signs but in the psychological and social factors relating to patient context. The scope of practice of Family Medicine is not defined by diagnoses or procedures, but by human needs. General Practitioners/Family Doctors are interested in personality, family patterns, and the effect of these on the presentation of symptoms as much as in diseases themselves. The focus is on the patient’s response to the illness rather than on the illness in itself. General practitioners/ Family Doctors are interested in the ecology of health and illness within communities and in the cultural determinants of health beliefs [1-3].


Introduction
The key point of the Family Medicine is that, this is the unique medical speciality that is interested in the people first and in the disease secondly. That is, understanding the patient and his disease based not only on symptoms and signs but in the psychological and social factors relating to patient context. The scope of practice of Family Medicine is not defined by diagnoses or procedures, but by human needs. General Practitioners/Family Doctors are interested in personality, family patterns, and the effect of these on the presentation of symptoms as much as in diseases themselves. The focus is on the patient's response to the illness rather than on the illness in itself. General practitioners/ Family Doctors are interested in the ecology of health and illness within communities and in the cultural determinants of health beliefs [1][2][3].
In connection with all these features of Family Medicine, it is taken into account, in the individual care, the presence of companions of the patients in the medical office [4]. Conventionally, physician focuses on an encounter between two people: the patient and the physician. In practice, a third person (a companion) frequently accompanies a patient during a medical encounter [5]. A second adult -usually parents or a husband or wife -accompanying the patient to the consultation is always significant and deserves the attention of the doctor, because it is a sign that speaks of family and patient context [6].
Besides, routine visits in which one or more family member is present in the medical office with the patient are frequent. Overall, it is accepted that in about 30% of consultations there is a companion with the patient, usually a family member, who can assume important roles in improving the understanding of both the patient and doctor [7,8].
The companion of the patient can be seen as an important element of the health network and social support. Thus, to include the companion could be a viable and practical strategy that can improve adherence and therefore promote better results in the patient, as well as to ensure the understanding of treatment recommendations by patients, achieving the presence of companion with an attitude of collaboration in the consultation, who, besides, can be used to determine the clinical and family history data during the interview. However, cases of "difficult" companions or companions with a not-collaborative attitude require a particular approach to avoid interfering with the development of the clinical interview [9].
Thus, although it 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 *Corresponding author: José Luis Turabián, Family Doctor, Servicio de Salud de Castilla-La Mancha, Centro de Salud Benquerencia, Gadarrama s/n, Toledo 45313, Spain, Tel: +44925154508; E-mail: jturabianf@hotmail.com of a companion of the patient in consultation, are rather scarce in our environment.
In this context, we present a study whose objective was to qualify the companion of the patient as with collaborative attitude or notcollaborative attitude, according to criteria of the professional, and analyze the characteristics associated with these two types of companion, of with the hypothesis that this classification, can not only allow to the doctor figure out whether there may be difficulties or problems in clinical interview with the companion and patient, to prevent or solve them, but also if there are relevant variables associated to consider, as explanatory of these types of companions of the patients.

Materials and Method
An observational study, which included patients of both sexes over 14 years was conducted in a Family Medicine office which has a quota of 2,000 patients (In Spain family doctors attend patients over 14 years old). The sample size for a hypothetical percentage of exposed individuals in group 1, of 30%, and a hypothetical percentage of exposed individuals in group 2 of 60%, with a confidence interval (two sides) of 95%, with a power of 80%, and with a sample size ratio of 1:1, was calculated. The sample size was of 88 individuals, 44 cases and 44 controls [10].
This study was part of other larger one, in the same line of research, about companions of the patients in the Family Medicine office [7].
From randomly chosen day for 15 consecutive days, from 26 November 2015 to 18 December 2015, the visited patients were included, and data from the companions with patients and from the companions without the presence of patients at the office, were collected. Companion was defined as any person who accompanied the patient in the consulting room or that consult instead the patient. Patients were included only one time. Thus, were excluded the repeated consultations of same patient, including only the first visit. If the patient had two companions only was included the data from the first of them in analysis.
For each patient and companion the following variables were collected: type of companion classified as "collaborator" and "noncollaborator" according to the definition given in Table 1 [9,11,12] from the decision of the usual doctor in the medical office, and who remains in the same consultation for over 25 years, age, sex, chronic disease (defined as "any alteration or deviation from normal that have one or more of the following characteristics: is permanent, leaves residual impairment, is caused by a non-reversible pathological alteration, it requires special training of the patient for rehabilitation, and/or can be expected to require a long period of control, observation or treatment") [13] and classified according to International Classification of Diseases (ICD-10) [14], taking medication, collecting the therapeutic drugs group, classified according to ATC code or system Anatomic Classification, Therapeutic, Chemical [15], sick leave of the patient, the problems in the family context (based on the genogram, and valued by the family doctor who performed the genogram at the past time, by viewing the family scheme (the genogram, schematic model of the structure and processes of a family, included the family structure, life cycle when that family is, the important life events, family resources, and family relational patterns) [16][17][18][19], social-occupancy class, according to the Registrar General's classification of occupations and social status code [20,21] if the analytical or imaging test was requested for the patient, if the patient needs a consultation with the specialist, the companion relationship with the patient, and the social availability of companion in relation to the patient.
A Microsoft Excel® file was built, and the IBM SPSS Statistics for Windows, Version 18.0. Armonk, NY: IBM Corp software was used [22].
Descriptive data, which were expressed by standard measures of central tendency and dispersion, were obtained. The bivariate comparisons were performed using the test of chi-square, with Yates correction when it was pertinent, for the percentages, the Student t test for the mean, exact probability Fischer, and the Mann-Whitney test for comparing means in variables with nonparametric distribution.
The informed consent of all patients or their guardians for using of data in research was obtained.
In the comparison between companions "collaborators" and companions "non-collaborators", the results were only statistically significant, and for the companions "non-collaborators", the following: more family problems and fewer workers, and students, and more housewives and unemployed ( Table 2; Figures 2 and 3).
In the comparison between patients with companions "collaborators" and patients with companions "non-collaborators",

"Collaborator"
Helps the doctor spontaneously and with respect, gives relevant information about the patient and adopts a position of responsibility in the therapeutic process. Notes the doctor's instructions. He or she asks questions. Explains the doctor's instructions to the patient "Non-collaborator" When he or she meets any of these criteria: 1.-He or she generally it remains in the waiting room. is not involved or does poorly in the development of clinical interview 2. He or she participate excessively actively in the interview, so he or she gives answers by the patient. instructs the doctor or induces responses in the patient. He or she Interrupted the doctor-patient relationship 3. He or she feels guilty about their inability to provide a certain level of care that are necessary for the patient, but that would require major changes in lifestyle of companion 4. He or she projects his symptoms on the patient. The companion is actually the real sick, and reflects their anxieties and demands on the patient 5. He or she ago criticism of a thing, especially for improvement. He or she can show anger, disgust or anger 6. There are verbal or physical aggression were found with statistically significant difference, and for patients with companions "non-collaborators" more family problems (Table 3).
In short, the companions of the patient classified as "noncollaborators" have more family problems, and are more housewives and unemployed. And patients with companions "non-collaborators" have also more family problems. Therefore, the companion "noncollaborator" is a housewife or unemployed with family problems, and accompanies a patient also with family problems.

Discussion
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 doctorpatient-companion). 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 [23].
Doctors often assess as positive the presence of a companion in the consultation. But the ability to find and understand why a patient and his or her companion come for help and advice, and agree with them decide what to do, requires in the family doctor technical skills, but also communication skills. Thus, the presence of family members (companions of the patients) in the office visit creates opportunities and challenges for health: it allows to talk to the patient and family about their family history and context, and this knowledge of the family context by the doctor may be important for decision-making and implementation of therapeutic measures; but also it can lead to barriers and difficulties.  Table 2: Comparison between companion's "collaborators" and companions "non-collaborators".  The patient need a consultation with the specialist 12.8% 19.6% 0.42 Table 3: Comparison between patients with companions "collaborators" and with companions "non-collaborators".
It has been described some types and characteristics of the companions from the point of view of medical professional ("collaborator", "passive", "intrusive", "ill", "observer", etc.). It has been reported that the frequency of companion "collaborator" in the medical office is among 48% to 68% of the companions [8,[24][25][26]. But it has also been reported that most of the companions remained passive and did not contribute to the physician-patient relationship [4], and the interference in the doctor-patient relationship is often neutral [27]. 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%). On the other hand, the family members are the most frequent companions of patient in the office [9], and we find that the companion "non-collaborator" is predominantly housewife and unemployed person (Table 2; Figure 3).
The companion can be an ally if we need it, or it can be "a problem". But what would be a bad companion of the patient? We have considered as such to him who, in short, becomes an obstacle in communication between the patient and your doctor (Table 1), we have listed as companion "non-collaborator" to any companion who had some of the characteristics of "liabilities", "intrusive", "fastidious", "guilty", "sick", "observer", "critical / displeased", or "aggressive" (Table 4) [9,23].
We must consider several potential limitations of our study: 1) classification of companions is from the point of view of the medical opinion; 2) the decision by the physician was subjective and not triangulated among several observers; and 3) any social general variables were collected, and they may have influenced the results (during the dates of the study, in Spain there was an economic crisis, which resulted in socio-health restrictions, which could have an impact on the general attitude of persons, including companions of the patients in medical consultation); and 4) also personality factors of the doctor, which were not collected, could influence the doctor's decision about the attitude of the companion, although it has been reported that specific interpersonal behaviours will lead to no modify of quality of care [28], but, physicians need to be conscious their own characteristics and perceptions influence the quality of care delivered to their patients [29].
We must not forget that the presence of the companions of the patients can influence the clinical exposed by the patient in the consultation. It is not just the same the diagnosis of a cough with or without a companion and as this "collaborator" or "non-collaborator" or if he or she is the spouse, children, mother, etc. of the patient. The companion 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 assertiveness or empathy, maintain control, avoid the appearance of a conflict, to perceive the need of 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 and safety [23].
With experience, the doctor can become familiar with companions and can use them for the benefit of the patient achieving a "good consultation". Knowing the type of companion, the family doctor could rely on him or her and use them as a "bridge" in the case of companion "collaborator", for involving them in the intervention, or avoid interference in the course of the clinical interview in the case a companion "non-collaborator" [30].
This study is part of other in the same research line, which showed that the presence of companion of the patient in consultation Family Medicine is associated with the existence familiar problems vs. the presence of unaccompanied patient [7]. Our actual study supports the existence of family problems in the companions "non-collaborators" (Figure 2), and patients with companions "non-collaborators" ( Table 2).
Future research can be centred on replication of this study in different medical and socio-economic contexts, to obtain data on the invariability of our results.
In summary and conclusion: • There is an important frequency of the presence of companion "non-collaborator" in Family Medicine consultation.