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Types of Companion of the Patient in Family Medicine | OMICS International
ISSN: 2380-5439
Journal of Health Education Research & Development
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Types of Companion of the Patient in Family Medicine

José Luis Turabián1*, Luis Enoc Minier-Rodriguez2, Sandra Moreno-Ruiz2, Francis Eliant Rodriguez-Almonte2, Raul Cucho-Jove2 and Alejandro Villarin-Castro3

1Servicio de Salud de Castilla-La Mancha, Centro de Salud Benquerencia, Gadarrama s/n, Toledo 45313, Spain

2Family Medicine and Community, Health Center Santa Maria de Benquerencia, Toledo, Spain

3Teaching Unit of Primary Care and Community, Primary Care Management, Toledo, Spain

*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: [email protected]

Received date: August 29, 2016; Accepted date: September 15, 2016; Published date: September 19, 2016

Citation: Turabián JL, Minier-Rodriguez LE, Moreno-Ruiz S, Rodriguez-Almonte FE, Cucho-Jove R, et al. (2016) Types of Companion of the Patient in Family Medicine. J Health Edu Res Dev 4:186. doi: 10.4172/2380-5439.1000186

Copyright: © 2016 Turabián 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

Objective: To know the frequency and characteristics of the types of companions of the patients, classified as “collaborators” and “non-collaborators” from the point of view of the doctor, and to compare them to assess whether there are relevant variables associated to take into account and for preventing difficulties in the clinical interview. Material and methods: An observational and analytical study, which included patients of both sexes over 14 years. For each patient and companion the following variables were collected, among others: type of companion classified as “collaborator” and “non-collaborator”, age, sex, chronic disease, taking medication, sick leave of the patient, the problems in the family context, social-occupancy class, the companion relationship with the patient, and the social availability of companion in relation to the patient. Results: 45% of companions of the patients were “collaborators” and 55% were “non-collaborators”. In the comparison between companions “collaborators” and companions “non-collaborators”, the results were only statistically significant, and for the companions “non-collaborators”, for more family problems and fewer workers, and students, and more housewives and unemployed. In the comparison between patients with companions “collaborators” and patients with companions “non-collaborators”, were found a statistically significant difference, for patients with companions “noncollaborators” for the presence of more family problems. Conclusions: We found a slight predominance of the companions “non-collaborators”, 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. If the family doctor knows the type of companion could strengthen the relationship in the case of companion “collaborator” and avoid interference in the course of the clinical interview in the case of a companion “non-collaborator”.

Objective: To know the frequency and characteristics of the types of companions of the patients, classified as “collaborators” and “non-collaborators” from the point of view of the doctor, and to compare them to assess whether there are relevant variables associated to take into account and for preventing difficulties in the clinical interview. Material and methods: An observational and analytical study, which included patients of both sexes over 14 years. For each patient and companion the following variables were collected, among others: type of companion classified as “collaborator” and “non-collaborator”, age, sex, chronic disease, taking medication, sick leave of the patient, the problems in the family context, social-occupancy class, the companion relationship with the patient, and the social availability of companion in relation to the patient. Results: 45% of companions of the patients were “collaborators” and 55% were “non-collaborators”. In the comparison between companions “collaborators” and companions “non-collaborators”, the results were only statistically significant, and for the companions “non-collaborators”, for more family problems and fewer workers, and students, and more housewives and unemployed. In the comparison between patients with companions “collaborators” and patients with companions “non-collaborators”, were found a statistically significant difference, for patients with companions “noncollaborators” for the presence of more family problems. Conclusions: We found a slight predominance of the companions “non-collaborators”, 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. If the family doctor knows the type of companion could strengthen the relationship in the case of companion “collaborator” and avoid interference in the course of the clinical interview in the case of a companion “non-collaborator”.

Keywords

Companion; Family; Physician–patient communications; Caregivers; Family practice; Physician–patient relations

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 [1-3].

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 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) [16-19], 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.

Type of Companion Definition
"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

Table 1: Definitions of the type of companion.

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.

Results

During the 15 days of data collection, a sample of 104 companions, of whom 47 (45.2%) were “collaborators” (Group 1) and 57 (54.8%) “Non-collaborators” (Group 2) was obtained (Figure 1).

health-education-research-development-Companions-patients-collaborator

Figure 1: Companions of the patients as “collaborator” and “non-collaborator”.

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).

health-education-research-development-patients-problems-familiar-context

Figure 2: Companions of the patients as problems familiar context.

health-education-research-development-Social-availability-companions

Figure 3: Social availability of companions of the patients.

  n=104
Types of Companion “Colaborador”
n=47 (45.2%)
“Non-collaborator”
N=57 (54.8%)
Significance
Age in years of companions 50.60 ± 15.52 52.88 ± 13.13 0.43
Companion female 72.3% 54.4% 0.07
The companion relationship with the
patient
Mother 19.6%
Father 4.3%
Brother 2.2%
Another familiar 2.2%
Friend 2.2%
Son 26.1%
No family member 2.2%
Husband / Wife 41.3%
Mother15.8%
Father8.8%
Brother 0%
Another familiar 3.5%
Friend 0%
Son 28.1%
No family member:0%
Husband / Wife 43.9%
0.76
Chronicdisease in companions 1.86 ± 1.64 2.13 ± 1.44 0.28
Medications taken by the companion 1.67 ± 2.45 1.85 ± 2.05 0.31
Problems familiar context of the
companion based on the genogram
28.6% 61.8% 0.002
Social-occupancy class of patients     0.105
-Highermanagerial 0% 0%
- Intermediate 5% 1.9%
-Specialized 2.5% 5.6%
-Workersmanuals 12.5% 5.6%
-Semiskilledworkers 20% 22.2%
-Unskilledworkers 50% 64.8%
-Students 10% 0%
The social availability of companion Workers 40.9%
Retired 25%
Students 9.1%
Housewives 25%
Unemployed 0%
Workers 33.9%
Retired 21.4%
Students 0%
Housewives 28.6%
Unemployed 16.1%
0.009

Table 2: Comparison between companion’s "collaborators" and companions "non-collaborators".

In the comparison between patients with companions “collaborators” and patients with companions “non-collaborators”, were found with statistically significant difference, and for patients with companions “non-collaborators” more family problems (Table 3).

  n=103 (One patient has two companions. but only it is included the first of them in data analysis)
Types of Companion “Collaborator”
n=47 (45.6%)
“Non-collaborator”
n=56 (54.4%)
Significance
Age in years of patients 53.33 ± 22.87 54.18 ± 22.54 0.851
Patientfemale 61.7% 58.9% 0.841
Chronicdisease in patients 2.26 ± 1.35 2.43 ± 1.62 0.73
Medications taken by the patient 2.83 ± 3.03 2.89 ± 2.83 0.74
Patientswithsickleave 12.8% 12.5% 1
Problems familiar context of the
companion based on the genogram
29.5% 60% 0.004
Social-occupancyclass of patients     0.14
-Highermanagerial 0% 3.6%
-Intermediate 0% 0%
-Specialized 6.8% 1.8%
-Workersmanuals 11.4% 3.6%
-Semiskilledworkers 9.1% 21.8%
-Unskilledworkers 56.8% 58.2%
-Students 15.9% 10.9%
Analytical test was requested for the patient 2.1% 5.4% PeF=0.62
Imaging test was requested for the patient 0% 1.8% PeF=1
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".

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.

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 [8,24-26]. 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].

Types of Companion Example
Collaborator” Carmen accompanies his elderly father to consultation. She is attentive to the development of the consultation. her mobile phone off, she helps his father to disrobe, helps interpret what was said by the doctor, asks questions of what does not understand, but without judging or putting into question the medical analysis ...
Non-collaborator” Passive:
Albert, 20, accompanies her mother. and enters to medical office reading a magazine, without be aware or participate in the analysis of the situation during the consultation.
Intrusive:
Maggie, 53, comes to the office with her sister, Katy and her father 80 years. Katy anticipates the responses of Maggie, and both sisters make her own query to the doctor, interrupting the course of the conversation. The words of Maggie and Katy are mixed together during conversation.
Annoying:
A middle-aged couple is in the office. Consultation is for him. but the wife interrupted the interview and insists that "he should tell everything to the doctor..., because to her husband really likes chocolate,And it is why he has high cholesterol "...
Guilty:
"Doctor, you have to do something!" -said the companion (while crying), he is a dependent elderly with dementia...
Sick:
Ann, 23, has irregular menstruation for years. The visit is done with her mother, who is leading the roost in the interview. The mother asks to doctor a referral to the endocrinologist and analysis for her daughter. Mother and daughter are anxious both and asks for information on the scope of diagnoses. The mother also used the consultation to show to doctor her visit she made to ENT ...
Observer:
Laura, 37, has congenital pulmonary atresia. She is accompanies for her husband. Kerry. He sits down something away from Laura and from doctor, and he makes drawings during the consultation. speaks little in the query. but is alert and concentrated...
Critical / Angered:
Sarah, 54, and her sister Victoria, 51, entered to the office. They were serious. Victoria did not want to sit. "I am very upset because not you treated to my sister, after the first X-ray…"
Aggressive:
William, 79, presented his second stroke a month ago. He walks and talks with difficulty; he need help for the tasks of daily living; he is incontinent urinary, and is developing dementia. Now comes at office Roselyn, his wife, "He has more fatigue", said Roselyn. "I can no longer with this situation. All this suffering...". The doctor gives to Roselyn a letter to go hospital with William. She throws down the paper, gets up from the chair and throws it against the ground ...

Table 4: Examples of different types of companions according to physician.

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.

• The companion “non-collaborator” is a housewife or unemployed with family problems, and accompanies a patient also with family problems.

• This study reinforces previous findings that associate the presence of companion of the patient in the consultation with family problems.

• The family doctor should look at the companion and classify in one of two typological groups (“collaborator” and “noncollaborator”). This can allow that the doctor thinks whether there will be difficulties or problems in clinical interview with the companion and patient, for preventing them or solve them, and in the case of companions “non-collaborators” who are housewives or unemployed, be aware that there is a high probability of the existence of family problems (explicit or covert), and intervene appropriately if necessary.

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” [31].

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