Am Fam Physician. 2007 May 1;75(9):1306-1310.
Family physicians encounter patients with a broad array of medical problems. The bio-psychosocial model encourages us to explore the impact of these problems on patients' abilities to function within daily spheres of life—family, friends, work, and school—to help them effectively.1 When stressors exceed patients' coping skills, their functional capacity becomes impaired, and they seek our attention. Arguably, the patient's most important resource is the family.2 Family is broadly defined as the group that helps the patient function. Taking steps to involve the family in the patient's care is particularly important. Time constraints, problem complexity, and lack of training often limit the extent to which family physicians recognize the importance of the patient's family and intervene successfully.3 In this editorial, we discuss ways of engaging the family that are based on the biopsychosocial model, patient-centered interviewing, and family therapy.4
Many medical problems (e.g., substance abuse, sexual problems, chronic illness) naturally involve the family. Other situations, such as initial patient encounters, hospitalizations, and well-child visits, present an opportunity for family physicians to engage the patient's family more proactively. For example, caring for an elderly patient who is overwhelmed with numerous medical problems compels the need to invoke the family. It has been shown that most patients prefer that physicians involve their families in their medical care.5 Because family members often accompany patients to office visits, we can take initiative in convening the family. With the patient's consent, physicians may contact key family members to share information, invite them to participate in follow-up visits, and brainstorm with them to help solve a problem.
Family members can share impressions of the patient's functioning at home and the effect of limitations on the family as a unit. This process provides an opportunity for the patient, family, and physician to hear each other's perspective and establish common ground. Among the many skills used to engage the family, perhaps the most important may be empathy. Empathy invites us to put ourselves in the shoes of the patient and the family and to convey our emotional understanding of their problems. Empathy also enhances patient satisfaction and increases the likelihood that patients and families will adhere to our recommendations.6
As we engage the patient's family, differences among family members can become apparent. Such differences produce a variety of emotions (e.g., anxiety, anger, sadness) that can lead to conflict and separation. Managing these emotions can be challenging, especially when multiple members of the family are present. Family members must know that they are being heard, understood, and acknowledged without being dismissed.7 Navigating the family's participation in this type of dialogue involves several skills designed to build connection. These skills include active listening, validation of thoughts and feelings, and bridging differences by finding similarities.8 Promoting this type of communication entails repeated effort and adequate follow-up.
When the complexity of a problem exceeds the physician's resources, referral to a mental health specialist is indicated. It is important to remember that the referral process can be perceived by patients as highly impersonal. For some patients, this referral may signify their physician's lack of interest and reinforce their sense of despair. Conversely, making a referral can convey concern for the patient and significantly enhance the patient-physician relationship. The physician can model the importance of acknowledging limitations and asking for help while renewing commitment to the patient and family. Occasionally, the referral process may fail to satisfy the patient's needs and adequately help the family. Arranging follow-up visits to reevaluate the patient's status, explore the effectiveness of the consultation, and provide continuing support can add to the sense of trust and collaboration essential for counseling to be effective.9
Throughout this process, working with the family can present multiple challenges. One consideration is the role that culture plays in shaping the beliefs, attitudes, and behaviors of the patient and physician. Cultural norms often influence the extent to which families participate in a patient's care. At the same time, they may limit the willingness of physicians and patients to involve the family and explore feelings and beliefs. Recognizing this reluctance and exploring its meaning in culturally sensitive ways is critical. Another consideration is the need to respect confidentiality and adhere to the Health Insurance Portability and Accountability Act.10 Patients may not wish to discuss or allow family members to learn certain information. Therefore, the physician must know the patient's preferences and obtain permission to share information accordingly.
In conclusion, it is important to recognize the patient's family as an invaluable resource. Engaging the family is a complex process that can bring satisfaction to both the patient and the physician. Indeed, perhaps our most important resource is sustaining our continuing relationship with our patients and their families.11
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7. Lang F, Marvel K, Sanders D, Waxman D, Beine KL, Pfaffly C, et al. Interviewing when family members are present. Am Fam Physician. 2002;65:1351–4.
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9. Pearson SD. Principles of generalist-specialist relationships. J Gen Intern Med. 1999;14:S13–20.
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11. Miller WL. The clinical hand: a curricular map for relationship-centered care. Fam Med. 2004;36:330–5.
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