Editorials
Family physicians encounter patients with a broad array of medical problems. The biopsychosocial 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
Address correspondence to Marc C. Newman, MD, at marc.c.newman@drexelmed.edu. Reprints are not available from the authors.
Author disclosure: Nothing to disclose.
REFERENCES
1. Little P, Everitt H, Williamson I, Warner G, Moore M, Gould C, et al. Preferences of patients for patient centered approach to consultation in primary care: observational study. BMJ 2001;322:468-72.
2. Cole-Kelly K, Seaburn DB. Five areas of questioning to promote a family-oriented approach in primary care. Fam Syst Health 1999;17: 341-8.
3. Marvel K, Major G, Jones K, Pfaffly C. Dialogues in the exam room: medical interviewing by resident family physicians. Fam Med 2000;32: 628-32.
4. Marvel MK, Schilling R, Doherty WJ, Baird MA. Levels of physician involvement with patients and their families: a model for teaching and research. J Fam Pract 1994;39:535-44.
5. Botelho RJ, Lue BH, Fiscella K. Family involvement in routine health care: a survey of patients' behaviors and preferences. J Fam Pract 1996;42:572-6.
6. Lewin SA, Skea ZC, Entwistle V, Zwarenstein M, Dick J. Interventions for providers to promote a patient-centered approach in clinical consultations. Cochrane Database Syst Rev 2001;(4):CD003267.
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.
8. Miller WL, Crabtree BF, Duffy MB, Epstein RM, Stange KC. Research guidelines for assessing the impact of healing relationships in clinical medicine [Published correction appears in Altern Ther Health Med 2003;9:17]. Altern Ther Health Med 2003;9:A80-95.
9. Pearson SD. Principles of generalist-specialist relationships. J Gen Intern Med 1999;14:S13-20.
10. Sankar P, Mora S, Merz JF, Jones NL. Patient perspectives of medical confidentiality: a review of the literature. J Gen Intern Med 2003;18:659-69.
11. Miller WL. The clinical hand: a curricular map for relationship-centered care. Fam Med 2004;36:330-5.
Adolescent Pregnancy and Associated Risks: Not Just a Result of Maternal Age
Adolescent pregnancy (i.e., in females 13 to 19 years of age) is associated with an increased risk of maternal complications during pregnancy and delivery, as well as increased risk to the fetus and neonate. Complications associated with adolescent pregnancy include preterm delivery, low birth weight, and infant mortality.1 However, age-related biologic factors alone are not associated with an increased risk of fetal death.2 In infants of teenage mothers, much of the risk of low birth weight is related to behavioral and psychosocial factors.3 Thus, psychosocial risk factors should be a major focus of care.
One risk factor for poor outcomes in adolescent pregnancy is a maternal history of adverse childhood experiences (e.g., emotional, physical, or sexual abuse; intimate partner violence; living with someone who has substance abuse or mental illness, or is involved in criminal activity; having parents who are divorced or separated). These experiences are associated with subsequent sexual risk behaviors, smoking, alcohol consumption, and mental health problems such as depression.2 A history of remote maternal exposure to adverse childhood experiences is associated with an increased risk of fetal death.2 However, not all children exposed to these conditions have adverse outcomes. Protective factors such as good parenting, feelings of self-worth and achievement, and strong connections to family, school, and community can modulate the effects of negative experiences.
Intimate partner violence is most often directed toward women. It is more common in women younger than 24 years and in women who have not completed high school or whose partner has not completed high school.4 Even though screening for intimate partner violence in health care settings has been endorsed by many organizations, screening rates remain low.
Children born to women with psychiatric disorders have a higher risk of psychological problems, which can lead to a multigenerational sequence of mental health disability. One half of women with mental health disabilities experienced physical or sexual abuse as children.5 Children whose mothers report poor interpersonal relationships or low self-esteem are twice as likely to be neglected or physically or sexually abused.6 Early recognition and treatment of psychiatric disorders in children and in adolescent mothers (especially perinatal depression and anxiety) are essential to interrupt this pattern. However, perinatal depression often goes undetected, and physicians often do not recognize maternal depression when seeing children for well-child care or acute illness. Unfortunately, evidence of improved outcomes from screening for perinatal and postpartum depression is inconsistent.7
In men, a history of adverse childhood events is associated with an increased risk of fathering a child with an adolescent mother.8 In partners of adolescent women, older age and lower education are associated with higher risk of pregnancy; 60 percent of mothers 15 to 17 years of age and one half of mothers 18 to 19 years of age have a partner at least three years older than themselves.9
Because family physicians care for patients of all ages and both sexes and often care for multiple members of a family, they are uniquely suited to address the full range of risks associated with adolescent pregnancy. Interventional programs to reduce rates of adolescent pregnancy and to modulate adverse health effects should be based on risk factors, including very young maternal age, exposure to adverse childhood experiences, maternal psychiatric morbidity, and paternal age and education level. Physicians should consider routinely questioning women about adverse childhood experiences. Similarly, more intensive clinical services and support may be appropriate for pregnant women who experienced abuse or other adverse conditions in childhood.10 More attention should be devoted to screening and treatment for depression in pregnant patients, especially adolescents.11 Physicians also should be alert to the risk of age disparities and educational deficits in sex partners of adolescents.
Although evidence exists for the benefit of identifying some of these risk factors, evidence is lacking for the effectiveness of integrated intervention programs. Family physicians should lead comprehensive program development and evaluation to reduce the likelihood and adverse effects of adolescent pregnancy.
Address correspondence to Michael K. Magill, MD, at michael.magill@ hsc.utah.edu. Reprints are not available from the authors.
Author disclosure: Nothing to disclose.
REFERENCES
1. Ventura SJ, Hendershot GE. Infant health consequences of childbearing by teenagers and older mothers. Public Health Rep 1984;99:138-46.
2. Hillis SD, Anda RF, Dube SR, Felitti VJ, Marchbanks PA, Marks JS. The association between adverse childhood experiences and adolescent pregnancy, long-term psychosocial consequences, and fetal death. Pediatrics 2004;113:320-7.
3. Reichman NE, Pagnini DL. Maternal age and birth outcomes: data from New Jersey [Published correction appears in Fam Plann Perspect 1998;30:127]. Fam Plann Perspect 1997;29:268-72, 295.
4. Walton-Moss BJ, Manganello J, Frye V, Campbell JC. Risk factors for intimate partner violence and associated injury among urban women. J Community Health 2005;30:377-89.
5. Tonmyr L, Jamieson E, Mery LS, MacMillan HL. The relation between childhood adverse experiences and disability due to mental health problems in a community sample of women. Can J Psychiatry 2005;50:778-83.
6. Bifulco A, Moran PM, Ball C, Jacobs C, Baines R, Bunn A, et al. Childhood adversity, parental vulnerability and disorder: examining inter-generational transmission of risk. J Child Psychol Psychiatry 2002;43:1075-86.
7. Gaynes BN. Perinatal depression: prevalence, screening accuracy, and screening outcomes. Evidence report/technology assessment no. 119. Rockville, Md.: Agency for Healthcare Research and Quality, 2005.
8. Anda RF, Chapman DP, Felitti VJ, Edwards V, Williamson DF, Croft JB, et al. Adverse childhood experiences and risk of paternity in teen pregnancy. Obstet Gynecol 2002;100:37-45.
9. Landry DJ, Forrest JD. How old are U.S. fathers? Fam Plann Perspect 1995;27:159-61, 165.
10. Mezey G, Bacchus L, Bewley S, White S. Domestic violence, lifetime trauma and psychological health of childbearing women. BJOG 2005;112:197-204.
11. American College of Obstetricians and Gynecologists Committee on Healthcare for Underserved Women. ACOG Committee Opinion No. 343: psychosocial risk factors: perinatal screening and intervention. Obstet Gynecol 2006;108:469-77.
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