While much of medicine focuses on treating individual patients, every practitioner knows that each patient is more than an individual. Whether it’s a spouse in the exam room or a friend in the waiting area, a patient’s family and community are a critical consideration when it comes to care.
One of my clearest memories of a 28-hour call during my intern year was when a patient’s pathology results were finally uploaded into the EHR at the end of my shift. He had been admitted to the hospital after a seizure with new onset encephalopathy, with initial imaging revealing a brain mass concerning for malignancy. Every day that his biopsy results were pending, his wife stood by his bedside and begged us to tell her right away when the results were completed.
I wanted to keep my promise to her despite my exhaustion and despite the fact that those results confirmed our worst fears. I don’t remember how long I was in that room with the patient’s wife, holding her as she cried from the fatigue of the nights waiting for the diagnosis and from anxiety about what lay ahead. I do know that she later thanked me profusely in spite of the terrible news that I brought because she was grateful that I took that time to be with her.
Not all encounters with a patient’s family are so dramatic, but they can all determine the quality of the care we provide. Here are three points in your day where your interactions with friends and family are crucial.
After introducing yourself and greeting the patient, getting a round of introductions from everyone in the exam room should be the first item on your agenda in any patient-physician encounter.
Learning everyone’s identity not only gives you a friendly yet professional way to address them, but it also provides you with information that may be essential for deciding on the best plan of care for a patient. For example, knowing that the woman sitting in the chair is a patient’s out-of-town sister instead of their spouse may be useful in how you proceed with the rest of the encounter.
In addition, knowing the relationship between your patient and their companions may also be important legally. In order to abide by HIPAA, your next question should be whether your patient is OK with you asking personal questions and/or performing an exam in front of the others in the room. Just because someone is accompanying your patient to their doctor’s appointment doesn’t always mean that they wish to share all their medical information. (An exception may be when you’re treating a pediatric patient.)
Beginning your encounter by learning who everyone is acknowledges their importance in your patient’s life, but asking for your patient’s permission before going ahead with an exam or questions recognizes the importance of their individual preferences.
Just as learning who everyone is at the beginning of an encounter can help you determine how to proceed, knowing the people in your room can also provide you with key information for the end of the visit. “Patient compliance” is a term often thrown around by healthcare professionals to describe how well a patient follows medical instructions, but believing that patient compliance depends only on the patient is short-sighted.
When providing a patient with instructions at the end of a visit, acknowledge the role that the friend, child or spouse in the exam room may play in how your patient follows your directions. For example, telling a diabetic patient what to eat may not be much use if their spouse is the primary cook, but sharing crucial information with both individuals can improve the patient’s health.
In fact, according to a meta-analysis of family interventions in diabetes self-care published in the Annals of the New York Academy of Sciences, involving patient’s families in these discussions has been linked with improvement in patients’ belief that they could take care of themselves, as well as their feeling of support from others in their lives. Another study, published in the Journal of ECT, suggests that in certain situations, such as electroconvulsive therapy, “an alliance with the [significant other] may at times be more crucial than the alliance with the patient.”
Delivering Bad News
Explaining that the outcome of a patient’s treatment isn’t what everyone hoped for is another time when conversations with a patient’s family may be more important than those with the patient themselves. While the circumstances of these situations vary widely, one of the most common reasons these physician-family conversations occur is that the patient is unable to actively participate, and a loved one is the only one who is there to receive news.
In these situations, it’s important to identify who a patient’s health care proxy is. It may be socially appropriate to talk about a patient’s prognosis in front of family, but it’s also be necessary to know who the designated legal decision-maker is if a patient is unable to decide for themselves. Often these conversations occur because a patient has a poor prognosis, and being able to deliver that news in an empathetic but truthful way is essential.
Though there’s really no way to make bad news better, the words of neurosurgeon Dr. Hilal Kanaan come to mind when I’m unable to tell a patient’s loved ones good news. “As physicians, we can be enriched more by the patients we cannot cure,” he wrote on Medium, “as long as we are humble enough to see that the absence of Hope sustains a vacancy for Grace and Love.”