One of the aspects that attracts many of us to medical practice is the uniqueness of the doctor-patient relationship; just you and your patient working together in the privacy of your consulting room.

In reality, however, the consulting room is pretty crowded. Although it might just be the two of you sitting in there, you both have a whole lot of other people virtually present who influence the consultation.

Through your medical knowledge and surgical training, you bring into the room a host of experts, teachers and mentors all of whom continue to influence your practice. On the patient’s side of the desk sit their family and friends, each of whom have some level of interest in the patient’s health and in your management of it. There are also dozens of neighbours and acquaintances who will not let their complete absence of medical training stand in the way of providing a critical post-fact appraisal of your skills. And, inevitably, there’s a small flock of lawyers and regulators circling lazily above your desk.

Most of the patient’s team will have his or her best interests firmly at heart and will support and assist your endeavours to do the best job you can. Emotions run hot within families, however, and the full gamut from guilt to greed can impact upon your work in the consulting room, the wards and theatre.

It’s wrong to paint family members who accompany patients to their appointments with you solely as a threat. They are stakeholders in your healthcare interaction and so their needs must be considered. Family members can be an invaluable source of information about their relative’s medical history, family history, symptoms and so on. In return, they can be wonderful adjuncts to your consultations, ensuring that the patient understands your explanations and reinforcing key messages at home. The patient remains the centre of the interaction, however, and your explanations must be directed at them no matter how tempting it might be to communicate directly with a more capable accompanying person. This is especially true when you do not share a language with the patient and a family member offers to assist. Many family members find it difficult to act purely as a translator rather than as an interpreter.

Giving the patient written information to take away and discuss with their family and friends is a useful strategy to help improve their understanding outside your consulting room. Inevitably, however, the authority consulted will be their son’s girlfriend who is a second year osteopathy student and so the information must be clear and robust. It is never enough to hand a brochure or information sheet to a departing patient and suggest that they get someone at home to explain it to them. Rather, the sheet needs to be discussed in some detail by you with frequent checks that the patient is following your explanation. Underline the key bits and annotate the sheet with facts that are specifically important to that patient. By all means encourage the patient to share the contents of the sheet with a family member or friend. I still recall doing a home visit on an elderly couple only to find my information sheet on erectile dysfunction prominently displayed on the fridge.

The Internet is another source of opinion against which your information will be measured. Professor Google from the University of Wikipedia seems to be the ultimate authority on most things medical. As frustrating as this is, it’s important to imbue your information sheets with your own authority so that incorrect or inaccurate internet postings do not confuse the patient. Having said that, there are some high quality websites available that may well reinforce your message if you check them out before recommending them.

Many patients have a tendency to give socially desirable responses when talking to doctors. The question: “Now, you understood all that, didn’t you?” really invites an affirmative response. Asking which bits of the explanation the patient did not understand, or – even better – asking them how they will explain it to their family members when they get home is much more appropriate. This gives the patient a chance to rehearse what they will say while you have the opportunity to correct any misunderstandings.

Some family members will play quite a prominent role in a patient’s medical decision making, and not just at the extremes of life. While it might seem inappropriate or even a waste of time to delve into a patient’s family constellation, the prudent clinician is aware of whom else needs to be brought on board before the patient can front up for an operative procedure with confidence and equanimity. Taking a preoperative phone call from a concerned family member is a wise investment of time for all concerned.

Building trust, rapport and understanding with patients and their families is an essential part of the consent process; this requires clear, effective communication. It is also an important aspect of minimising the fall-out when something inevitably goes wrong. It’s well known that families and significant others play an important role in influencing the decision to litigate after adverse events (1,2). After all, where there’s a will there’s a relative…

Author: Professor Stephen Trumble Chair, Editorial Board Specialist Management Services

References

1 Liebman CB, Hyman CS. A mediation skills model to manage disclosure of errors and adverse events to patients. Health Affairs 2004 Jul-Aug;23(4):22-32.

2 Hickson GB, Clayton EW, Githens PB, Sloan FA. Factors that prompted families to file medical malpractice claims following perinatal injuries. Journal of the American Medical Association 1992; 267 (10): 1359–1363.

This article was first published as an insert in the March 2009 edition of Surgical News.

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