GPs have a commonly used title of 'family doctor'. However, the likelihood of this being the case has drastically declined in recent decades.
Many families are now split across local practices as well as geographically. This can make our job harder but the fact is that consulting with family members present is a daily event for most of us.
Little has been written on the subject and there is almost no worthwhile research to speak of, unlike family therapy, for example. What guidance there is mainly comes from medical ethicists and the GMC.
However, experience and common sense suggests that some communication strategies are likely to work better than others.
The following advice may help you to get the best out of a consultation where family members attend surgery together.
- Greet each individual, including children, in such a way as to encourage their participation in the consultation.
- Keep confidentiality issues high on your agenda. Make sure that patients are happy to discuss health issues in front of family members.
- Watch for any emotions expressed by any of the family members. Both positive and negative emotions should be acknowledged.
- Try to control family members monopolising the consultation and try to limit persistent interruptions.
- Remember to emphasise the positive.
There are a number of ways in which the doctor's communication can impact negatively on the family consultation.
- Letting one individual regularly speak for another.
- Taking the side of one family member over another.
- Offering advice without fully exploring the problem.
- Leaving the computer screen notes of one family member available for another to view.
The dynamics of the consultation are very different when a third party participates and the central aim of the consultation, which is to achieve a shared understanding based on your and their medical knowledge, becomes much harder.
The central issue can be dissected by thinking of agendas; but whose? There is the patient's agenda (and it may not always be clear who that is), the family member's agenda and the doctor's agenda.
Consider a consultation with a 14-year-old girl who would like to start having sex, and her mother. The fact that mother is there usually indicates that her agenda is probably closely linked to her daughter's and that there is unlikely to be a conflict. Both think the daughter should have the pill and both want some professional input to legitimise the socially normal but technically illegal decision.
Then what about the consultation where Gillick competence should be considered? Here an angry mother comes in with a sheepish daughter brandishing a packet of the pill that you have prescribed, who is the patient here? And whose agenda is paramount?
Your own agenda, influenced by your religious, ethical and practical beliefs, becomes important. The consultation will be guided by who you deem to be the patient. Most will choose the daughter, but for some it will be the mother and thus her agenda holds centre stage.
There is likely to be tension during this consultation, so diffusing this unhelpful atmosphere must be a priority.
Listening professionally is usually the best way to do it. This will allow you to establish their agendas and guide your subsequent interventions.
It is a good strategy in all three-way consultations to let the most eager participant begin; in this case it will probably be wise to let mother have her say first.
It is important to listen and not judge. Watch the daughter's non-verbal behaviour to get a clue as to the type and levels of emotion that is involved.
When you have allowed the mother to express her expectations, her concerns and gauged the depth of feeling, it is time to let the daughter have her say.
You must treat her as an equal and at all costs respect her vulnerability and her confidentiality. It is important not to have the computer screen of her recent medical history visible for her mother to scrutinise.
She is young, and this consultation may set her expectations of the medical profession for the rest of her life.
It is only after you have understood the differing viewpoints that you can have a role in the resolution, and of course the act of being a calming referee is often very therapeutic and may be all that is needed.
It is vital to remember that in all consultations with family members it is the various agendas that matter.
In the scenario of the younger member translating for the older family member, keep this rule in mind, otherwise it is the translator's agenda and not the patient's you may find yourself addressing.
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These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.
- Dr Tate is a retired GP in Corfe Castle, Dorset and the author of The Doctor's Communication Handbook