KEY POINTS FOR CLINICIANS
Traditionally, physician training focuses on an encounter between 2 people: the patient and the physician. In practice, a third person frequently accompanies a patient to the medical encounter. The American Medical Association Council on Scientific Affairs states that primary care physicians “need a strong and effective model to guide their relationships with family caregivers” and recommends that physicians tend to the needs of individuals assisting patients and to the patients themselves.13 In family practice, family members commonly accompany one another,2 but conflict between families and health care professionals can occur.3 Interviews with hospital counsel and medical staff have identified families as the primary difficulty in end of life situations.4 Nevertheless, family members provide invaluable information about the patient’s broader psychological and sociocultural dimensions and the personal relationships that contribute to the patient’s functional autonomy.5- Sixteen percent of adult patients have a companion present in the examination room during their ambulatory medical appointments.
- Companions are more common with older, less well educated, and more medically or socially complex patients.
- Companions participate actively during the encounter.
- Companions often improve patient and physician understanding during the encounter.
Although common, third party involvement in adult medical care has not been well studied. This prospective study explored the frequency of companions, the reasons for accompaniment, and the companion’s influence on the medical encounter from the perspective of the patient, the companion, and the physician.
Methods
Setting, physicians, and patients
The study was conducted at the general internal medicine practice of the University of Colorado Health Sciences Center. Fifteen full-time faculty and 42 internal medicine residents participated. A companion was defined as any person older than 18 years who accompanied a patient to a medical visit and was designated as an examination room companion if that person spent any portion of the visit in the examination room; otherwise, that person was designated as a waiting room companion. Persons employed solely to provide transportation services for patients were not considered companions.
Study design
The study consisted of 2 parts: a prospective study to document the frequency of patient accompaniment by a third person to ambulatory medicine visits, and a survey of patients, companions, and physicians to explore the rationales and influence of the companion during the medical encounter. A professional research assistant was present for an average of 8 of 10 half-day clinics per week. To accomplish the first objective, a research assistant directly observed 1294 consecutive patient visits from September 22 to October 29, 1998. To accomplish the second objective, from mid-September to mid-November, a professional research assistant attempted to enroll all consecutive patients accompanied to their appointments. Unaccompanied patients were approached for consent at the convenience of the research assistant. Patients and their companions were approached for consent in the waiting room immediately before their visits.
For inclusion, patients and companions provided consent and were literate in English. Patients, companions, and physicians independently completed self-administered questionnaires immediately after their visits. All were informed that responses were confidential and would not be disclosed to one another. This study was reviewed and approved by the Colorado Multiple Institutional Review Board.
Questionnaire development
The survey instruments were developed after a thorough review of existing research1,6-10and refined by pilot testing and review with a professional survey consultant. Patients and companions completed demographic questions (Table 1). Patients rated their overall health, stated their relationship to the companion, and indicated the reasons for companion accompaniment (Table 2). Patients and companions indicated from a list of 7 items (Table 2) how the companion influenced the visit and rated the companion’s helpfulness during the encounter (5-point Likert scale: 1 = very unhelpful to 5 = very helpful).
TABLE 1
Patient demographics and characteristics*
| Companion in examination room (A) | Patient alone (B) | P, A vs B | Companion in waiting room (C) | P, A vs C | |
|---|---|---|---|---|---|
| Total | 115 | 121 | 85 | ||
| Female | 57 (54) | 76 (73) | .19 | 58 (71) | .022 |
| Age (y) | |||||
| 18–44 | 21 (20) | 39 (33) | <.001> | 16 (20) | .06 |
| 45–64 | 34 (33) | 55 (46) | 39 (49) | ||
| ≥65 | 49 (47) | 26 (22) | 25 (31) | ||
| Race | |||||
| White | 73 (72) | 79 (66) | .09 | 56 (73) | .73 |
| Black/African American | 7 (7) | 22 (18) | 8 (10) | ||
| Hispanic/Latino | 16 (16) | 14 (12) | 11 (14) | ||
| Other | 5 (5) | 5 (5) | 2 (3) | ||
| Education ≤ high school | 57 (56) | 40 (33) | <.001> | 48 (61) | .56 |
| Income (US dollars/y) | |||||
| 47 (51) | 61 (54) | .82 | 39 (53) | .50 | |
| 15,000–35,000 | 23 (25) | 29 (25) | 22 (30) | ||
| >35,000 | 23 (25) | 24 (21) | 13 (18) | ||
| Self-noted health | |||||
| Poor/fair | 58 (53) | 53 (44) | .37 | 40 (48) | .13 |
| Good | 28 (25) | 34 (28) | 32 (38) | ||
| Very good/excellent | 24 (22) | 34 (28) | 12 (14) | ||
| Medical and social complexity (MD rating) | |||||
| Simple/straightforward | 6 (5) | 27 (24) | <.001> | 11 (13) | <.001> |
| Average | 24 (21) | 36 (32) | 32 (39) | ||
| Somewhat/very complex | 83 (73) | 51 (45) | 39 (48) | ||
| Patient visit type | |||||
| Return with primary provider | 85 (75) | 73 (64) | .16 | 51 (62) | .07 |
| New with primary provider | 18 (16) | 28 (25) | 15 (18) | ||
| Episodic with provider other than primary | 10 (9) | 13 (12) | 16 (20) | ||
| Physician | |||||
| Faculty | 68 (62) | 55 (45) | .01 | 44 (52) | .19 |
| Resident | 42 (38) | 66 (55) | 40 (48) | ||
| Some categories are missing data, so the columns do not equal n. Percentages were computed based on available data, and some columns equal 101% because of round-off error. | |||||
| *Values are number (percentage) unless otherwise indicated. | |||||