December 13, 1999
Physicians-in-training learn how to work in partnership with patients’ families
Across the nation, many physicians-in-training are learning to go beyond the routine family medical history and gain a better understanding of a patient?s family situation. They also are learning how to marshal resources to help families of patients with serious or chronic illness.
The drive toward emphasizing family-centered care in medical school is fueled by several factors: a greater appreciation of the role of family dynamics in health and illness, more recognition of the effects of a patient?s condition on the immediate family, the increasing role of family members as caregivers for their relatives, and changes in family visitation policies at some hospital birthing rooms, intensive care units and hospices.
At the University of Washington School of Medicine (UW), family-centered care is taught in many disciplines: family medicine, obstetrics, psychiatry, pediatrics, geriatrics, general internal medicine and others.
“What has improved in recent years is that we now have greater knowledge about family health and better tools to assess and assist families,” said Dr. Ronald Schneeweiss, professor and former chair of the UW Department of Family Medicine.
In the UW?s family practice residency network, Schneeweiss said, residents are taught how to respectfully explore patients? emotional supports and the relationships within their families. The doctors learn to sensitively discuss family issues and find out what the patient?s family is like. He stressed that physicians are not family therapists, but they often consult with a family therapist if needed.
In the UW?s family medicine teaching programs, medical students may arrange to go to patients? homes with a visiting nurse. Residents may make home visits on their own. Schneeweiss said home visits can be invaluable in helping physicians understand issues that wouldn?t arise during office appointments. He gave as an example an ?gr?ho worked herself almost to the point of collapse taking care of her disabled husband alone, unaware that assistance was available. In this case the health-care team mobilized community resources for the couple. Schneeweiss predicts that 21st century medicine will have more doctors who offer home visits.
Another core educational tool is a genogram, an efficient, systematic way to map family structure, relationships, patterns and major events. Students begin by looking at the genograms of historical figures such as Alexander Graham Bell, Elizabeth Blackwell and Albert Einstein.
“The genogram,” explained Larry Mauksch, clinical associate professor of family medicine and a behavioral scientist who directs the family medicine clerkship at UW Medical Center, “is used in family assessment and problem-solving.” It can, for example, show how family patterns might affect illness management, such as adherence to treatment plans; which family patterns are repeating so that preventive steps might be taken; and imbalances in family dynamics, such as overly responsible and irresponsible family members — a situation that frequently underlies depression, alcoholism and domestic violence. Genograms also reveal sources of support and strength that enable families to adjust to the unexpected, as when a family member suffers a heart attack, or to long-term conditions such as diabetes.
Mauksch teaches collaborative family health care, a style of practice that emphasizes a cohesive partnership among the primary provider, the patient, the patient?s family and other providers, particularly mental health professionals. This practice style integrates biomedical and psychosocial factors, and overcomes the mind/body split of the current health-care system.
While a patient?s family structure is not significant for routine care of self-limiting diseases, family practice residents are taught how to include family members if the patient is experiencing a pregnancy, a terminal illness, a complicated or out-of-control condition, chronic disorders or psychosocial problems. They may enlist family support if a patient is trying to correct unhealthy living habits, such as smoking.
One of the opportunities UW medical students have to observe how physicians provide family-centered care is during their required family medicine clerkship, which is offered at more than 24 sites, including several rural towns. Rural physicians are often highly attuned to family issues, Schneeweiss said, because they are acquainted with most people in their small town.
Medical students? professional development is such, added Dr. Tom Greer, associate professor and director of medical student education in the Department of Family Medicine, that learning family-centered care is incremental and builds on basic skills such as doctor/patient communication.
“We try to help medical students see the big picture,” he said, “and consider the context in which our patients live.”
