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Point / Counter Point 1

Posted By Randall Reitz, Thursday, March 1, 2012
Updated: Thursday, March 1, 2012

Dejected Views
on Family-Hating

Barry J. Jacobs

The surreptitious eye-roll is bearable. The low groan is regrettable but not worth reproaching. But what irks me most about the occasional reactions of my family medicine residents to their patients’ relatives is the smug, dismissive, professionally rendered character assassination, complete with technical terminology. "The spouse is in denial,” they point out to their fellow inpatient team members when an overwhelmed and grieving husband or wife is unwilling to change a patient’s code status. "The daughters are being manipulative,” they observe about adult children who are urging their mother to resist physicians’ recommendations to undergo surgery or take a new medication. "They’re over-stepping boundaries,” they claim about family members who call them repeatedly or accost them with concerns in the hospital or office hallway.

It’s not that other healthcare professionals are substantively more family-friendly. For many of my mental health colleagues, hate of (or at least discomfort with) families is a many splendored thing. They focus on individual dynamics and prerogatives, invoking the delicateness of the therapeutic alliance or the sanctity of confidentiality as justifications for eschewing family contact. They cringe at the prospect of family meetings. They regard family systems thinking as a relic of the ‘60s, unsupported by current research or modern expediency.

I’m incredulous at these attitudes; I take them personally. From my teenage years caring for my father with brain cancer to my middle-aged years caring for my aging mother and demented step-father, I know in my gut how families affect patients’ clinical outcomes and how patients’ illnesses affect family caregivers. Others, clearly, don’t share the same visceral conviction. So what do I make of the widespread phenomenon of family-hating? Here are some over-the-top theories:

We operate in evidence-reinforced comfort zones: Much of healthcare practice and consequently research is focused on individual patients. In an era when clinicians are reminded at every turn to treat according to evidence-based principles, family-centered practices—lacking the same degree of empirical support—therefore seems the riskier clinical gamble. This is compounded by the fact that many healthcare professionals do not receive much training in the nuts-and-bolts of working with patients’ family members—e.g., running family meetings, addressing family conflicts. The seemingly prudent and comfortable treatment approach is centered on patients, leaving family members in the wings.

We are rats in templated, encoded mazes: Medical care, especially primary care, is being increasingly shaped by the clinical pathways that are the basis for the templates of our electronic medical records. By clicking through those templates, physicians not only have the assurance of following the so-called highest standards of care but are also working toward completing their progress notes for medical sessions as quickly as possible. It should come as no surprise that those EMR templates reflect bias toward individually-focused treatments. Family-centered healthcare is off-the-templates.

At the same time, clinicians are under enormous pressure to maximize reimbursement for healthcare services. The billing codes—aka CPT codes—they use have a powerful effect on practice. CPT codes for individually-oriented treatments are reimbursed by insurance companies. CPT codes for meeting with patients’ family members are generally not. We follow the money and avoid the family members.

Beaten and bedraggled, we cling to our authority: I don’t need to tell you that every year healthcare providers are worked harder, blamed more for rising healthcare costs, and disparaged more frequently by angry patients and aggressive lawyers. Evoking Rodney Dangerfield, all we want is a little respect. Now comes the dawning age of the patient-centered medical home with its emphasis on team-based care and who wants a place at the decision-making table as partners in care? Family caregivers do. (For example, see this recent AARP Public Policy Institute report). I think it’s tough for us to give up some of our remaining power to family members. When I hear professionals complain that patients’ family members somehow obstruct the treatment plans of the healthcare team, I infer that they don’t want their scant authority challenged any more than it already has been.

We are all adolescents at heart: Many of us give lip service to the importance of family members to patients’ care. But in our own lives, in our heart of hearts, we feel ambivalently about families. We want their support but don’t want them to encroach on the individual’s rights and independence. It reminds me a little of the sentiment captured in the title of the 2002 book on teenager psychology, Get Out of My Life, but First Could You Drive Me and Cheryl to the Mall. We want family members to drive our patients to our offices but then don’t make a fuss in the exam rooms. We want them to help our patients adhere to our treatment plans but not have input into those plans. That’s not family-centered care. That’s not even respectful of what family members know and have to offer. It marginalizes families. It’s reflexively oppositional and hateful.

For more on this general subject, check out the seminal article, "The Trouble with Families: Toward an Ethic of Accommodation” by Carol Levine and Connie Zuckerman in the Annals of Internal Medicine, 1999, vol. 130, pages 148-152.

Also please see "Interacting with Patients’ Family Members During the Office Visit” in the Oct. 1, 2011 issue of American Family Physician; it’s a tepid, timid approach to incorporating family members into primary care but at least represents some effort to do so.

I Beg to Differ

David B. Seaburn

I beg to differ with my good friend Barry Jacobs’ blog posting entitled, "Dejected View on Family-Hating.” Not only is he (uncharacteristically) off-base, but he may not even be on the playing field.

He notes that family-hating is rampant in the medical field as well as in most mental health disciplines. While I don’t espouse family-hatred, I doubt that any well-trained family-oriented mental health professional isn’t at least ambivalent about families from time to time. They are messy and confusing and inconsistent and wonderfully Resilient in their efforts to get us to respect their integrity. Non-family-oriented healthcare professionals are not the only ones to unfairly label families. In moments of frustration, I have considered whether "borderline” might be an apt relational diagnosis, especially when I don’t know what to do with a family.

Which brings me back to Jacobs’ criticism of residents. If as an experienced family therapist (35 years), I, at times, label and very nearly hate a family, what can be expected of residents. Remember---these are medical professionals who have been trained almost exclusively in a paradigm that focuses on the life and death of an individual patient; who have been acculturated to think reductionistically ("Let’s find the single cause of this patient’s symptoms”); who then enter a healthcare system that mitigates against inclusion of families due to time (see what it’s like to care for four or more patients per hour), diagnoses and healthcare reimbursement. If that were my professional background, my professional culture, I would run the other way when I saw a complex, demanding, needy family coming my way, as well.

I was a residency educator for almost twenty years. Early in my tenure I learned that I was a visitor in a different culture and, as such, I needed to enter that culture with respect and an eye to learning as much as I could to be of value. At first I thought I needed to convert the heathens to a family systems paradigm. If they could only become like me! Soon I realized that that wasn’t what was needed. More than anything else, residents needed help with their most difficult patients. As a family systems professional, my help with challenging patients often (but not always) included involvement of the family as a resource to the resident or as an important source for understanding the patient’s problems. Once residents saw that family could be integral to care and that involving family in challenging patient situations made their lives easier, residents often caught the family system’s bug. For me the lesson was---Don’t preach family-systems, just do it. Making it work in the exam room is the best evidenced-based example you can provide.

The challenge for family-oriented residency educators is to be comfortable and creative taking a one down position (yes, even after all these years!) in a system that is slow to accept differences, let alone change. That means wielding power and influence differently, if, at times, not equally. Becoming a recalcitrant adolescent ourselves is not the answer. Instead, we must recognize that as a maturing member of the medical education family, family-oriented healthcare educators must demonstrate the capacity to be systems-oriented in our clinical, research, educational, administrative and policy-making endeavors. We must leave "evidence” of who we are everywhere we go. I think that the better angels of Dr. Jacobs’ nature recognize this.

Barry Jacobs
Dave Seaburn
Barry Jacobs and Dave Seaburn are family medicine educators and long-term collaborators. Barry is the Director of Behavioral Sciences at the Crozer-Keystone Family Medicine Residency in Springfield, PA and the author of The Emotional Survival Guide for Caregivers—Looking After Yourself and Your Family While Helping an Aging Parent. Dave recently retired from a distinguished career as the behavioral science faculty in the University of Rochester Family Medicine Residency and has taken to writing novels, including Charlie No Face.

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Randall Reitz says...
Posted Thursday, March 1, 2012
One of my shocks in transitioning from safety net health care to medical education was the language that was used in describing families (and individual patients) in educational settings. I've been repeatedly told that this behind the scenes "venting" is necessary and healing, but I haven't yet been convinced that it doesn't affect the care provided in the exam room. But, then again, maybe I just like people more than most.
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Jackie M. Williams Reade says...
Posted Thursday, March 1, 2012
I, too, am in a medical education setting and have been shocked at the negative language used! The first few times I experienced it, I felt very strongly that I should insert a strong statement against this kind of talk, but couldn't see how that wouldn't potentially isolate me from the group. Then I swung the other way and found myself joining in on more than one occasion! The power of the group norm and the temptation to vent about clients lulled me in, and, while it felt good for a moment, I also felt myself shutting off my compassion and curiosity towards the patients in question. I think this is why it is so important for a patient and family advocate to be a part of the medical team. It is so tempting to blame the patient/family for all the trouble and stop thinking of new ways to help. It takes discipline to stay curious and compassionate and I think that is one of our biggest contributions to the healthcare system.
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Mark Yaffe, MD says...
Posted Saturday, March 3, 2012
Barry, you write exceedingly well and forcefully! I have actually read what you and David have written 3 times, and pondered it further. The discourse reminded me a bit of the classic shtetl rebbe who when asked a question, responded with "on the one hand" ...."but on the other hand"...."and , on the other hand".......You and David are not that different on the issue: you have identified a concern and a problem, and he seems to be offering the reasons for why it is the way it is. From the my perspective, as the non-psychologist, I nonetheless boil this all down to problems with counter-transference. Some clinicians appreciate the potential benefit of family perspective, but they are:

1. Threatened by it when it contradicts , or is better than what the doctor has to say.....i.e. it challenges the doctor as authority. Hence, instead of this issue being a patient or family issue, it becomes the doctor's issue.

2. Afraid of partnership or collaborative care, because such care appears time-consuming, and few doctors have been trained to get to the families' bottom line issues, which sometimes comes with emotional baggage. The great thing about family practice is that if you know the family members you have some opening or "permission" to cut to the chase. This approach actually saves time in the long run.

3. Frightened of one of my first papers on surveying docs about relationships with caregivers one of the highest ranked doctor concerns was how to deal with situations when patient and family disagreed, or doctor and patient/family disagreed. I think I suggested to you when we first started to correspond that we need to develop a simple means to teach family docs how to do/handle conflict in such situations.
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Carol Levine says...
Posted Saturday, March 3, 2012
Hi Barry—What an interesting, frank exchange. I appreciate your reference to the Annals article, and while your colleague has a valid perspective, you win hands down. Carol
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Richard Birkel says...
Posted Saturday, March 3, 2012
I like the blog. Yes, there is ambivalence here for sure. I also like the observation about docs chasing the code. That is so true - they respond to that and, I am learning - peer pressure--what they think their colleagues down the line will think of their work when "their" patient shows up. I heard this as a lament when family docs told me why they were afraid to restrict end of life measures-- what would their colleagues in ICU think at the end? And recently from a specialist who made the same comment when telling me why he "had to order a test"--a test we both knew was without value. I am finding overall that patient engagement and self-management is something many clinicians don't "get" and really are not interested in. It's still a lot like a garage mechanic, when that car comes into their shop. They see the car and not the owner, and they feel a sense of pride in the work they do on the auto body.
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Andrea Farkas Patenaude, Ph.D. says...
Posted Saturday, March 3, 2012
Dear Barry,
You are very brave to bring this important issue to light so directly! (but then we knew you didn’t shy away from tough topics or roles). I like the teenager – get out of my life, but could you first drive me to the mall-analogy. It is a very interesting discussion, too, about how “venting” negatively affects the interactions with family members. It does seem that it is, as if, instead of being all on the same team working for the optimal functioning of the patient and family, that there is subtle or not-so-subtle competition for who can be really the most helpful and who gets the credit. It is, granted, hard work. This caretaking and caregivers, professional and familial, can feel quite depleted and needy, but this is where joining rather than competing would have major benefits. Anyway, Barry, kudos for making this larger discussion happen.
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Paul Simmons says...
Posted Saturday, March 3, 2012
The ethical principle that is being ignored in this discussion is, in my opinion, the irreducible professional obligation of the physician: to diagnose and treat disease. The sick individual is my patient. His or her family, his or her community, his or her culture and society--these factors are important and interesting to a good doctor as risk factors and influences on health behavior, but they are not my responsibility. The individual patient is.

The golden mean we should train our residents to pursue is neither disdain and "hatred" for the individual and the family, nor an all-inclusive love-fest that takes on family, societal or galactic concerns. Either extreme introduces too much corrupting emotion into the fundamental role of diagnosis and treatment. William Carlos Williams described this golden mean well: "And though I might be attracted or repelled [by the patient--and I would add, the family], the professional attitude which every physician must call on would steady me, dictate the terms on which I was proceed."

That professional attitude constrains both our tendencies for judgmental disgust and the temptations of soft-headed enmeshment that adds nothing to diagnosis and treatment. As the neurologist William DeMyer wrote: "Treating each patient as a coequal organism consisting of neural circuits that operate a set of levers, apertures, tubes and glands focuses on our elemental unity and limitations--the pathos of being human."

I do not expect the patient's family to see their mother, son or grandparent as deranged neural circuits and tubes. Nor should they expect me to love their loved one, nor to accept their medical opinions as valid as my own. We each have different roles to play in the drama of illness.

Both distancing hatred and enmeshment in the social milieu tempt physicians to forget our ultimate role - diagnosis and treatment of the individual patient.
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Barry J. Jacobs says...
Posted Sunday, March 4, 2012
Thank you all for these fascinating comments. You bring out nuances of these issues that neither Dave nor I have considered. When I hear about "venting" and "group norms," I'm immediately put in mind of the dynamics of prejudice. And perhaps Paul would argue that physicians need to be prejudicial--i.e., discerning--in order to maintain the utmost concentration on diagnosing and treating disease--or, as Rick might put it, diagnosing what's wrong with your car. To my way of thinking, however, embracing the family enables better clinical outcomes, not muddies them. I think that Mark--and, for that matter, Dave, my erstwhile foe--put it best when they point out that dealing with families raises anxiety and anxiety causes proud professionals to take high-falutin' stances as a means of sanctimoniiously backing off. Everyone--collaborative team members, patients, family members--will work better together when trust can be instilled and anxiety-levels lowered.
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David Seaburn says...
Posted Sunday, March 4, 2012
My view on this discussion is that whatever contributes to or alleviates a patient's illness, disease, distress needs to be considered when providing healthcare. Just as family therapists have needed to be educated in considering the indvidual and the body in the last 20 years, the same is true for physicians. If family is a factor in a patient's problem, then family needs to be involved. If that is beyond the phsycian's skill set, then he/she as in other medical presentations, needs to partner with a 'specialist' (FT) who has the necessary skill to contribute to good care.

I agree with Barry's comments on trust. We used to say that the collaboration is built on relationship, relationship, relationship. This brings us back to the training issue, in my view. The more that medical and mental health professionals are co-trained or at least exposed to each other during training, the greater the likelihood that trust will develop that hopefully will inform their future practices.
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Randall Reitz says...
Posted Sunday, March 4, 2012
Esteemed Watson (aka Paul Simmons),

As you fancy yourself a Holmes-phile, I know you would rather play Sherlock to my John, but alas, you chose the wrong branch of the human sciences. While you view a human as a bag of organs and viruses, there are far more data present when the game is afoot in the exam room. Yes, the empirical sciences are at their purest when positivistic, but when addressing only one stream of data (that which is measurable in laBORatories and radiological centres), you are willingly turning a blind eye to some of the key evidence.

To borrow your word, humans are irreducible. That is, we are products of the social determinants of health. When sequestering patients from their distracting families and refusing to engage in the “love-fest” (again, your word—obviously not mine) of actually attempting to understand a patient, you willingly choose to provide poorer care. When treating a 500 pound gentleman’s diabetes, you can micro-manage his pending morbidity and mortality by tinkering with his medicines, referring him to an ophthalmologist for his failing vision, to a urologist for his flaccid penis, and to a hospice to comfort his last weeks. And, as you ostentatiously observed, you can take comfort in the fact that your medical opinions will generally be more valid than those of the ever-dying patient.

Or, you can choose to enter the chaos that is his life: invite his family into the room, understand the community from whence he hails, and develop a behavioral plan that will engage his close relations in treating the actual illness rather than simply mucking around the margins.

The choice, dear Watson, is yours alone.
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