Natalia and Norberto* attended my clinic's diabetes group medical appointment for the first time. They are both immigrants from a Spanish-speaking country who reside in a small town in western Colorado. Natalia has very limited English ability and Norberto knows just enough English to speak for her and to correct the interpreter. Both of them are 5'3” tall. His BMI is 41; hers is 55. Both have diabetes, chronic pain, and numerous other chronic conditions that are caused by or exacerbated by their weights
The topic for the group appointment was "sexual health with diabetes” and the patients were asked to submit anonymous questions to a panel that included a family physician, a family therapist (me), and a resident physician. Despite the promises of confidentiality, few patients submitted questions. We received a question about Viagra, a question about female Viagra alternatives, and a question about how diabetes can affect sexual performance. Natalia submitted a very detailed question which roughly translated to "My husband is now unable to ever have sex with me. He cannot maintain an erection. I am sexually unfulfilled and am not sure what I can do. What do you recommend?”
The panel attempted to maintain confidentiality with this question, but about 1 minute into the discussion Natalia interjected to clarify her question. Norberto then provided a rejoinder, and the couple started a sexual repartee in front of the group. The panelists redirected the discussion, but failed to fully respond to the question.
At the end of the group all participants set a self-management goal for themselves, which they report out to everyone. When it was Natalia's turn, Norberto stated that she needed to drink less soda. Natalia clarified that she only drinks 1-2 diet sodas per day. Norberto stated that it was at least 3-4. Their dialogue continued for about 5 minutes at which point Natalia stated "Why aren't you more worried about your 4-5 beers per night and less worried about my diet soda?” Norberto didn't respond and a silence fell over the room.
Four Months Later
I was precepting residents as they come out of exam rooms and report on their cases. A first year resident was seeing Natalia (and Norberto) so I joined the presentation along with the attending physician. The resident informed us that Natalia has end-stage renal failure and has been referred to hospice. As I knew the couple and have reasonably good medical Spanish I was asked to interpret for the last portion of the visit. The goal was to clarify what the couple understood and to answer any questions they might have.
After greeting the patients and explaining my role, I assumed my customary interpreter's position, slightly behind and to one side of the patient. The resident asked Natalia if she understood why she had received a visit from a hospice social worker. Natalia stated that when the person first came she didn't know she was going to die. She was in her home with Norberto and their adult children when she was told that she would probably only live for 6 to 12 months. At first she was shocked and everyone started crying. In the 2-3 weeks since then she has come to greatly appreciate hospice's home-based care. She credits them with helping to manager her pain and for being very responsive to her calls. She is very pleased to be receiving her care in-home and hopes not to leave.
During our visit Natalia and Norberto reprised their previous interaction of speaking over and contradicting each other. At one point he called her a "masoquista” and she often struggled to speak with the resident, as her husband continued over her. She reported that she has been sleepwalking and he has installed an alarm on their bedroom door so he will know if she is at-risk during a sleepwalking spell.
The resident seeing the patient that day was due to invite a patient or family to "Psych Day”. So, I suggested that she invite Natalia, Norberto, and their children to come. I will attend this visit along with a 2nd resident. I will assist with the patient's care and the 2nd resident will observe and provide feedback.
If you had 45 minutes to work with a family in this setting, what would you want to accomplish? How would you focus the discussion?
Have you ever provided a family conference such as this? If so, what was the outcome?
*The patients' names and identifying information have been changed. Additionally, the content of this blog post was approved by my hospital's risk management department and the patients provided verbal consent to have it published online.
||Randall Reitz is the Director of Social Media for CFHA and the Behavioral Science Faculty at the St Mary's Family Medicine Residency in Grand Junction, Colorado. He studied family therapy at Brigham Young University and Indiana State University.|
He is the author of CFHA's CollaboBlog.