I overheard a family physician lament about the unraveling of family practice. It was after a long day of seeing single parent families, grandparents raising children, and endless single pregnant women. The statement was something along the lines of “A single mother and her baby are not a family. This is not why I went into practice.” I sensed frustration and disillusionment from someone who idealized caring for mom, dad, kids, and grandma and grandpa. I put my initial feelings aside and tried stepping into his shoes. A theme I kept coming back to was: how do provider definitions of ‘family’ or the ‘ideal family’ impact patient care and provider wellbeing?
Within the past few years, there has been increased discussion about both how to define family and who defines family. The Syrian refugee crisis has reignited debate over the laws that govern and programs that service immigrant, refugee, and undocumented families. It has also highlighted how families are torn apart in times of war and conflict, leaving them grappling to redefine themselves. Gay marriage has also been legalized in our country more recently, and there continue to be discussions about its legality and morality. Family structures have changed in other ways as well. Births to older women are on the rise and overall birth rates are low (Howe, 2015; Matthews & Hamilton, 2014). Statistics also indicate that approximately 60% of children live in a family with married parents where at least one works. The other 40% live with single parents, grandparents, a parent and their significant other, or other situations (Council on Contemporary Families, 2012). In 2012, the chances that two children selected at random would share the same family constellation was just under 50%, compared to about 80% in 1960 (Council on Contemporary Families, 2012). In other situations and within certain cultures, family members may not be blood relatives but close friends. At this point, it is challenging to identify the ‘typical American family’ because there is no dominant family form (Council on Contemporary Families, 2012).
If there is no dominant family form, how do we provide family healthcare? How family is legally defined in healthcare influences treatment. We are reminded of this as non-legal significant others or non-legal parents have a more difficult time obtaining information and making treatment decisions for minor patients or unresponsive loved ones. They are not considered next of kin, and proper paper work needs to be in place to ensure communication with healthcare providers. How we address these ethical and legal issues could be a blog post in itself!
Perhaps most relevant to the physician’s comment… how much do providers’ personal definitions of family influence care? In February 2015, a news story came out about a pediatrician who declined to treat a lesbian couple’s baby. According to the note the physician sent the couple, she feared she would not be able to establish a good doctor-patient relationship the way she normally does. She did not elaborate whether this was due to the couple’s sexual orientation, but many believed it did. The story raised questions about how the physician handled the manner, and whether it was appropriate, moral, and legal. Assuming the concern was over the morality of their family structure, what would have happened if the pediatrician HAD chosen to work with that family? How could her beliefs influence care? What about the family physician I overheard who was frustrated that the families he treated did not fit his definition of family? Did he take a subtle tone of frustration or disapproval into the room? Did he spend less time with those patients?
Conversely, did he spend more time out of possibly misplaced fear about children’s well-being in a ‘broken home’? Sometimes a provider views the family as ‘un-whole’ or ‘broken’ and may treat members with pity or attribute their concerns to their ‘brokenness’. At that point, the provider has decided to define the family’s value based on personal biases and assumptions instead of the patient’s perspective and circumstances. If a single mother chooses to be single because she can keep her children safe or hold a higher paying job, the family may not need pity or additional resources. A well-intentioned provider may react without knowing the family’s story or integrating the family’s perspective into treatment.
One way to address assumptions and biases is during training. Across the nation, medical students and residents learn algorithms, evidence-based medicine, procedures, and standards of care. They learn how to assess, diagnose, and treat. Self-reflection becomes secondary, tertiary, or non-existent. Especially for those who plan to work with families, reflection ought to be structured into their training. Providers should be able to identify ways to address family concerns or structures they find questionable and be aware of how their treatment of these families may be subtly different. At the very least, there should be a willingness to be open and vulnerable and to wrestle with these questions. There should be safe places built into curriculum for this exploration. Practitioners are human. They hold a variety of beliefs and definitions of family. They are also accountable for providing quality family-centered care.
At the end of my day, I heard something that made me smile. A resident who was opposed to premarital sex visited with a scared, newly pregnant, unwed teenage couple. In both her check-out with the preceptor and in the room with the patients, she remained respectful, family-centered, and encouraging. The physician said to the couple “A baby doesn’t see teenage parents. Baby sees mom and dad. Be that mom and dad.”
||Lisa Zak-Hunter, PhD, LMFT is Behavioral Science Educator/Clinical Assistant Professor at the University of Kansas School of Medicine-Wichita at Via Christi Family Medicine Residency. Her main clinical, teaching, and research interests lie in the realms of collaborative health care, increasing biopsychosocial understanding of mental and medical health conditions, and practitioner self-care. She has a particular interest in adult eating disorders. Within CFHA, she co-edits the Families and Health Blog and serves as Social Media Director.