This is the second in a four-part series. Click here for Part 1.
Family oriented care—it’s what sets Family Medicine apart from other specialties.
In medical school, doctors learn to think systemically. Our job as educators in family oriented care is to translate this from biological systems to family systems, to enhance physicians’ ability to care for patients in context and care for families across the life span.
As a result of our personal family experiences, we acquire a system of shared beliefs that influence our world view. These beliefs are informed by health, illness, religion, culture, race, politics, and socioeconomic status. Beliefs acquired in childhood may change as we grow and mature. It’s important that we have the freedom to question or express conflicting viewpoints. In some families, there’s not a lot of freedom to deviate from the shared belief system which results in emotional instability of the system and relationship stress even into adulthood.
When we teach about family health beliefs in the residency, we explore the role of our family experiences. Meaning of illness and coping strategies often reflect family folklore, practices from different cultures, or the strong influence of family health experts. We use case examples and reflections of our own personal stories to enhance resident understanding of these concepts.
Let’s follow Nancy and Chuck.
When they married, each brought their own core values and beliefs, which had been influenced by their family, culture and experiences.
Their developmental task was to integrate their values and shape the shared beliefs of their new family.
With a value of self-efficacy, they modeled the importance of self-care through organic gardening, a vegetarian diet, nutritional supplements and practiced transcendental meditation. They had informed partnership with their family doctor… but like in their own families of origin, health concerns were minimized and details were kept private.
At 51, an episode of hematuria led Nancy to an uncharacteristic and very private place of worry. Though her doctor felt confident this was just a UTI, Nancy shared her fear that this could be a sign of kidney disease. You see, she lost her father to kidney disease at age 52.
Patients aren’t always that forthcoming with us. Doctors and other healthcare providers need to be trained to recognize family health beliefs and utilize them in the care of patients. Our task is to teach physicians to be curious; to adjust their lens and take a closer look.
Our STFM and CFHA colleagues have created and shared valuable resources to support the development of knowledge and skills in family oriented care: books, patient and family centered observation forms, and a variety of teaching tools available on STFM Digital Resources Library. All there for you to adapt and use in your own program or setting.
We believe the learner’s family experience is an essential starting place when teaching family oriented care. We talk about what it means to have your family “in the room” with you and use guided self-reflection to help residents understand how their experiences and beliefs impact their care of patients and families. We discuss how to respect and manage instances when our values and beliefs are in conflict with those of our patients. Including, when it is appropriate to intervene or educate, and how to do this without damaging the doctor patient relationship.
Much of our Family Health Beliefs teaching takes place in a longitudinal small group seminar. In addition to assessing specific family oriented interviewing skills in video review, we coach residents to “listen for” and address family health beliefs through rich examples during video review.
One strategy for discovering important family beliefs is our “genogram in a nugget” question. We teach residents to ask “What’s the most important thing about your family history you want me to know?” In doing so, residents uncover significant beliefs or worries (often psychosocial in nature) that would be missed when taking a family medical history.
As an example, we share the story of a mom who brought her 8 year old in for the third time in a week due to an episode of bloody diarrhea. The resident was unable to reassure mom that this was just due to a GI bug the child had. Once he traded his annoyance for curiosity, he learned that mom’s brother was diagnosed with colon cancer, which presented as bloody stool. This completely changed how he handled the encounter.
We also layer teaching about family during home visits. Due to concerns about missed well child visits and multiple no-shows, we visited a young mom and her 3 children in their home. We learned that mom was raised with the belief that you don’t go to the doctor unless you’re sick, which led us to alter our approach to partnering with this family.
So, with layers of teaching about family in multiple settings, our residents are developing proficiency in providing family oriented care. They are able to recognize and utilize the influence of family beliefs in the care of patients, and they even prompt each other to take a closer look. Caring for families brings joy and meaning to our work.
Through the years, Chuck and Nancy have become more open to talking about medical issues. After running out of treatment options for multiple myeloma, Nancy underwent a stem cell transplant at 75. As a gesture of support, Chuck shaved his head and she wore a pink wig for her homecoming with the grandchildren… diffusing the worry they held for their Nana. Through their example, the family is learning how to live with illness.
Nancy is now 80 and has dementia. A consummate problem solver, Chuck devours the literature and tries a variety of alternative treatments to slow the progression of her decline: Reiki, targeted supplements, marijuana, stem cell therapy, coconut oil, alkaline diet, etc.
Valuing his opinion, Chuck updates their family doctor on Nancy’s symptoms and his efforts to find something to make a difference. Their doctor listens reflectively. Gently, he suggests the evidence for these things is weak at best. He pauses, then sharpens his focus on the patient and caregiver. He recognizes Chuck’s dedication and love for Nancy. The best intervention he can offer is to hold their hope and respect his efforts. He is just what they need during this difficult time.
Amy Romain, LMSW, ACSW, is an Assistant Professor and Director of Behavioral Medicine in the Sparrow-Michigan State University Family Medicine Residency Program. She is passionate about the importance of understanding and utilizing the patient’s context to the doctor-patient relationship and in clinical decision making. Amy is a champion for family oriented care and primary care behavioral health integration. This blog post is an adaptation of her recent Pecha Kucha presentation at the STFM Annual Spring Conference.