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- Sixteen percent of adult patients have a companion present in the examination room during their ambulatory medical appointments.
- Companions are more common with older, less well educated, and more medically or socially complex patients.
- Companions participate actively during the encounter.
- Companions often improve patient and physician understanding during the encounter.
Although common, third party involvement in adult medical care has not been well studied. This prospective study explored the frequency of companions, the reasons for accompaniment, and the companion’s influence on the medical encounter from the perspective of the patient, the companion, and the physician.
Methods
Setting, physicians, and patients
The study was conducted at the general internal medicine practice of the University of Colorado Health Sciences Center. Fifteen full-time faculty and 42 internal medicine residents participated. A companion was defined as any person older than 18 years who accompanied a patient to a medical visit and was designated as an examination room companion if that person spent any portion of the visit in the examination room; otherwise, that person was designated as a waiting room companion. Persons employed solely to provide transportation services for patients were not considered companions.
Study design
The study consisted of 2 parts: a prospective study to document the frequency of patient accompaniment by a third person to ambulatory medicine visits, and a survey of patients, companions, and physicians to explore the rationales and influence of the companion during the medical encounter. A professional research assistant was present for an average of 8 of 10 half-day clinics per week. To accomplish the first objective, a research assistant directly observed 1294 consecutive patient visits from September 22 to October 29, 1998. To accomplish the second objective, from mid-September to mid-November, a professional research assistant attempted to enroll all consecutive patients accompanied to their appointments. Unaccompanied patients were approached for consent at the convenience of the research assistant. Patients and their companions were approached for consent in the waiting room immediately before their visits.
For inclusion, patients and companions provided consent and were literate in English. Patients, companions, and physicians independently completed self-administered questionnaires immediately after their visits. All were informed that responses were confidential and would not be disclosed to one another. This study was reviewed and approved by the Colorado Multiple Institutional Review Board.
Questionnaire development
The survey instruments were developed after a thorough review of existing research1,6-10and refined by pilot testing and review with a professional survey consultant. Patients and companions completed demographic questions (Table 1). Patients rated their overall health, stated their relationship to the companion, and indicated the reasons for companion accompaniment (Table 2). Patients and companions indicated from a list of 7 items (Table 2) how the companion influenced the visit and rated the companion’s helpfulness during the encounter (5-point Likert scale: 1 = very unhelpful to 5 = very helpful).
TABLE 1
Patient demographics and characteristics*
| Companion in examination room (A) | Patient alone (B) | P, A vs B | Companion in waiting room (C) | P, A vs C | |
|---|---|---|---|---|---|
| Total | 115 | 121 | 85 | ||
| Female | 57 (54) | 76 (73) | .19 | 58 (71) | .022 |
| Age (y) | |||||
| 18–44 | 21 (20) | 39 (33) | <.001> | 16 (20) | .06 |
| 45–64 | 34 (33) | 55 (46) | 39 (49) | ||
| ≥65 | 49 (47) | 26 (22) | 25 (31) | ||
| Race | |||||
| White | 73 (72) | 79 (66) | .09 | 56 (73) | .73 |
| Black/African American | 7 (7) | 22 (18) | 8 (10) | ||
| Hispanic/Latino | 16 (16) | 14 (12) | 11 (14) | ||
| Other | 5 (5) | 5 (5) | 2 (3) | ||
| Education ≤ high school | 57 (56) | 40 (33) | <.001> | 48 (61) | .56 |
| Income (US dollars/y) | |||||
| 47 (51) | 61 (54) | .82 | 39 (53) | .50 | |
| 15,000–35,000 | 23 (25) | 29 (25) | 22 (30) | ||
| >35,000 | 23 (25) | 24 (21) | 13 (18) | ||
| Self-noted health | |||||
| Poor/fair | 58 (53) | 53 (44) | .37 | 40 (48) | .13 |
| Good | 28 (25) | 34 (28) | 32 (38) | ||
| Very good/excellent | 24 (22) | 34 (28) | 12 (14) | ||
| Medical and social complexity (MD rating) | |||||
| Simple/straightforward | 6 (5) | 27 (24) | <.001> | 11 (13) | <.001> |
| Average | 24 (21) | 36 (32) | 32 (39) | ||
| Somewhat/very complex | 83 (73) | 51 (45) | 39 (48) | ||
| Patient visit type | |||||
| Return with primary provider | 85 (75) | 73 (64) | .16 | 51 (62) | .07 |
| New with primary provider | 18 (16) | 28 (25) | 15 (18) | ||
| Episodic with provider other than primary | 10 (9) | 13 (12) | 16 (20) | ||
| Physician | |||||
| Faculty | 68 (62) | 55 (45) | .01 | 44 (52) | .19 |
| Resident | 42 (38) | 66 (55) | 40 (48) | ||
| Some categories are missing data, so the columns do not equal n. Percentages were computed based on available data, and some columns equal 101% because of round-off error. | |||||
| *Values are number (percentage) unless otherwise indicated. | |||||
TABLE 2
Patients’ and companions’ reports of companion’s reasons for accompaniment and influence on the medical encounter*
| Patient’s report | Companion’s report | ||||||
|---|---|---|---|---|---|---|---|
| Companion in waiting room | Companion in examination room | P † waiting room | Companion in waiting room | Companion in examination room | P † waiting room | ||
| Companion’s reasons for accompaniment | |||||||
| Help with transportation | 58 (69) | 61 (55) | .05 | 64 (79) | 66 (58) | .003 | |
| Provide company | 39 (46) | 58 (53) | .39 | 43 (53) | 55 (49) | .59 | |
| Help communicate concerns to the doctor | 6 (7) | 56 (51) | <.001> | 5 (6) | 60 (53) | <.001> | |
| Help remember physician’s advice and instructions | 4 (5) | 51 (46) | <.001> | 5 (6) | 54 (48) | <.001> | |
| Provide emotional support | 20 (24) | 48 (44) | .004 | 27 (33) | 60 (53) | .006 | |
| Express concerns regarding the patient to the physician | 6 (7) | 41 (37) | <.001> | 9 (11) | 51 (45) | <.001> | |
| Help make decisions | 5 (6) | 39 (35) | <.001> | 2 (2) | 32 (28) | <.001> | |
| Help with language barriers | 1 (1) | 14 (13) | .003 | 0 (0) | 12 (11) | <.002> | |
| Help with insurance or payment forms | 7 (8) | 11 (10) | .69 | 7 (9) | 5 (4) | .23 | |
| Companion’s influence on medical encounter | |||||||
| No influence or don’t know | 57 (70) | 28 (25) | <.001> | 58 (72) | 24 (21) | <.001> | |
| Companion influenced | |||||||
| Physician understanding | 5 (6) | 63 (57) | <.001> | 5 (6) | 69 (61) | <.001> | |
| Patient understanding | 3 (4) | 59 (54) | <.001> | 10 (12) | 68 (60) | <.001> | |
| Tests ordered | 3 (4) | 13 (12) | .039 | 1 (1) | 12 (11) | .01 | |
| Prescribed treatment | 1 (1) | 26 (24) | <.001> | 4 (5) | 26 (23) | <.001> | |
| Number of referrals | 0 (0) | 10 (9) | .005 | 1 (1) | 6 (5) | .13 | |
| Length of visit | 7 (8) | 19 (17) | .07 | 6 (7) | 20 (18) | .04 | |
| *Values are number (percentage) unless otherwise indicated. | |||||||
| † Difference between waiting room and examination room companion. | |||||||
TABLE 3
Physician report of examination room companion’s influence on the medical encounter*
| Decreased | No influence | Increased | |
|---|---|---|---|
| Communication | |||
| Physician’s understanding | 1 (1) | 43 (39) | 66 (60 |
| Patient’s understanding | 0 (0) | 59 (54) | 51 (46) |
| Resource use | |||
| Time spent explaining/ counseling | 9 (8) | 66 (60) | 35 (32) |
| Length of visit | 6 (7) | 75 (68) | 28 (25) |
| Treatment recommended | 2 (2) | 106 (96) | 2 (2) |
| Number of referrals | 1 (1) | 106 (96) | 2 (2) |
| Number of tests ordered | 2 (2) | 106 (96) | 1 (1) |
| n = 114. | |||
| *Values are number (percentage). | |||
Physician report of examination room companion’s behaviors
| Behavior | n (%) |
|---|---|
| Active behaviors | |
| Clarified or expanded history | 71 (65) |
| Supportive/encouraging toward patient | 71 (65) |
| Asked questions/requested explanations | 53 (48) |
| Discussed concerns about patient’s symptoms/problems | 50 (45) |
| Made evaluation or treatment requests | 19 (17) |
| Took notes | 14 (13) |
| Distractive behaviors | |
| Discussed own symptoms | 16 (15) |
| Discouraging/controlling toward patient | 7 (6) |
| Passive behaviors | |
| Passive observer | 17 (15) |
| n = 114. | |
Data analysis
Data were used from each member of a set regardless of survey completion by other set members. One patient had 2 examination room companions and 2 patients had 2 waiting room companions. In each case, both companions were surveyed. In the 2 cases in which a patient had waiting and examination room companions, the examination room companion was considered more influential for the medical encounter and only that person was surveyed.
The data were analyzed with SAS version 6.12 (SAS Inc, Cary, NC) using bivariate and multivariable methods. Comparisons were made between patient categories (patient alone, patient with examination room companion, patients with waiting room companion) using the chi-square statistic for categorical variables.
Multivariable analyses were conducted to explore the effects of various independent variables on the decision to bring a companion into the examination room. The outcome variables for the regression models were defined by patient status (patient alone, patient with examination room companion, patient with waiting room companion). All significant variables (P ≤ .05) in bivariate analyses were entered into the multivariate analyses. Odds ratios (ORs) with 95% confidence intervals (CIs) were obtained for each variable in the model.
Patient and companion agreement on the reasons for accompaniment and influence on the medical encounter were measured with the kappa statistic. Kappas (κ) of 1.0 to .75 denote excellent agreement, .4 to .75 denote good agreement, and 0 to .4 denote marginal agreement.11
RESULTS
Of the 1294 patient visits, 834 (64%) were to faculty physicians and 451 (35%) were to resident physicians. Overall, companions were present for 29% (n = 374) of patient visits and accompanied the patient into the examination room for 16% (n = 212) of visits. Companions accompanied patients to 23% (n = 196) of faculty visits and 39% (n = 178) of resident visits (P P = .98).
Ninety-three percent (121/130) of unaccompanied patients and 92% (200/217) of consecutive patient–companion pairs approached for consent agreed to participate in the study. In 26 cases the patient or the companion refused to participate for 1of the following reasons: language barrier, too ill, lack of time, invasion of privacy, or uncomfortable with process of consent. Patients and physicians completed surveys for 97% of patient encounters, and companions completed surveys for 99% of patient encounters.
Comparisons between accompanied and unaccompanied patients are presented in Table 1. The fact that faculty physicians had a greater proportion of accompanied patients who received and completed surveys is likely due to the necessity of English literacy for inclusion into the survey study. At this practice site, patients cared for by residents are more likely to be non-English speaking and have a companion for the purpose of translation. Examination room companions were often the spouse or partner (55%), parents (17%), or less frequently roommate or friend (7%), whereas waiting room companions were commonly a spouse or partner (46%) or roommate or friend (24%). Overall, family members accounted for 93% of examination room companions and 76% of waiting room companions. Examination room companions were more likely to be female than waiting room companions (65% vs 51%, P = .05). Patients who were older, less well educated, and whose cases had greater medical or social complexity were more likely to have a companion in the examination room.
Patients’ and companions’ assessments of the reasons for accompaniment and the companions’ influence on communication and resource use are shown in Table 2. The patients’ and companions’ stated reasons for companion accompaniment were in good agreement with the kappa statistic ranging from 0.41 for “help with insurance forms” to 0.61 for “help remember the physician’s advice.” Patients’ and companions’ agreement regarding the influence of the companion on the medical visit was less than 0.4, suggesting marginal agreement for tests ordered (κ = .29), prescribed treatment (κ = .36), and length of visit (κ = .33). There was good agreement for number of referrals (κ = .45) and for physician and patient understanding (κ = .62 and .60, respectively).
Table 3 displays the physicians’ reports of the examination room companion’s influence on the medical encounter. Table 4 shows the physicians’ reports of the behavior of the examination room companions.
Patients regarded examination and waiting room companions as “very helpful” for 84% and 71% of visits, respectively, and as “very unhelpful” for 1% of visits. Of the 121 patients who came alone to their medical visits, 7% indicated that they considered bringing a companion to their visits and 16% thought a companion’s presence would have been helpful.
Physicians regarded examination room companions as “somewhat to very helpful” for 66% of visits. When physicians did not have contact with a companion, they indicated that contact would have been helpful for 16% of patient encounters.
Multivariable analyses explored the effects of independent variables on the decision to bring a companion into the examination room. A physician rating of a case of having greater medical and social complexity was the only variable associated with companion accompaniment to the examination room vs not having a companion (OR, 1.7; 95% CI, 1.4–2.1). Patient characteristics and patients’ reported reasons for accompaniment were factors influencing accompaniment into the examination room vs the waiting room. A need for help with communicating concerns to the physician (OR, 7.8; 95% CI, 2.4–25.6), help with remembering the physician’s advice and instructions (OR, 7.1; 95% CI, 2.0–25.3), and greater medical and social complexity of cases (OR, 1.5; 95% CI, 1.1–2.0) were associated with being accompanied to the examination room over just the waiting room. In contrast, needing help with transportation was negatively associated with having a companion in the examination room vs the waiting room (OR, 0.2; 95% CI, 0.1–0.5).
DISCUSSION
Companions frequently accompany adult patients and participate in ambulatory medical encounters. We found that companions accompanied 29% of patients and were present in the examination room for 16% of outpatient medical encounters. Examination room companions often were present to aid communication with the physician and to help the patient remember instructions. Physicians, patients, and companions believed that physician and patient understanding often were favorably affected by the presence of a companion. A companion’s presence in the examination room had beneficial effects on patient and physician understanding and very rarely had a negative effect. These findings reflect the results of previous studies in which approximately 33% of patients were accompanied to family medicine and geriatric encounters and 66% of these companions were present in the examination room.1,7-10,12,13 The only variable associated with accompaniment into the examination room vs presenting to one’s appointment alone was a physician rating of greater medical and social complexity. This finding also corroborates the findings of other studies.7,14,15
Some research has suggested a negative effect of a third person during the medical encounter. For example, older patients in triadic encounters raise fewer topics, are less assertive, and participate less in humor and joint decision making.6 Other research has failed to find a benefit in health outcomes with the presence of a companion, and unaccompanied patients rated themselves as having greater understanding of their medical problems and greater faith that their physicians were doing everything possible for them than patients accompanied to their visits.15 Still others have found that physicians provide more information and time but less emotional support to accompanied patients.7
Unique to our study was the specific assessment of companion influence on various aspects of the medical encounter from the perspectives of the companion, patient, and physician. As expected, examination room companions had significant influence on aspects of communication. Examination room companions were generally considered helpful by patients and physicians. Physicians may use the companion and patient as barometers of the visit’s accomplished goals. Hence, the time spent listening to a companion provide information about a patient’s medical problems might be balanced by the provision of less emotional support to the patient, especially if the companion is providing that support. The physician may offer an explanation until confident that either party (patient or companion) has a complete understanding. As demonstrated by the results, physicians, patients, and companions thought that patient understanding was increased in approximately 50% of encounters by a companion’s presence, and companions overwhelmingly were considered very helpful by patients.
Our study was limited to 1 urban, academic, general internal medicine practice and may not be generalizable to other settings. The method of assessing medical and social complexities was simple, and the very presence of an examination room companion may have biased physicians to rate these patients as having more complex problems than unaccompanied patients. Also, the longer period of the second part of the study necessary to enroll 200 patient–companion pairs, compared with the companion frequency data of the first part of the study, suggested that we did not enroll “consecutive” patient–companion pairs. This may be explained by the exclusion of patient–companion pairs when either party was not literate in English. Also, the logistics of obtaining consent and administering post visit questionnaires by a single research assistant interfered with the attempt to enroll all patient–companion pairs. Convenience enrollment of unaccompanied patients may have been biased. The effect of the companion on the medical encounter was not verified by objective measures such as timing visit length. Further, patients, companions, and physicians rated the effect of the companion’s presence immediately after the encounter; the full effect of the companion’s presence might require more time to emerge.
Companions frequently accompany patients to their ambulatory general medicine visits. The companion is usually a family member who is present at the request of the patient. Companions assume important roles and are overwhelmingly considered helpful by patients. Nonetheless, some of the behaviors that contribute to an effective physician–patient relationship might be diluted by the presence of a companion. Future directions of study include (1) assessing the effect of the companion on the physician–patient relationship, including specific aspects of communication and behavior, and (2) determining whether companion involvement influences health outcomes or resource use.
· Acknowledgments ·
We thank Marcia Blake, MA, for her statistical expertise; Jean Kutner, MD, MSPH, for her assistance with data analysis and statistical expertise; and Robert Dellavalle, MD, PhD, for his editorial assistance.
1. American Medical Association, Council on Scientific Affairs. Physician and family caregivers: a model for partnership. JAMA 1993;269:1282-4.
2. Botelho RJ, Lue BH, Fiscella K. Family involvement in routine health care: a survey of patients’ behaviors and p. J Fam Pract 1996;42:572-6.
3. Levine C, Zuckerman C. The trouble with families: toward an ethic of accommodation. Ann Intern Med 1999;130:148-52.
4. Zuckerman C. End of Life Care Decisions and Hospital Legal Counsel: Current Involvement and Opportunities for the Future. New York: Milbank Memorial Fund; 1999:8.
5. Jecker NS. The role of intimate others in medical decision making. Gerontologist 1990;30:65-71.
6. Greene MG, Majerovitz D, Adelman RD, Rizzo C. The effects of the presence of a third person on the physician older patient medical interview. J Am Geriatr Soc 1994;42:413-9.
7. Labrecque MS, Blanchard CG, Ruckdeschel JC, Blanchard EB. The impact of family presence on the physician cancer patient interaction. Soc Sci Med 1991;33:1253-61.
8. Medalie JH, Zyzanski SJ, Langa D, Stange KC. The family in family practice: is it a reality? J Fam Pract 1998;46:390-5.
9. Brown JB, Brett P, Stewart M, Marshall JN. Roles and influence of people who accompany patients on visits to the doctor. Can Fam Phys 1998;44:1644-50.
10. Beisecker AE, Brecheisen MA, Ashworth J, Hayes J. Perceptions of the role of cancer patients’ companions during medical appointments. J Psychosoc Oncol 1996;14:29-45.
11. Rosner B. Fundamentals of Biostatistics. San Francisco, CA: Duxbury Press; 1995.
12. Greene MG, Adelman RD, Charon R, Hoffman S. Ageism in the medical encounter: an exploratory study of the doctor elderly patient relationship. Lang Commun 1986;6:113-24.
13. Beisecker AE. The influence of a companion on the doctor elderly patient interaction. Health Commun 1989;1:55-70.
14. Beiseker AE. Aging and the desire of information and input in medical decisions: patients’ consumerism in medical encounters. Gerontologist 1998;28:330-5.
15. Prohaska TR, Glasser M. Patients’ views of family involvement in medical care decisions and encounters. Res Aging 1996;18:52-69.
- Sixteen percent of adult patients have a companion present in the examination room during their ambulatory medical appointments.
- Companions are more common with older, less well educated, and more medically or socially complex patients.
- Companions participate actively during the encounter.
- Companions often improve patient and physician understanding during the encounter.
Although common, third party involvement in adult medical care has not been well studied. This prospective study explored the frequency of companions, the reasons for accompaniment, and the companion’s influence on the medical encounter from the perspective of the patient, the companion, and the physician.
Methods
Setting, physicians, and patients
The study was conducted at the general internal medicine practice of the University of Colorado Health Sciences Center. Fifteen full-time faculty and 42 internal medicine residents participated. A companion was defined as any person older than 18 years who accompanied a patient to a medical visit and was designated as an examination room companion if that person spent any portion of the visit in the examination room; otherwise, that person was designated as a waiting room companion. Persons employed solely to provide transportation services for patients were not considered companions.
Study design
The study consisted of 2 parts: a prospective study to document the frequency of patient accompaniment by a third person to ambulatory medicine visits, and a survey of patients, companions, and physicians to explore the rationales and influence of the companion during the medical encounter. A professional research assistant was present for an average of 8 of 10 half-day clinics per week. To accomplish the first objective, a research assistant directly observed 1294 consecutive patient visits from September 22 to October 29, 1998. To accomplish the second objective, from mid-September to mid-November, a professional research assistant attempted to enroll all consecutive patients accompanied to their appointments. Unaccompanied patients were approached for consent at the convenience of the research assistant. Patients and their companions were approached for consent in the waiting room immediately before their visits.
For inclusion, patients and companions provided consent and were literate in English. Patients, companions, and physicians independently completed self-administered questionnaires immediately after their visits. All were informed that responses were confidential and would not be disclosed to one another. This study was reviewed and approved by the Colorado Multiple Institutional Review Board.
Questionnaire development
The survey instruments were developed after a thorough review of existing research1,6-10and refined by pilot testing and review with a professional survey consultant. Patients and companions completed demographic questions (Table 1). Patients rated their overall health, stated their relationship to the companion, and indicated the reasons for companion accompaniment (Table 2). Patients and companions indicated from a list of 7 items (Table 2) how the companion influenced the visit and rated the companion’s helpfulness during the encounter (5-point Likert scale: 1 = very unhelpful to 5 = very helpful).
TABLE 1
Patient demographics and characteristics*
| Companion in examination room (A) | Patient alone (B) | P, A vs B | Companion in waiting room (C) | P, A vs C | |
|---|---|---|---|---|---|
| Total | 115 | 121 | 85 | ||
| Female | 57 (54) | 76 (73) | .19 | 58 (71) | .022 |
| Age (y) | |||||
| 18–44 | 21 (20) | 39 (33) | <.001> | 16 (20) | .06 |
| 45–64 | 34 (33) | 55 (46) | 39 (49) | ||
| ≥65 | 49 (47) | 26 (22) | 25 (31) | ||
| Race | |||||
| White | 73 (72) | 79 (66) | .09 | 56 (73) | .73 |
| Black/African American | 7 (7) | 22 (18) | 8 (10) | ||
| Hispanic/Latino | 16 (16) | 14 (12) | 11 (14) | ||
| Other | 5 (5) | 5 (5) | 2 (3) | ||
| Education ≤ high school | 57 (56) | 40 (33) | <.001> | 48 (61) | .56 |
| Income (US dollars/y) | |||||
| 47 (51) | 61 (54) | .82 | 39 (53) | .50 | |
| 15,000–35,000 | 23 (25) | 29 (25) | 22 (30) | ||
| >35,000 | 23 (25) | 24 (21) | 13 (18) | ||
| Self-noted health | |||||
| Poor/fair | 58 (53) | 53 (44) | .37 | 40 (48) | .13 |
| Good | 28 (25) | 34 (28) | 32 (38) | ||
| Very good/excellent | 24 (22) | 34 (28) | 12 (14) | ||
| Medical and social complexity (MD rating) | |||||
| Simple/straightforward | 6 (5) | 27 (24) | <.001> | 11 (13) | <.001> |
| Average | 24 (21) | 36 (32) | 32 (39) | ||
| Somewhat/very complex | 83 (73) | 51 (45) | 39 (48) | ||
| Patient visit type | |||||
| Return with primary provider | 85 (75) | 73 (64) | .16 | 51 (62) | .07 |
| New with primary provider | 18 (16) | 28 (25) | 15 (18) | ||
| Episodic with provider other than primary | 10 (9) | 13 (12) | 16 (20) | ||
| Physician | |||||
| Faculty | 68 (62) | 55 (45) | .01 | 44 (52) | .19 |
| Resident | 42 (38) | 66 (55) | 40 (48) | ||
| Some categories are missing data, so the columns do not equal n. Percentages were computed based on available data, and some columns equal 101% because of round-off error. | |||||
| *Values are number (percentage) unless otherwise indicated. | |||||
TABLE 2
Patients’ and companions’ reports of companion’s reasons for accompaniment and influence on the medical encounter*
| Patient’s report | Companion’s report | ||||||
|---|---|---|---|---|---|---|---|
| Companion in waiting room | Companion in examination room | P † waiting room | Companion in waiting room | Companion in examination room | P † waiting room | ||
| Companion’s reasons for accompaniment | |||||||
| Help with transportation | 58 (69) | 61 (55) | .05 | 64 (79) | 66 (58) | .003 | |
| Provide company | 39 (46) | 58 (53) | .39 | 43 (53) | 55 (49) | .59 | |
| Help communicate concerns to the doctor | 6 (7) | 56 (51) | <.001> | 5 (6) | 60 (53) | <.001> | |
| Help remember physician’s advice and instructions | 4 (5) | 51 (46) | <.001> | 5 (6) | 54 (48) | <.001> | |
| Provide emotional support | 20 (24) | 48 (44) | .004 | 27 (33) | 60 (53) | .006 | |
| Express concerns regarding the patient to the physician | 6 (7) | 41 (37) | <.001> | 9 (11) | 51 (45) | <.001> | |
| Help make decisions | 5 (6) | 39 (35) | <.001> | 2 (2) | 32 (28) | <.001> | |
| Help with language barriers | 1 (1) | 14 (13) | .003 | 0 (0) | 12 (11) | <.002> | |
| Help with insurance or payment forms | 7 (8) | 11 (10) | .69 | 7 (9) | 5 (4) | .23 | |
| Companion’s influence on medical encounter | |||||||
| No influence or don’t know | 57 (70) | 28 (25) | <.001> | 58 (72) | 24 (21) | <.001> | |
| Companion influenced | |||||||
| Physician understanding | 5 (6) | 63 (57) | <.001> | 5 (6) | 69 (61) | <.001> | |
| Patient understanding | 3 (4) | 59 (54) | <.001> | 10 (12) | 68 (60) | <.001> | |
| Tests ordered | 3 (4) | 13 (12) | .039 | 1 (1) | 12 (11) | .01 | |
| Prescribed treatment | 1 (1) | 26 (24) | <.001> | 4 (5) | 26 (23) | <.001> | |
| Number of referrals | 0 (0) | 10 (9) | .005 | 1 (1) | 6 (5) | .13 | |
| Length of visit | 7 (8) | 19 (17) | .07 | 6 (7) | 20 (18) | .04 | |
| *Values are number (percentage) unless otherwise indicated. | |||||||
| † Difference between waiting room and examination room companion. | |||||||
TABLE 3
Physician report of examination room companion’s influence on the medical encounter*
| Decreased | No influence | Increased | |
|---|---|---|---|
| Communication | |||
| Physician’s understanding | 1 (1) | 43 (39) | 66 (60 |
| Patient’s understanding | 0 (0) | 59 (54) | 51 (46) |
| Resource use | |||
| Time spent explaining/ counseling | 9 (8) | 66 (60) | 35 (32) |
| Length of visit | 6 (7) | 75 (68) | 28 (25) |
| Treatment recommended | 2 (2) | 106 (96) | 2 (2) |
| Number of referrals | 1 (1) | 106 (96) | 2 (2) |
| Number of tests ordered | 2 (2) | 106 (96) | 1 (1) |
| n = 114. | |||
| *Values are number (percentage). | |||
Physician report of examination room companion’s behaviors
| Behavior | n (%) |
|---|---|
| Active behaviors | |
| Clarified or expanded history | 71 (65) |
| Supportive/encouraging toward patient | 71 (65) |
| Asked questions/requested explanations | 53 (48) |
| Discussed concerns about patient’s symptoms/problems | 50 (45) |
| Made evaluation or treatment requests | 19 (17) |
| Took notes | 14 (13) |
| Distractive behaviors | |
| Discussed own symptoms | 16 (15) |
| Discouraging/controlling toward patient | 7 (6) |
| Passive behaviors | |
| Passive observer | 17 (15) |
| n = 114. | |
Data analysis
Data were used from each member of a set regardless of survey completion by other set members. One patient had 2 examination room companions and 2 patients had 2 waiting room companions. In each case, both companions were surveyed. In the 2 cases in which a patient had waiting and examination room companions, the examination room companion was considered more influential for the medical encounter and only that person was surveyed.
The data were analyzed with SAS version 6.12 (SAS Inc, Cary, NC) using bivariate and multivariable methods. Comparisons were made between patient categories (patient alone, patient with examination room companion, patients with waiting room companion) using the chi-square statistic for categorical variables.
Multivariable analyses were conducted to explore the effects of various independent variables on the decision to bring a companion into the examination room. The outcome variables for the regression models were defined by patient status (patient alone, patient with examination room companion, patient with waiting room companion). All significant variables (P ≤ .05) in bivariate analyses were entered into the multivariate analyses. Odds ratios (ORs) with 95% confidence intervals (CIs) were obtained for each variable in the model.
Patient and companion agreement on the reasons for accompaniment and influence on the medical encounter were measured with the kappa statistic. Kappas (κ) of 1.0 to .75 denote excellent agreement, .4 to .75 denote good agreement, and 0 to .4 denote marginal agreement.11
RESULTS
Of the 1294 patient visits, 834 (64%) were to faculty physicians and 451 (35%) were to resident physicians. Overall, companions were present for 29% (n = 374) of patient visits and accompanied the patient into the examination room for 16% (n = 212) of visits. Companions accompanied patients to 23% (n = 196) of faculty visits and 39% (n = 178) of resident visits (P P = .98).
Ninety-three percent (121/130) of unaccompanied patients and 92% (200/217) of consecutive patient–companion pairs approached for consent agreed to participate in the study. In 26 cases the patient or the companion refused to participate for 1of the following reasons: language barrier, too ill, lack of time, invasion of privacy, or uncomfortable with process of consent. Patients and physicians completed surveys for 97% of patient encounters, and companions completed surveys for 99% of patient encounters.
Comparisons between accompanied and unaccompanied patients are presented in Table 1. The fact that faculty physicians had a greater proportion of accompanied patients who received and completed surveys is likely due to the necessity of English literacy for inclusion into the survey study. At this practice site, patients cared for by residents are more likely to be non-English speaking and have a companion for the purpose of translation. Examination room companions were often the spouse or partner (55%), parents (17%), or less frequently roommate or friend (7%), whereas waiting room companions were commonly a spouse or partner (46%) or roommate or friend (24%). Overall, family members accounted for 93% of examination room companions and 76% of waiting room companions. Examination room companions were more likely to be female than waiting room companions (65% vs 51%, P = .05). Patients who were older, less well educated, and whose cases had greater medical or social complexity were more likely to have a companion in the examination room.
Patients’ and companions’ assessments of the reasons for accompaniment and the companions’ influence on communication and resource use are shown in Table 2. The patients’ and companions’ stated reasons for companion accompaniment were in good agreement with the kappa statistic ranging from 0.41 for “help with insurance forms” to 0.61 for “help remember the physician’s advice.” Patients’ and companions’ agreement regarding the influence of the companion on the medical visit was less than 0.4, suggesting marginal agreement for tests ordered (κ = .29), prescribed treatment (κ = .36), and length of visit (κ = .33). There was good agreement for number of referrals (κ = .45) and for physician and patient understanding (κ = .62 and .60, respectively).
Table 3 displays the physicians’ reports of the examination room companion’s influence on the medical encounter. Table 4 shows the physicians’ reports of the behavior of the examination room companions.
Patients regarded examination and waiting room companions as “very helpful” for 84% and 71% of visits, respectively, and as “very unhelpful” for 1% of visits. Of the 121 patients who came alone to their medical visits, 7% indicated that they considered bringing a companion to their visits and 16% thought a companion’s presence would have been helpful.
Physicians regarded examination room companions as “somewhat to very helpful” for 66% of visits. When physicians did not have contact with a companion, they indicated that contact would have been helpful for 16% of patient encounters.
Multivariable analyses explored the effects of independent variables on the decision to bring a companion into the examination room. A physician rating of a case of having greater medical and social complexity was the only variable associated with companion accompaniment to the examination room vs not having a companion (OR, 1.7; 95% CI, 1.4–2.1). Patient characteristics and patients’ reported reasons for accompaniment were factors influencing accompaniment into the examination room vs the waiting room. A need for help with communicating concerns to the physician (OR, 7.8; 95% CI, 2.4–25.6), help with remembering the physician’s advice and instructions (OR, 7.1; 95% CI, 2.0–25.3), and greater medical and social complexity of cases (OR, 1.5; 95% CI, 1.1–2.0) were associated with being accompanied to the examination room over just the waiting room. In contrast, needing help with transportation was negatively associated with having a companion in the examination room vs the waiting room (OR, 0.2; 95% CI, 0.1–0.5).
DISCUSSION
Companions frequently accompany adult patients and participate in ambulatory medical encounters. We found that companions accompanied 29% of patients and were present in the examination room for 16% of outpatient medical encounters. Examination room companions often were present to aid communication with the physician and to help the patient remember instructions. Physicians, patients, and companions believed that physician and patient understanding often were favorably affected by the presence of a companion. A companion’s presence in the examination room had beneficial effects on patient and physician understanding and very rarely had a negative effect. These findings reflect the results of previous studies in which approximately 33% of patients were accompanied to family medicine and geriatric encounters and 66% of these companions were present in the examination room.1,7-10,12,13 The only variable associated with accompaniment into the examination room vs presenting to one’s appointment alone was a physician rating of greater medical and social complexity. This finding also corroborates the findings of other studies.7,14,15
Some research has suggested a negative effect of a third person during the medical encounter. For example, older patients in triadic encounters raise fewer topics, are less assertive, and participate less in humor and joint decision making.6 Other research has failed to find a benefit in health outcomes with the presence of a companion, and unaccompanied patients rated themselves as having greater understanding of their medical problems and greater faith that their physicians were doing everything possible for them than patients accompanied to their visits.15 Still others have found that physicians provide more information and time but less emotional support to accompanied patients.7
Unique to our study was the specific assessment of companion influence on various aspects of the medical encounter from the perspectives of the companion, patient, and physician. As expected, examination room companions had significant influence on aspects of communication. Examination room companions were generally considered helpful by patients and physicians. Physicians may use the companion and patient as barometers of the visit’s accomplished goals. Hence, the time spent listening to a companion provide information about a patient’s medical problems might be balanced by the provision of less emotional support to the patient, especially if the companion is providing that support. The physician may offer an explanation until confident that either party (patient or companion) has a complete understanding. As demonstrated by the results, physicians, patients, and companions thought that patient understanding was increased in approximately 50% of encounters by a companion’s presence, and companions overwhelmingly were considered very helpful by patients.
Our study was limited to 1 urban, academic, general internal medicine practice and may not be generalizable to other settings. The method of assessing medical and social complexities was simple, and the very presence of an examination room companion may have biased physicians to rate these patients as having more complex problems than unaccompanied patients. Also, the longer period of the second part of the study necessary to enroll 200 patient–companion pairs, compared with the companion frequency data of the first part of the study, suggested that we did not enroll “consecutive” patient–companion pairs. This may be explained by the exclusion of patient–companion pairs when either party was not literate in English. Also, the logistics of obtaining consent and administering post visit questionnaires by a single research assistant interfered with the attempt to enroll all patient–companion pairs. Convenience enrollment of unaccompanied patients may have been biased. The effect of the companion on the medical encounter was not verified by objective measures such as timing visit length. Further, patients, companions, and physicians rated the effect of the companion’s presence immediately after the encounter; the full effect of the companion’s presence might require more time to emerge.
Companions frequently accompany patients to their ambulatory general medicine visits. The companion is usually a family member who is present at the request of the patient. Companions assume important roles and are overwhelmingly considered helpful by patients. Nonetheless, some of the behaviors that contribute to an effective physician–patient relationship might be diluted by the presence of a companion. Future directions of study include (1) assessing the effect of the companion on the physician–patient relationship, including specific aspects of communication and behavior, and (2) determining whether companion involvement influences health outcomes or resource use.
· Acknowledgments ·
We thank Marcia Blake, MA, for her statistical expertise; Jean Kutner, MD, MSPH, for her assistance with data analysis and statistical expertise; and Robert Dellavalle, MD, PhD, for his editorial assistance.
- Sixteen percent of adult patients have a companion present in the examination room during their ambulatory medical appointments.
- Companions are more common with older, less well educated, and more medically or socially complex patients.
- Companions participate actively during the encounter.
- Companions often improve patient and physician understanding during the encounter.
Although common, third party involvement in adult medical care has not been well studied. This prospective study explored the frequency of companions, the reasons for accompaniment, and the companion’s influence on the medical encounter from the perspective of the patient, the companion, and the physician.
Methods
Setting, physicians, and patients
The study was conducted at the general internal medicine practice of the University of Colorado Health Sciences Center. Fifteen full-time faculty and 42 internal medicine residents participated. A companion was defined as any person older than 18 years who accompanied a patient to a medical visit and was designated as an examination room companion if that person spent any portion of the visit in the examination room; otherwise, that person was designated as a waiting room companion. Persons employed solely to provide transportation services for patients were not considered companions.
Study design
The study consisted of 2 parts: a prospective study to document the frequency of patient accompaniment by a third person to ambulatory medicine visits, and a survey of patients, companions, and physicians to explore the rationales and influence of the companion during the medical encounter. A professional research assistant was present for an average of 8 of 10 half-day clinics per week. To accomplish the first objective, a research assistant directly observed 1294 consecutive patient visits from September 22 to October 29, 1998. To accomplish the second objective, from mid-September to mid-November, a professional research assistant attempted to enroll all consecutive patients accompanied to their appointments. Unaccompanied patients were approached for consent at the convenience of the research assistant. Patients and their companions were approached for consent in the waiting room immediately before their visits.
For inclusion, patients and companions provided consent and were literate in English. Patients, companions, and physicians independently completed self-administered questionnaires immediately after their visits. All were informed that responses were confidential and would not be disclosed to one another. This study was reviewed and approved by the Colorado Multiple Institutional Review Board.
Questionnaire development
The survey instruments were developed after a thorough review of existing research1,6-10and refined by pilot testing and review with a professional survey consultant. Patients and companions completed demographic questions (Table 1). Patients rated their overall health, stated their relationship to the companion, and indicated the reasons for companion accompaniment (Table 2). Patients and companions indicated from a list of 7 items (Table 2) how the companion influenced the visit and rated the companion’s helpfulness during the encounter (5-point Likert scale: 1 = very unhelpful to 5 = very helpful).
TABLE 1
Patient demographics and characteristics*
| Companion in examination room (A) | Patient alone (B) | P, A vs B | Companion in waiting room (C) | P, A vs C | |
|---|---|---|---|---|---|
| Total | 115 | 121 | 85 | ||
| Female | 57 (54) | 76 (73) | .19 | 58 (71) | .022 |
| Age (y) | |||||
| 18–44 | 21 (20) | 39 (33) | <.001> | 16 (20) | .06 |
| 45–64 | 34 (33) | 55 (46) | 39 (49) | ||
| ≥65 | 49 (47) | 26 (22) | 25 (31) | ||
| Race | |||||
| White | 73 (72) | 79 (66) | .09 | 56 (73) | .73 |
| Black/African American | 7 (7) | 22 (18) | 8 (10) | ||
| Hispanic/Latino | 16 (16) | 14 (12) | 11 (14) | ||
| Other | 5 (5) | 5 (5) | 2 (3) | ||
| Education ≤ high school | 57 (56) | 40 (33) | <.001> | 48 (61) | .56 |
| Income (US dollars/y) | |||||
| 47 (51) | 61 (54) | .82 | 39 (53) | .50 | |
| 15,000–35,000 | 23 (25) | 29 (25) | 22 (30) | ||
| >35,000 | 23 (25) | 24 (21) | 13 (18) | ||
| Self-noted health | |||||
| Poor/fair | 58 (53) | 53 (44) | .37 | 40 (48) | .13 |
| Good | 28 (25) | 34 (28) | 32 (38) | ||
| Very good/excellent | 24 (22) | 34 (28) | 12 (14) | ||
| Medical and social complexity (MD rating) | |||||
| Simple/straightforward | 6 (5) | 27 (24) | <.001> | 11 (13) | <.001> |
| Average | 24 (21) | 36 (32) | 32 (39) | ||
| Somewhat/very complex | 83 (73) | 51 (45) | 39 (48) | ||
| Patient visit type | |||||
| Return with primary provider | 85 (75) | 73 (64) | .16 | 51 (62) | .07 |
| New with primary provider | 18 (16) | 28 (25) | 15 (18) | ||
| Episodic with provider other than primary | 10 (9) | 13 (12) | 16 (20) | ||
| Physician | |||||
| Faculty | 68 (62) | 55 (45) | .01 | 44 (52) | .19 |
| Resident | 42 (38) | 66 (55) | 40 (48) | ||
| Some categories are missing data, so the columns do not equal n. Percentages were computed based on available data, and some columns equal 101% because of round-off error. | |||||
| *Values are number (percentage) unless otherwise indicated. | |||||
TABLE 2
Patients’ and companions’ reports of companion’s reasons for accompaniment and influence on the medical encounter*
| Patient’s report | Companion’s report | ||||||
|---|---|---|---|---|---|---|---|
| Companion in waiting room | Companion in examination room | P † waiting room | Companion in waiting room | Companion in examination room | P † waiting room | ||
| Companion’s reasons for accompaniment | |||||||
| Help with transportation | 58 (69) | 61 (55) | .05 | 64 (79) | 66 (58) | .003 | |
| Provide company | 39 (46) | 58 (53) | .39 | 43 (53) | 55 (49) | .59 | |
| Help communicate concerns to the doctor | 6 (7) | 56 (51) | <.001> | 5 (6) | 60 (53) | <.001> | |
| Help remember physician’s advice and instructions | 4 (5) | 51 (46) | <.001> | 5 (6) | 54 (48) | <.001> | |
| Provide emotional support | 20 (24) | 48 (44) | .004 | 27 (33) | 60 (53) | .006 | |
| Express concerns regarding the patient to the physician | 6 (7) | 41 (37) | <.001> | 9 (11) | 51 (45) | <.001> | |
| Help make decisions | 5 (6) | 39 (35) | <.001> | 2 (2) | 32 (28) | <.001> | |
| Help with language barriers | 1 (1) | 14 (13) | .003 | 0 (0) | 12 (11) | <.002> | |
| Help with insurance or payment forms | 7 (8) | 11 (10) | .69 | 7 (9) | 5 (4) | .23 | |
| Companion’s influence on medical encounter | |||||||
| No influence or don’t know | 57 (70) | 28 (25) | <.001> | 58 (72) | 24 (21) | <.001> | |
| Companion influenced | |||||||
| Physician understanding | 5 (6) | 63 (57) | <.001> | 5 (6) | 69 (61) | <.001> | |
| Patient understanding | 3 (4) | 59 (54) | <.001> | 10 (12) | 68 (60) | <.001> | |
| Tests ordered | 3 (4) | 13 (12) | .039 | 1 (1) | 12 (11) | .01 | |
| Prescribed treatment | 1 (1) | 26 (24) | <.001> | 4 (5) | 26 (23) | <.001> | |
| Number of referrals | 0 (0) | 10 (9) | .005 | 1 (1) | 6 (5) | .13 | |
| Length of visit | 7 (8) | 19 (17) | .07 | 6 (7) | 20 (18) | .04 | |
| *Values are number (percentage) unless otherwise indicated. | |||||||
| † Difference between waiting room and examination room companion. | |||||||
TABLE 3
Physician report of examination room companion’s influence on the medical encounter*
| Decreased | No influence | Increased | |
|---|---|---|---|
| Communication | |||
| Physician’s understanding | 1 (1) | 43 (39) | 66 (60 |
| Patient’s understanding | 0 (0) | 59 (54) | 51 (46) |
| Resource use | |||
| Time spent explaining/ counseling | 9 (8) | 66 (60) | 35 (32) |
| Length of visit | 6 (7) | 75 (68) | 28 (25) |
| Treatment recommended | 2 (2) | 106 (96) | 2 (2) |
| Number of referrals | 1 (1) | 106 (96) | 2 (2) |
| Number of tests ordered | 2 (2) | 106 (96) | 1 (1) |
| n = 114. | |||
| *Values are number (percentage). | |||
Physician report of examination room companion’s behaviors
| Behavior | n (%) |
|---|---|
| Active behaviors | |
| Clarified or expanded history | 71 (65) |
| Supportive/encouraging toward patient | 71 (65) |
| Asked questions/requested explanations | 53 (48) |
| Discussed concerns about patient’s symptoms/problems | 50 (45) |
| Made evaluation or treatment requests | 19 (17) |
| Took notes | 14 (13) |
| Distractive behaviors | |
| Discussed own symptoms | 16 (15) |
| Discouraging/controlling toward patient | 7 (6) |
| Passive behaviors | |
| Passive observer | 17 (15) |
| n = 114. | |
Data analysis
Data were used from each member of a set regardless of survey completion by other set members. One patient had 2 examination room companions and 2 patients had 2 waiting room companions. In each case, both companions were surveyed. In the 2 cases in which a patient had waiting and examination room companions, the examination room companion was considered more influential for the medical encounter and only that person was surveyed.
The data were analyzed with SAS version 6.12 (SAS Inc, Cary, NC) using bivariate and multivariable methods. Comparisons were made between patient categories (patient alone, patient with examination room companion, patients with waiting room companion) using the chi-square statistic for categorical variables.
Multivariable analyses were conducted to explore the effects of various independent variables on the decision to bring a companion into the examination room. The outcome variables for the regression models were defined by patient status (patient alone, patient with examination room companion, patient with waiting room companion). All significant variables (P ≤ .05) in bivariate analyses were entered into the multivariate analyses. Odds ratios (ORs) with 95% confidence intervals (CIs) were obtained for each variable in the model.
Patient and companion agreement on the reasons for accompaniment and influence on the medical encounter were measured with the kappa statistic. Kappas (κ) of 1.0 to .75 denote excellent agreement, .4 to .75 denote good agreement, and 0 to .4 denote marginal agreement.11
RESULTS
Of the 1294 patient visits, 834 (64%) were to faculty physicians and 451 (35%) were to resident physicians. Overall, companions were present for 29% (n = 374) of patient visits and accompanied the patient into the examination room for 16% (n = 212) of visits. Companions accompanied patients to 23% (n = 196) of faculty visits and 39% (n = 178) of resident visits (P P = .98).
Ninety-three percent (121/130) of unaccompanied patients and 92% (200/217) of consecutive patient–companion pairs approached for consent agreed to participate in the study. In 26 cases the patient or the companion refused to participate for 1of the following reasons: language barrier, too ill, lack of time, invasion of privacy, or uncomfortable with process of consent. Patients and physicians completed surveys for 97% of patient encounters, and companions completed surveys for 99% of patient encounters.
Comparisons between accompanied and unaccompanied patients are presented in Table 1. The fact that faculty physicians had a greater proportion of accompanied patients who received and completed surveys is likely due to the necessity of English literacy for inclusion into the survey study. At this practice site, patients cared for by residents are more likely to be non-English speaking and have a companion for the purpose of translation. Examination room companions were often the spouse or partner (55%), parents (17%), or less frequently roommate or friend (7%), whereas waiting room companions were commonly a spouse or partner (46%) or roommate or friend (24%). Overall, family members accounted for 93% of examination room companions and 76% of waiting room companions. Examination room companions were more likely to be female than waiting room companions (65% vs 51%, P = .05). Patients who were older, less well educated, and whose cases had greater medical or social complexity were more likely to have a companion in the examination room.
Patients’ and companions’ assessments of the reasons for accompaniment and the companions’ influence on communication and resource use are shown in Table 2. The patients’ and companions’ stated reasons for companion accompaniment were in good agreement with the kappa statistic ranging from 0.41 for “help with insurance forms” to 0.61 for “help remember the physician’s advice.” Patients’ and companions’ agreement regarding the influence of the companion on the medical visit was less than 0.4, suggesting marginal agreement for tests ordered (κ = .29), prescribed treatment (κ = .36), and length of visit (κ = .33). There was good agreement for number of referrals (κ = .45) and for physician and patient understanding (κ = .62 and .60, respectively).
Table 3 displays the physicians’ reports of the examination room companion’s influence on the medical encounter. Table 4 shows the physicians’ reports of the behavior of the examination room companions.
Patients regarded examination and waiting room companions as “very helpful” for 84% and 71% of visits, respectively, and as “very unhelpful” for 1% of visits. Of the 121 patients who came alone to their medical visits, 7% indicated that they considered bringing a companion to their visits and 16% thought a companion’s presence would have been helpful.
Physicians regarded examination room companions as “somewhat to very helpful” for 66% of visits. When physicians did not have contact with a companion, they indicated that contact would have been helpful for 16% of patient encounters.
Multivariable analyses explored the effects of independent variables on the decision to bring a companion into the examination room. A physician rating of a case of having greater medical and social complexity was the only variable associated with companion accompaniment to the examination room vs not having a companion (OR, 1.7; 95% CI, 1.4–2.1). Patient characteristics and patients’ reported reasons for accompaniment were factors influencing accompaniment into the examination room vs the waiting room. A need for help with communicating concerns to the physician (OR, 7.8; 95% CI, 2.4–25.6), help with remembering the physician’s advice and instructions (OR, 7.1; 95% CI, 2.0–25.3), and greater medical and social complexity of cases (OR, 1.5; 95% CI, 1.1–2.0) were associated with being accompanied to the examination room over just the waiting room. In contrast, needing help with transportation was negatively associated with having a companion in the examination room vs the waiting room (OR, 0.2; 95% CI, 0.1–0.5).
DISCUSSION
Companions frequently accompany adult patients and participate in ambulatory medical encounters. We found that companions accompanied 29% of patients and were present in the examination room for 16% of outpatient medical encounters. Examination room companions often were present to aid communication with the physician and to help the patient remember instructions. Physicians, patients, and companions believed that physician and patient understanding often were favorably affected by the presence of a companion. A companion’s presence in the examination room had beneficial effects on patient and physician understanding and very rarely had a negative effect. These findings reflect the results of previous studies in which approximately 33% of patients were accompanied to family medicine and geriatric encounters and 66% of these companions were present in the examination room.1,7-10,12,13 The only variable associated with accompaniment into the examination room vs presenting to one’s appointment alone was a physician rating of greater medical and social complexity. This finding also corroborates the findings of other studies.7,14,15
Some research has suggested a negative effect of a third person during the medical encounter. For example, older patients in triadic encounters raise fewer topics, are less assertive, and participate less in humor and joint decision making.6 Other research has failed to find a benefit in health outcomes with the presence of a companion, and unaccompanied patients rated themselves as having greater understanding of their medical problems and greater faith that their physicians were doing everything possible for them than patients accompanied to their visits.15 Still others have found that physicians provide more information and time but less emotional support to accompanied patients.7
Unique to our study was the specific assessment of companion influence on various aspects of the medical encounter from the perspectives of the companion, patient, and physician. As expected, examination room companions had significant influence on aspects of communication. Examination room companions were generally considered helpful by patients and physicians. Physicians may use the companion and patient as barometers of the visit’s accomplished goals. Hence, the time spent listening to a companion provide information about a patient’s medical problems might be balanced by the provision of less emotional support to the patient, especially if the companion is providing that support. The physician may offer an explanation until confident that either party (patient or companion) has a complete understanding. As demonstrated by the results, physicians, patients, and companions thought that patient understanding was increased in approximately 50% of encounters by a companion’s presence, and companions overwhelmingly were considered very helpful by patients.
Our study was limited to 1 urban, academic, general internal medicine practice and may not be generalizable to other settings. The method of assessing medical and social complexities was simple, and the very presence of an examination room companion may have biased physicians to rate these patients as having more complex problems than unaccompanied patients. Also, the longer period of the second part of the study necessary to enroll 200 patient–companion pairs, compared with the companion frequency data of the first part of the study, suggested that we did not enroll “consecutive” patient–companion pairs. This may be explained by the exclusion of patient–companion pairs when either party was not literate in English. Also, the logistics of obtaining consent and administering post visit questionnaires by a single research assistant interfered with the attempt to enroll all patient–companion pairs. Convenience enrollment of unaccompanied patients may have been biased. The effect of the companion on the medical encounter was not verified by objective measures such as timing visit length. Further, patients, companions, and physicians rated the effect of the companion’s presence immediately after the encounter; the full effect of the companion’s presence might require more time to emerge.
Companions frequently accompany patients to their ambulatory general medicine visits. The companion is usually a family member who is present at the request of the patient. Companions assume important roles and are overwhelmingly considered helpful by patients. Nonetheless, some of the behaviors that contribute to an effective physician–patient relationship might be diluted by the presence of a companion. Future directions of study include (1) assessing the effect of the companion on the physician–patient relationship, including specific aspects of communication and behavior, and (2) determining whether companion involvement influences health outcomes or resource use.
· Acknowledgments ·
We thank Marcia Blake, MA, for her statistical expertise; Jean Kutner, MD, MSPH, for her assistance with data analysis and statistical expertise; and Robert Dellavalle, MD, PhD, for his editorial assistance.
1. American Medical Association, Council on Scientific Affairs. Physician and family caregivers: a model for partnership. JAMA 1993;269:1282-4.
2. Botelho RJ, Lue BH, Fiscella K. Family involvement in routine health care: a survey of patients’ behaviors and p. J Fam Pract 1996;42:572-6.
3. Levine C, Zuckerman C. The trouble with families: toward an ethic of accommodation. Ann Intern Med 1999;130:148-52.
4. Zuckerman C. End of Life Care Decisions and Hospital Legal Counsel: Current Involvement and Opportunities for the Future. New York: Milbank Memorial Fund; 1999:8.
5. Jecker NS. The role of intimate others in medical decision making. Gerontologist 1990;30:65-71.
6. Greene MG, Majerovitz D, Adelman RD, Rizzo C. The effects of the presence of a third person on the physician older patient medical interview. J Am Geriatr Soc 1994;42:413-9.
7. Labrecque MS, Blanchard CG, Ruckdeschel JC, Blanchard EB. The impact of family presence on the physician cancer patient interaction. Soc Sci Med 1991;33:1253-61.
8. Medalie JH, Zyzanski SJ, Langa D, Stange KC. The family in family practice: is it a reality? J Fam Pract 1998;46:390-5.
9. Brown JB, Brett P, Stewart M, Marshall JN. Roles and influence of people who accompany patients on visits to the doctor. Can Fam Phys 1998;44:1644-50.
10. Beisecker AE, Brecheisen MA, Ashworth J, Hayes J. Perceptions of the role of cancer patients’ companions during medical appointments. J Psychosoc Oncol 1996;14:29-45.
11. Rosner B. Fundamentals of Biostatistics. San Francisco, CA: Duxbury Press; 1995.
12. Greene MG, Adelman RD, Charon R, Hoffman S. Ageism in the medical encounter: an exploratory study of the doctor elderly patient relationship. Lang Commun 1986;6:113-24.
13. Beisecker AE. The influence of a companion on the doctor elderly patient interaction. Health Commun 1989;1:55-70.
14. Beiseker AE. Aging and the desire of information and input in medical decisions: patients’ consumerism in medical encounters. Gerontologist 1998;28:330-5.
15. Prohaska TR, Glasser M. Patients’ views of family involvement in medical care decisions and encounters. Res Aging 1996;18:52-69.
1. American Medical Association, Council on Scientific Affairs. Physician and family caregivers: a model for partnership. JAMA 1993;269:1282-4.
2. Botelho RJ, Lue BH, Fiscella K. Family involvement in routine health care: a survey of patients’ behaviors and p. J Fam Pract 1996;42:572-6.
3. Levine C, Zuckerman C. The trouble with families: toward an ethic of accommodation. Ann Intern Med 1999;130:148-52.
4. Zuckerman C. End of Life Care Decisions and Hospital Legal Counsel: Current Involvement and Opportunities for the Future. New York: Milbank Memorial Fund; 1999:8.
5. Jecker NS. The role of intimate others in medical decision making. Gerontologist 1990;30:65-71.
6. Greene MG, Majerovitz D, Adelman RD, Rizzo C. The effects of the presence of a third person on the physician older patient medical interview. J Am Geriatr Soc 1994;42:413-9.
7. Labrecque MS, Blanchard CG, Ruckdeschel JC, Blanchard EB. The impact of family presence on the physician cancer patient interaction. Soc Sci Med 1991;33:1253-61.
8. Medalie JH, Zyzanski SJ, Langa D, Stange KC. The family in family practice: is it a reality? J Fam Pract 1998;46:390-5.
9. Brown JB, Brett P, Stewart M, Marshall JN. Roles and influence of people who accompany patients on visits to the doctor. Can Fam Phys 1998;44:1644-50.
10. Beisecker AE, Brecheisen MA, Ashworth J, Hayes J. Perceptions of the role of cancer patients’ companions during medical appointments. J Psychosoc Oncol 1996;14:29-45.
11. Rosner B. Fundamentals of Biostatistics. San Francisco, CA: Duxbury Press; 1995.
12. Greene MG, Adelman RD, Charon R, Hoffman S. Ageism in the medical encounter: an exploratory study of the doctor elderly patient relationship. Lang Commun 1986;6:113-24.
13. Beisecker AE. The influence of a companion on the doctor elderly patient interaction. Health Commun 1989;1:55-70.
14. Beiseker AE. Aging and the desire of information and input in medical decisions: patients’ consumerism in medical encounters. Gerontologist 1998;28:330-5.
15. Prohaska TR, Glasser M. Patients’ views of family involvement in medical care decisions and encounters. Res Aging 1996;18:52-69.