Skills, Process, and Content
Let's have you watch another video. This one will be much longer than the others (although still edited for length), but you'll focus on the three largest sections of the FCOF.
Before you push play it's essential that you first understand what you'll be looking for in the video. Take a moment to review these categories and read below about any skills you may need more explanation for, or examples of. When you are ready, watch the video and mark your observations and comments.
Family-Centered Interviewing - SKILLS
1. Use jargon-free language (or explain terms)
What counts as jargon? Anything that your patient doesn't understand. Some words like "epigastrium" are obviously medical jargon; however, even commonly used words can be jargon, such as "hereditary," "acute," or "triage." If you must use a medical terminology that's ok, just verify that the patient and family members understand the meaning of it.
2. Ask open-ended questions
Open-ended questions allow for open-ended answers, whereas closed-ended questions are often answered with yes, no, or some other short confirmatory response. Open-ended questions frequently begin with what, why, or how (as opposed to the closed-ended "Do you..." or "Have you..."). They allow for more thoughtful conversation. Examples:
- "What have you tried?" (Instead of "Have you tried...?")
- "How do you take your medication?" (Instead of "Do you take your medication?")
3. Reflect content to emphasize or clarify
Reflecting is not the same thing as restating. A reflection is not just repeating back to the patient what he/she just said. Rather, reflect back in your own words the patient's or family member's main point(s). Sometimes you'll reflect back in order to clarify (e.g. "So the pain comes and goes throughout the day but it's worst in the evenings, right?"). Other times you might reflect back in order to emphasize a key point (e.g."You've been taking pain meds for four years now, yet your pain is getting worse to where you can't even go upstairs anymore.")
4. Explain physical exam and findings
During a physical exam, be sure to explain what you're doing and what you find, even it it's as simple as "Now I'm going to listen to your lungs" and then "They sound fine." Including the patient and family members in this way is not only courteous and professional, but it continues to send the message that you want them involved as much as possible in their own healthcare.
5. Summarize key points and patterns
A summary is more than a simple reflection, though it is similar. A good summary highlights key elements of the conversation to help transition or emphasize important content. A summary allows you to stay in charge of the structure of the visit, while still allowing the patient and family members to guide the content.
6. Redirect the conversation topic as needed
Suppose your patient's mother has gone off on a conversational tangent, providing you far more history than is needed. You may need to redirect the conversation. A brief summary can be a good way to do this, but there are many other good ways. No matter how you do it, make sure that your redirection is professionally appropriate. Don't just change the subject or cut off the patient as if you were not listening. You can excuse yourself if you need to interrupt ("Forgive me for cutting you off..."), but even if it is your turn to speak, acknowledge what they are saying before you move the conversation elsewhere. For example, "Yeah that seems like a big deal. And perhaps we should discuss it in more detail in the future, but for now let's get back to..."
7. Ask the patient’s permission to discuss info with FM(s)
Your patient may have things that he/she is willing to discuss with you, but not with his/her family. Respect their privacy. Instead of a closed-ended question such as: "Do you care if we discuss this in front of your mom?", ask an open-ended version, such as:"What things you would prefer we not discuss when your mother is here?"
8. Clarify whether an interview with the patient alone is needed
As is the case with sensitive physical exams, sometimes sensitive interviews need to be conducted without family members present. If so, don't say, "Would you like me to have your dad leave the room?", rather say something like, "Would you like to discuss this with me alone?" because it focuses more on the patient than on the family member. If you're not sure if an interview alone is needed just ask, and pay attention to nonverbal cues as well. If you do arrange to speak with the patient alone, ensure that you're doing so to respect your patient's privacy and autonomy, and not just because it's emotionally easier for you to speak with one person at a time.
9. Solicit each person’s perspective
Be sure that each person's voice has been heard. Sometimes you can solicit someone's perspective passively through simple body language that says "I'm listening." Making eye contact can do this. Other times you may need to actively solicit their perspective by asking, "What do you think...?"
10. Block interruptions when necessary
In order to make sure each person's voice has been heard you may need to block others from talking or answering all your questions. There may be unspoken rules in the family about who speaks first or who is the expert on health in the family. For example, maybe the patient's daughter is a nurse and she answers all your questions, even the questions you ask to your patient. While being sensitive to culture, it is important that you give all a chance to speak. You may need to say something like, "I do appreciate your input Maria, but I'd really like to hear from your mother. Mrs. Martinez, how do you...?"
11. Verbally acknowledge differing perspectives
People often disagree and that's ok. It is also ok if they don't necessarily come to agreement by end of the time you spend with them. Chances are that their differing perspectives existed long before your interview and they will likely continue after. Although information you provide can sometimes help people resolve their differing opinions, your job is simply to acknowledge the differing perspectives so each has a chance to be voiced and validated. Verbally acknowledging differing opinions facilitates better listening.
12. Verbally acknowledge shared perspectives
Patients and family members may share opinions and have similar perspectives, but they may not realize it. When you verbally acknowledge shared perspectives you help build consensus in decision making and encourage unity in the family system. Again, your goal is not necessarily to change their perspectives, but to acknowledge where they align to help facilitate understanding and communication.
Family-Centered Interviewing - PROCESS
1. Was “present” (e.g. curious, attentive, not rushed)
There is an aspect of being patient- and family-centered that has less to do with what you say or do, and more to do with who you are or how you "be with" people. Ignore distractions. Keep track of time, but avoid allowing your attention to drift to other patients and responsibilities while you are not present with them. Be curious and accepting, caring and compassionate. Try not to subconsciously compare who your patients and their family members are to who you are, or to who you think they should/could be. Accept what is and be present with it.
2. Was sensitive to matters of culture and diversity
It's important to recognize that families come in a diverse range of structures and styles. Be careful not to assume that they see the world the way you do. Being culturally sensitive means more than just knowing about and understanding your patient's gender, race, ethnicity, religion, sexual orientation, nationality, or any other aspect of their background. Family culture is often as influential as any other culture, and families are diverse even within larger cultures (e.g. not all Asian American families are the same. Obviously). Listen to and learn the diverse cultures of the patients you treat, and be sensitive to their unique needs.
3. Maintained eye contact with everyone in room
Position your chair so that you can see everyone and everyone can see you. It is fine to look at your computer screen briefly, but if it’s going to be for more than a few seconds let them know what you are doing (e.g. “I’m just checking your chart to see your latest lab results”). The point is to convey that they always have your attention and that everyone is invited to contribute to the conversation.
4. Maintained neutrality / avoided taking sides
The best way to maintain neutrality isn't by not validating anyone's opinion, but by validating all opinions. In other words, instead of not taking sides, take everyone's side, and do so openly and transparently. Avoid being triangulated. People rarely directly say "Take my side"; rather, they use more subtle methods such as asking you to validate their opinion over someone else's, or by passively putting words in your mouth (e.g. "I told my husband that even you think he's faking it" - you don't think that - "but he just keeps acting this way"). Offer insight if needed, but allow them to remain responsible for resolving their own conflict.
5. Was empathetic (verbally or non-verbally) toward patient
Patients seek empathy from their doctors. Yes they want your skills, knowledge, tools, tests, procedures, and prescriptions too, but they desire that fundamental human need to be understood at an emotional level. Show your patients that you understand their behaviors and thoughts in the context of whatever distress they may be in. This can be as overt and outspoken such as, "Yeah that must be very frustrating for you" or "I can tell you're really struggling with this, and it makes sense, honestly, given your situation." Or it can be as simple as a compassionate look or a caring hand on their shoulder. Even if you can't understand what they feel, simply showing that you are trying to can validate their experience and relieve some distress.
6. Was empathetic (verbally or non-verbally) toward FM(s)
A great way to partner with patient's family members is to show them the same kind of empathy that you show your patient. However, be sure to keep the focus of the visit on the patient's health goals and problems and not on the family member(s)' problems. This is the patient's visit. Your empathy should not invite the family members into a patient role; rather, it should help identify, clarify, and encourage that family member to take a contributing role on the family-centered care team.