By now you have noticed that the FCOF is two-sided. Even though the two sides look similar, they are not the same and each has a distinct purpose. Side A should be used when your patient has one or more of his/her family members present at the visit. Research shows that this happens in about about 1/3 of primary care outpatient medical visits. (1)
A healthcare provider can provide family-centered care even when the patient has come alone to clinic. In these instances the healthcare provider should be observed using Side B.
Side B should also be used when more than the patient is present but the patient cannot speak for himself/herself. For example, if your patient has severe dementia and you are seeing her with only her husband present, use Side B. Another example might be a mother bringing her baby in for a well-child check. Even though he is technically your patient, he cannot speak, hence the healthcare provider will only be interacting with one person (the mother) so Side B should be used to observe the visit. If the child's mother AND father are present, (or any other able-to-speak family member), use Side A.
How can you offer family-centered care if your patient's family members are not present at the visit? Can you really include them if they are not even there? Relational questioning (sometimes called circular questioning) is a way of inviting the family system's perspective into the room even when the patient is alone. Relational questions cause the patient to consider things from the perspectives of his/her family members. Relational questions can generate great insight for both you and the patient. Here are a few examples:
Examples of DIRECT Questioning
How do you think your pain affects your family?
What do you want to discuss with me today?
What does it mean to you that you're dependent on pain killers?
What do you think might be the best option for your mom?
What makes you think that your child needs ADHD medications?
Examples of RELATIONAL Questioning
How does your wife think your pain affects your family?
What does your family want you to discuss with me today?
What does it mean to your kids that you're dependent on pain killers?
If your mom could speak, what would she say would be the best option?
What makes his father think that he does NOT need ADHD medications?
The goal of relational questioning is simply to provide you and your individual patient with a family-centered perspective because health does not happen in a silo. Health and wellness occur in a familial context. Families have a powerful influence on a patient's health and illness.
Change is an inherent part of our treatment plans in primary care, whether it is simple change such as, "Take this pill each night for seven nights" or more complex change such as, "Reorganize your life so that you can eat right, exercise, and lose weight." Whatever the treatment is that you recommend, ensure that it fits within the context of the patient's family. If family members are present at the visit invite them to help the patient make these changes, but if the patient is alone at the visit use relational questioning to understand and partner with his/her family.
Notice in the FCOF that in the CONTENT category on SIDE B there is a distinction made between direct and relational questioning. Mark these items accordingly.
- Medalie, J. H., Zyzanski, S. J., Langa, D., & Stange, K. C. (1998). The family in family practice: is it a reality?. Journal of Family Practice, 46 (5), 390-397.