Interviewing When Family Members Are Present

FORREST LANG, M.D., East Tennessee State University, Johnson City, Tennessee
KIM MARVEL, PH.D., Fort Collins Family Medicine Residency Program, Fort Collins, Colorado
DAVID SANDERS, PSY.D., St. Anthony Family Medicine Residency, Denver, Colorado
DAEL WAXMAN, M.D., Carolinas Medical Center, Charlotte, North Carolina
KATHLEEN L. BEINE, M.D., East Tennessee State University, Johnson City, Tennessee
CAROL PFAFFLY, PH.D., Fort Collins Family Medicine Residency Program, Fort Collins, Colorado
ELIZABETH MCCORD, M.S., M.D., East Tennessee State University, Johnson City, Tennessee

The presence of family members at an office visit creates unique opportunities and chal-
lenges for the physician while interviewing the patient. The physician must address issues
of confidentiality, privacy, and agency. Special skills are required to respectfully and effi-
ciently involve family members, while keeping the patient at the center of the visit. A core
set of interviewing skills exists for office visit interviews with family members present.
These skills include building rapport with each participant by identifying their individual
issues and perspectives, and encouraging participation by listening to and addressing the
concerns of all persons. Physicians should also avoid triangulation, maintain confidentiality,
and verify agreement with the plan. It may be necessary to use more advanced family inter-
viewing skills, including providing direction despite problematic communications; managing
conflict; negotiating common ground; and referring members to family therapy. (Am Fam
Physician 2002;65:1351-4. Copyright© 2002 American Academy of Family Physicians.)

P
hysicians interact with family and privacy; and (3) legal issues of agency 4 in
members in a variety of situa- situations involving a third party who han-
tions, such as routine prenatal dles financial or legal decisions for the patient
visits involving both of the (e.g., the mother of a child or the guardian of
expectant parents, well-child vis- an adult who is impaired or has dementia).
its with parents, and follow-up visits for hyper- One study 4 found that a third person in the
tension in an elderly patient accompanied by a examination room decreased the amount of
family member. Research1-3 shows that family time the patient talked to the physician.
members are present in about one third of Conversely, family members can be a valu-
office visits; however, most of the literature on able resource of information and can help in
medical interviews has focused on the physi- the implementation of and compliance with
cian’s relationship with individual patients. a treatment plan.5,6 The presence of a family
This article will identify the unique character- member strengthens the alliance between the
istics of interviews that include family mem- physician and the patient without lengthen-
bers and will describe the necessary skills for ing the office visit.7 One study3 showed that
conducting an effective family interview. physicians rated family involvement as hav-
ing a positive influence in 95 percent of office
Unique Characteristics visits.
of the Family Interview
The presence of a family member at the Description of Family Interviewing Skills
office visit presents several issues that can Family interviewing skills require a foun-
make the interview more complex, including: dation of individual interviewing skills,
(1) additional concerns or questions about including data gathering (i.e., open-ended
the patient’s health from the family members; questions, facilitation, and identifying and
(2) ethical dilemmas involving confidentiality exploring clues),8 responding empathetically,
and reaching common ground.9,10 These skills
See editorial on page 1277. can be divided into core and advanced skills
of family interviewing (Table 1).

APRIL 1, 2002 / VOLUME 65, NUMBER 7 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1351
TABLE 1
Core and Advanced Family Interviewing Skills

Core skills Advanced skills

Greet and build rapport Guide communication
Identify each person’s agenda Manage conflict
Check each person’s perspective Reach common ground
Allow each person to speak Consider referral for family therapy
Recognize and acknowledge feelings perspective on the issue or problem. These
Avoid taking sides additional perspectives may broaden the
Respect privacy and maintain confidentiality physician’s differential diagnosis, including
Interview the patient separately, if needed those related to family dynamics.14
Evaluate agreement with the plan
ALLOW EACH PERSON TO SPEAK
During a family interview, one member
Core Family Interviewing Skills may exhibit patterns of ineffective communi-
Core family interviewing skills are used in cation, such as monopolizing the interaction,
routine interviews in which another person expressing thoughts and feelings for others,
accompanies the patient. Core skills suffice or speaking directly to the physician about a
when family members communicate effec- family member who is present. In these situa-
tively and when minimal differences exist tions, the physician should provide each
between the family members, patient, and member an equal opportunity to speak. If
physician. Using these skills, the physician can ineffective communication patterns persist,
conduct an efficient and productive interview the advanced interviewing skills discussed
that involves everyone present. later in this article may be needed.

GREET AND BUILD RAPPORT RECOGNIZE AND ACKNOWLEDGE FEELINGS

The physician should greet and establish a Emotions expressed by the patient or their
rapport with everyone present. Personal intro- family members should be acknowledged
ductions to persons who are accompanying the and legitimized. This skill is challenging
patient provide an important foundation for when a family member expresses concern
future interactions. Extra attention may be given about the health behaviors of the patient
to establishing a rapport with a new member. (e.g., inconsistently taking medication).
Physicians should find a balanced approach
IDENTIFY EACH PERSON’S AGENDA that responds to the concerns but does not
A major objective of a successful interview is divert the focus of the discussion from the
to clarify and prioritize the objectives of every- patient. The physician should also pay close
one involved.11,12 First, the patient’s agenda attention to nonverbal clues, such as seating
should be established, and then the family arrangements, physical closeness, eye gaze,
members should be asked if they have any and response sequence. Finally, the physician
additional concerns. Identification of every- should communicate important emotional
one’s expectations early in the process can help information and provide an opportunity to
to avoid concerns that arise late in the inter- acknowledge and explore everyone’s emo-
view.13 Summarizing agenda items can help to tional reactions to the disease and its associ-
organize the interview and validate everyone’s ated consequences.
interests. Multiple agendas should be priori-
tized to keep within the time limits of the visit. AVOID TAKING SIDES
As with an interview with just the patient, it Occasionally, identifying everyone’s per-
may be necessary to discuss the most pressing spectives results in a disagreement about the
issues first, and to schedule future sessions to health of the patient, and the physician is
cover the remaining concerns. asked to take sides. However, the physician-
patient relationship can be negatively
CHECK EACH PERSON’S PERSPECTIVE impacted by the physician’s agreement with
The physician can facilitate the discussion the family member. A helpful approach in
of an agenda item by asking for each person’s these situations is to acknowledge the family

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 Family Interview

member’s concern and then listen to the interaction patterns. The physician may use
patient’s response to that concern.2 techniques, such as reframing, decision analy-
sis, criteria setting and brainstorming, to direct
RESPECT PRIVACY AND MAINTAIN CONFIDENTIALITY the interactions and conflicts, negotiate com-
The physician must be careful to avoid mon ground, and, if needed, refer the family
potential breaches of patient confidentiality for more intensive family therapy.
that may arise when discussing diagnostic and
treatment decisions in the presence of family GUIDE COMMUNICATION
members, especially with adolescent patients Communication among family members
or with sensitive issues such as substance can be ineffective when members exhibit the
abuse and sexual history. The privacy of the following behaviors: interrupting one another;
patient must be respected at all times. Some showing poor attention or poor listening skills;
patients may also be reluctant to provide accu- monopolizing the discussion; using critical or
rate information about sensitive or embar- sarcastic comments; making demands; or
rassing issues when other persons are present. speaking for others. The physician can im-
prove communication by recognizing these
INTERVIEWING THE PATIENT ALONE problems and providing guidance.
An optimal time to interview the patient
alone is after the family interview has MANAGE CONFLICT
addressed the issues and agendas of the fam- When addressing conflict among family
ily members. The physical examination is a members, the physician should first highlight
perfect opportunity to have a one-on-one the conflict in a professional way that encour-
discussion with the patient about issues that ages open discussion rather than personal
are private or confidential. attacks. Reframing is a method of restating a
confrontational or demanding position in a
EVALUATE AGREEMENT WITH THE PLAN way that allows each family member to under-
The physician should work with the patient stand and appreciate the others’ viewpoints.
and family members to develop a plan that
addresses the various concerns discussed dur- REACHING COMMON GROUND
ing the family interview. After the physician Reaching common ground is a vital phase
describes the plan, the patient and then the of the family interview in which there is
family members should be asked how they strong disagreement.11 Various tools are avail-
feel about the plan. If differences exist, ad- able to help everyone reach common ground,
vanced family interviewing skills and addi- including reframing, brainstorming, decision
tional office sessions may be necessary. analysis and criteria setting. The physician
can use brainstorming methods to explore
Advanced Family Interviewing Skills potential solutions after each person’s per-
Advanced family interviewing skills are use- spective has been established. The process of
ful in situations where the family exhibits inef- decision analysis considers the perceived
fective communication, has difficulty resolving problems and benefits of the current situa-
a conflict, or when intense emotions arise. The tion, and the barriers and incentives of the
goal of these interviews is to assist the family in proposed solution. In some cases, family
communicating or managing conflict suffi- members may need more time or more infor-
ciently enough to address the immediate mation to make a decision. It may be useful
patient care issues; however, unlike therapy, the for the patient and the family members to
use of these advanced skills is not intended to write down suggestions for reaching common
create a permanent change in the family’s ground after the interview.

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Family Interview

ting and problem solving that involves the

CONSIDER REFERRAL FOR FAMILY THERAPY patient and family members. The skills de-
Referral to family therapy should be con- scribed in this article should enable physicians
sidered when a high level of unresolved con- to assist a family in reaching a decision about
flict remains that affects individuals and the a specific issue; this process is not intended to
entire family. After a difficult interview, fam- “fix” family conflicts.
ily members should be informed that partici-
pation in the office visit interview signifies a The authors indicate that they do not have any con-
flicts of interest. Sources of funding: none reported.
desire on their part to improve the relation-
ship, and that family therapy may be appro- REFERENCES
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