Physician–elderly patient–companion communication and roles of companions in Japanese geriatric encounters
Introduction
The elderly population is growing rapidly in many developed countries, including Japan. Due to a general decline in their health with age, this segment of the population tends to be a heavy user of health care services. It has been noted that additional difficulties are likely to be experienced in medical encounters with elderly patients because of their sensory deficits, cognitive impairment, functional limitations, and the frequent presence of an accompanying person in the medical visit (Adelman, Greene, & Ory, 2000; Roter, 2000). In particular, the presence of a third person may make the communication dynamics more complex and time-consuming. The triad is a common phenomenon in geriatric practice. Previous studies have reported that 20–57% of the elderly patients were accompanied by a third person in their visits (Adelman, Greene, & Charon, 1987; Beisecker, 1989; Brown, Brett, Stewart, & Marshall, 1998; Main, Holcomb, Dickinson, & Crabtree, 2001; Prohaska & Glasser, 1996). However, with the exception of some pediatric studies in which the communication between the physician and both the patient (child) and his or her parent is assessed, communication analysis has primarily focused on dyadic exchanges. Visits that included a patient companion were generally dropped from the study sample or the companion's contribution to the communication was ignored. As a result, there have been only limited empirical studies on physician–patient–companion interactions.
The third persons accompanying patients are family members in most cases, and the majority of them are women (Baker, Yoels, Clair, & Allman, 1997; Greene, Adelman, Friedmann, & Charon, 1994). Thus, they are considered as a caregiver or a potential caregiver for the patient. From this point, Beisecker (1989) has indicated that the triadic medical encounter is an intersection of the informal (family) care system and the formal (professional) care system. Given the rapid increase in the elderly population and in chronic illnesses that requires long-term care, the coordination of professional care at medical institutions and self-care at home becomes increasingly important. It is necessary to explore the characteristics of the physician–patient–companion triad in medical encounters, in order to promote the benefits of the companion's presence in building patient–physician relationships and enhancing quality of care for elderly patients.
Recent trends in Japanese medicine have drawn increasing attention to the physician's ability to communicate with patients. However, most of the theories and models related to the communication in the patient–physician relationship have been imported from western countries without seriously considering the social and cultural relevance to Japan. Numerous cross-cultural studies have indicated general differences in interpersonal relationships and communication between western countries and Japan (Barnlund, 1989). For example, the way that collectivism and the Confucian tradition underlying Japanese culture has shaped the physician–patient–family relationship in Japan differs from the influence of individualism and traditions of Christianity in many western countries (Fetters, 1998; Hoshino, 1995). It is therefore important to explore the characteristics of physician–patient–companion communication in Japan.
From a sociological perspective, Simmel has suggested that the addition of the third person to a two-person group completely changes the dynamics of interaction (Wolf, 1950). First, intimacy tends to be lost in triads regardless of the strength of the triadic relationship. Second, it makes it easier for one member to refrain from participating in discourse because the other two members can continue the conversation. Third, there is a potential of coalition forming among participants in triads unlike dyads where there can be no majority. Coalition is defined as an effort by two members of the triad to achieve a mutually desired goal despite the active or passive resistance of the third member (Coe & Prendergast, 1985). Caplow (1956) suggested that the formation of coalitions depended predictably on the initial distribution of power, presenting different patterns of coalitions in the triad whose members were not identical in power.
Such coalition forming has been observed in physician–patient–companion triads as well. Baker et al. (1997) illustrated the coalition forming between the physician and the third person by examining the distribution of laughter amongst physician, patient, and third persons in medical encounters. Their analyses revealed that there were 85 out of 368 instances (23%) where patients seemed to be excluded from the topic of laughter, and especially when the third person instigated laughter: 62% (24/39) of these instances excluded patients.
Further, Adelman et al. (1987) hypothesized the third person's roles from the patient's perspective. Three major roles were suggested, namely the advocate, the passive participant, and the antagonist. The advocate companion serves as a patient promoter who supports the patient's agenda, a patient extender who acts as the voice of the patient, and a mediator who bridges the gap between physician and patient. The companion as a passive participant is present but is minimally involved in the encounter. The antagonist companion is a saboteur who works against the patient, and an opportunist who tries to take advantage of the patient and/or the physician.
There has been very limited empirical study examining the influence of the accompanying person on the communication process during the consultation. Beisecker (1989) reported that the presence of companions made no significant difference to the length of interaction, suggesting that companions, by speaking, might take time away from the patient and reduce the interaction time between physician and patient. On the other hand, another study showed that the average triadic medical encounter was slightly longer than the average dyadic encounter (Greene et al., 1994).
Greene and her colleagues (1994) also found that patients in triadic encounters raised fewer topics, were less responsive, and were rated as less assertive and expressive than those in dyadic encounters, although the specific content of physician's talk and quality of responsiveness were not affected by the accompaniment status. In addition, there was less joint decision-making and shared laughter between physician and patient, and patients were frequently excluded from conversations in triadic encounters. The presence of a third person may thus limit the exchange of information and the establishment of good rapport between the physician and patient.
The types of communication a companion actually contributes during the medical encounters and how those behaviors impact patient and physician communication have not been well described. This study was designed to address these questions and to describe the communication characteristics of physician–patient–companion triads through a comparison with physician–patient dyads in Japanese geriatric encounters, and to explore the companion's role in communication during the visit from the patient's as well as companion's perspectives.
Section snippets
Study population and setting
The sample of this study was elderly patients and their companions, who visited the Department of Geriatric Medicine at the University of Tokyo Hospital in Japan. Nine attending physicians (8 males and 1 female) at this outpatient service volunteered to participate in the study. The average age of the physicians was 40 years (range: 33–53 years), and they had 14.3 years of experience on average (range: 8–30 years). The number of patients each physician saw per shift (within 3 h) greatly varied
Sample description
One patient was excluded from the analysis because of incomplete recording due to a mechanical problem. Consequently, the final sample became 145 visits including 82 dyads and 63 triads. Almost all patients visited this geriatric clinic for some chronic diseases such as hypertension, osteoporosis, chronic obstructive pulmonary disease (COPD), diabetes, hyperlipidemia, bronchial asthma and so on. They were under continuous care of the study physicians, and the majority (77.4%) had seen their
Discussion
This study applied the RIAS to the analysis of the triadic communication in Japanese geriatric encounters, and proposed additional categories to code aspects of communication specific to triads. By analyzing the companion's communication using the RIAS with the additional categories, it has illustrated how much they involved themselves and what roles they took in communicating with the physician during the visit.
Acknowledgement
This research was supported by a grant from the Pfizer health research foundation. We sincerely thank all physicians, patients, and accompanying persons who participated in this study at the University of Tokyo Hospital, Department of Geriatric Medicine. Many thanks go to Drs. Koichi Kozaki, Takahide Nagase, Yasuyoshi Ouchi, and Masao Yoshizumi for their kind help in conducting the survey. Also, we are grateful to Dr. Hideki Hashimoto for his constructive comments and valuable suggestions at
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