Epidemiology of companions of the patients in family medicine: Making the invisible visible

Objective: Describe the frequency of companion with the patient, and the characteristics of both, in Family Medicine consultations. Methodology: Observational, descriptive and prospective study in a Family Medicine office in Toledo, Spain. For each patient and companion, the following variables were collected, among others: age, gender, chronic illness, chief complaint, medications taken, social class, request for additional tests, kinship, social status and availability of companion. Descriptive data, which were expressed by standard measures of central tendency and dispersion were obtained. Results: A sample of 445 patients was obtained. The frequency of the presence of a companion was 23.8%. In the companions, the age group between 40-64 years with 60% [95% CI 50.17 to 69.99] was the predominant. Kinship of companions was mainly wife in 43%. The availability status of companions was: worker in the 37%, housewife 27%, and retired 23%. The 45% of companions were classified as collaborators. In patients predominated: the age group ≥ 65 years: 39% [95% CI 29.67 to 49.05], the 59% [95% CI 49.46 to 68.86] were women, with an average of 2 chronic diseases, and taking an average of 3 drugs, and with derivations hospital specialist in 18% of patients [95% CI 11.15 to 26.56]. Conclusions: There is a moderately high prevalence of the presence of a companion, who is in almost one of every 4 visits served in Family Medicine. The accompanying “type” is a middle-aged adult, predominantly the couple, worker, housewife or retired. Accompanying patients are older women, with polypharmacy, and that generate hospital referrals. The companion of the patient is an area of Family Medicine which has received little attention, and his presence may go unnoticed, but his frequency deserves the attention of the physician, who must deepen his characteristics and meanings, “making the invisible visible” in the care of these patients with companions. Correspondence to: José Luis Turabian, Teaching Unit of Primary Care and Community, Primary Care Management, Toledo, Spain, E-mail: jturabianf@hotmail.com


Introduction
An important feature of Family Medicine is taken into account the companions in attendance of individual patients. The physician-patient relationship is part of the patient's larger social system and is influenced by the patient's family. The context of the patient includes family, friends, work, religion, school, and health resources. Recognition of this context allows the doctor does not see health problems as isolated events but as a response to, or inserted in, life crises, stress, inadequate habits, or family dysfunction [1,2].
Many consultations occur on a patient only, but other times involve companions with patients in the medical office. A patient's family member can be a valuable source of health information and can collaborate in making an accurate diagnosis and planning a treatment strategy during the visit to the office [3]. A second adult-usually parents or husband or wife accompanying the patient consultation is always significant and deserves the attention of the doctor [4].
Conventionally, physician focuses on an encounter between two people: the patient and the physician. In practice, a third person (a companion) frequently accompanies a patient during a medical encounter [5,6], and these companions are usually family members [7]. Thus, it is necessary to institute a mode of practice family oriented, where clinician-family relationships are critical elements to improve quality of care [8].
The medical attention taking into account the "companion" of the patient is a particular case of the care focused on the "context" of the patient. The family doctor, to treat patients, goes from context to body (not the other way around: from the body to context). The family doctor makes a "care centered on the context of the patient". In the consultation of Family Medicine, first, the doctor should put attention to the context of the patient: his or her "companions" -family, community...-, before treating patient complaint [9]. Therefore, it is important that when our patient goes into to consultation, the family doctor loses a few seconds to observe the companion. This could give much information [1,10].
The major results of existing studies suggest that the regular presences of companions of the patients in consultations are often perceived as helpful. Accompaniment to medical visits is associated with better self-care maintenance and management, and this effect may be mediated through satisfaction with provider communication [11]. Also companions provide company, emotional support; and they have a role in mobility and decision making of the patients [12]. However, their participation often poses challenges. Doctors may differ about the most useful behaviors of companions (e.g., information or support) and can have problems (for example the companion dominant or with demanding behavior).
Despite all the above, the reports, reviews or investigations about the presence of a companion of the patient in consultation, are rather scarce in our environment. Very little research has examined the influence of people who accompany patients on everyday visits to the doctor [13,14], and previous research on the communication in medical encounters has primarily focused on dyadic interactions between physician and patient [15].
In this context, we present a study whose objectives were: 1.-To describe the frequency of the presence of the companion of the patient in Family Medicine consultation.
2.-To describe the characteristics the patient and his companion in Family Medicine consultation, according age, sex, disease, drugs, and others variables.
3. Qualify the companion of the patient according to his attitude.

Material and method
Observational, descriptive, prospective study, which included patients of both sexes over 14 years of a Family Medicine office which has a quota of 2,000 patients. We calculated the sample size for an estimated rate of companion of 30%, for a population of consultation of 2000 persons, a confidence limit of 5%, and a confidence interval of 95%, in 278 patients [16].
From randomly chosen day for 15 consecutive days, from 26 November 2015 to 18 December 2015, the visited patients were included, and data from the companions with patients were collected. Companion was defined as any person who accompanied the patient in the consulting room or that consulted instead the patient. Patients were included only one time. Thus, were excluded the repeated consultations of same patient, including only the first visit. If the patient had two companions only was included the data from the first of them in analysis.
For each patient and companion the following variables were collected: age, sex, chronic disease (defined as "any alteration or deviation from normal that have one or more of the following characteristics: is permanent, leaves residual impairment, is caused by a non-reversible pathological alteration, it requires special training of the patient for rehabilitation, and/or can be expected to require a long period of control, observation or treatment") [17], and classified according to International Classification of Diseases (ICD-10) [18], taking medication, collecting the therapeutic drugs group, classified according to ATC code or system Anatomic Classification, Therapeutic, Chemical [19], sick leave of the patient, the problems in the family context (based on the genogram, and valued by the family doctor who performed the genogram at the past time, by viewing the family scheme (the genogram was a schematic model of the structure and processes of a family, included the family structure, life cycle when that family is, the important life events, family resources, and family relational patterns) [20][21][22][23], social-occupancy class, according to the Registrar General's classification of occupations and social status code [24,25], type of companion classified as "Collaborator", "Passive", "Intrusive", "Guilty", "Sick", and "Critical / Angered" according to the definition given in Table 1 [1,26,27] from the decision of the usual doctor in the medical office, and who remains in the same consultation for over 25 years, if the analytical or imaging test was requested for the patient, if the patient needs a consultation with the specialist, the companion relationship with the patient, and the social availability of companion in relation to the patient.
A Microsoft Excel® file was built, and the the IBM SPSS Statistics for Windows, Version 18.0. Armonk, NY: IBM Corp software was used [28]. Descriptive data, which were expressed by standard measures of central tendency and dispersion, were obtained. The informed consent of all patients or their guardians for using of data in research was obtained.

Results
During the 15 days of data collection, a sample of 445 patients was obtained, of whom 106 were patients with a companion (24% frequency or prevalence of the presence of the companion) ( Figure 1). In 63% of consultations with companion (95% CI 53.28 to 72.36) the patient was present. With the 106 patients were 104 companions (there were patients who shared companion).

Definitions of the Type of Companion Definition
"Collaborator" Helps the doctor spontaneously and with respect, gives relevant information about the patient and adopts a position of responsibility in the therapeutic process. Notes the doctor's instructions. He or she asks questions. Explains the doctor's instructions to the patient "Passive" He or she generally it remains in the waiting room, is not involved or does poorly in the development of clinical interview "Intrusive" He or she participate excessively actively in the interview, so he or she gives answers by the patient, instructs the doctor or induces responses in the patient. He or she Interrupted the doctor-patient relationship "Guilty" He or she feels guilty about their inability to provide a certain level of care that are necessary for the patient, but that would require major changes in lifestyle of companion "Sick" He or she projects his symptoms on the patient. The companion is actually the real sick, and reflects their anxieties and demands on the patient "Critical / Angered" He or she ago criticism of a thing, especially for improvement. He or she can show anger, disgust or anger
There were 2 companions with one patient in the 2% of patients (95% CI 0.22 to 6.65). Kinship of the companion was predominantly wife in 43%, the child / girl in 27%, and the mother in 17%. Companions have a total of 2 ± 2 chronic diseases. Musculoskeletal system and connective tissue diseases in 30% of companions, mental and behavioral disorders in 29% of the companions, and circulatory system diseases in 26%, were predominant. The companions took an average of 2 ± 2 medications. Medications taken predominantly were of cardiovascular system with 22%, nervous system with 20%, and system skeletal muscle 18%. The problems in familiar context of companion were found in 47% (95% CI 37.18 to 57.81). The social class-occupancy prevalent in the companion was unskilled workers in 58%. The situation of social availability of companion was predominantly worker in 37%, housewife 27%, and retired at 23%. Companions were classified as "collaborators" in the 45.2% (Table 2).
The predominant diseases were of the circulatory system in 41% of patients, endocrine, nutritional and metabolic diseases in 31%, mental and behavioral 31% disorders, diseases of the musculoskeletal system and connective tissue in 28%, and respiratory system diseases in 19%. Patients were taking an average of 2.96 ± 3.03 drugs. The predominant group was nervous system drugs, in 41% of patients, the cardiovascular system in 35%, and the digestive system and metabolism 30%. The 12% (95% CI 6.69 to 55.26) of patients were off work. In 45% (95% CI 35.22 to 55.26) of the patients was considered that there were problems in the family context. The 57% were unskilled workers, 17% semi-skilled, 13% students. They consulted predominantly by diseases of the circulatory system in 19%; by diseases of the respiratory system in 14%; and by musculoskeletal disorders and connective tissue in 14%. An analytic test was ordered in 4% (95% CI 1.03 to 9.38) of patients, and an imaging test in 1% (95% CI 0.02 to 5.14). There were specialist hospital referrals in 18% of patients (95% CI 11.15 to 26.56) ( Table 3).

Discussion
The presence of family members in the office visit creates opportunities for the family doctor: it allows speak with the patient and family on their family history and context, and this knowledge can be important for decision-making and implementation of therapeutic measures. The positive consequences of the presence of companions would be: he or she can give information on the severity of the disease, prevents anxiety, builds trust, promotes obtaining more information on the health situation and disease patient, it favours family dialogue, aids to decision-making, improves satisfaction, provides support, and improves patient health outcomes. Consequently, it is recognized that to improve attendance and potential outcomes of the patient, the doctor should focus on a whole range of approaches to facilitate the participation of companions-caregivers in clinical encounters [1].

Prevalence of the companion of the patient in consultation
It has been reported that visits in which one or more family members are present, are quite common, and their prevalence figures or frequency are ranging from 16%, 30%, 35%, 39%, 53%, and up to 62% [5,7,8,13,[29][30][31]. We found that 23.86% of the interviews were with companions, the same figure as Castillo- Barrera (27), also in Spain.

Features of the companions
The companions of the patients are usually family members, and this relationship is present in 93% of cases [5], being a woman in 73% [13,30], aged between 21-40 years [13], and she is the wife in 48% [29,31]. Our study reproduces these data, being the companion predominant a middle-aged adult, usually the couple and housewife. We also found that their social availability to be the companion of the patient was predominantly worker in 37%, housewife 27%, and retired 23%.
On the other hand, doctors may differ about the most useful behaviors of companions (e.g., information support) and less useful (for example, dominant companions or demanding behavior), so that preferences for participation of companions can vary greatly between different doctors. We found companions "collaborators" in the 45%. These data are consistent with previously published [7,29]. It has been reported that the most frequent companion is a collaborator (67%), followed of liabilities-silent observer (29-69%) and intrusive (5%) [13,27,30]. The problems in familiar context of companion were found in 47% (95% CI 37.18 to 57.81). Our research group has communicated that the presence of companion of the patient in consultation Family Medicine is associated with familiar problems vs. the presence of unaccompanied patient [32].
The companion assumes the value as intermediary and caregiver. The care of patients "very fragile", the increasing dependence on their families of elderly patients and / or significant chronic problems, along with the complexity of health services, contributing to the perception that informal caregivers and companions have a role indispensable as "intermediaries between the health system and patient." Therefore, it is desirable to emphasize the need to discuss further about the fragility of patients with their family companions, who can be supported and trained to participate in decision-making on tasks for the care of the sick, so that they meet the needs of the patient, the doctor and family [1].
The presence of family members at an office visit creates unique opportunities and challenges for the physician while interviewing the patient. The physician must address issues of confidentiality, privacy, and agency. Special skills are required to respectfully and efficiently involve family members, while keeping the patient at the center of the visit. These skills include building rapport with each participant by identifying his 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 [33].

Limitations of our study and possible future research
Some of the limitations are: 1) the dynamics of the interview was not studied; 2) it was not collected the meaning or reason to be present companion; 3) the reasons for to be accompanied to the consultation were not collected; and 4) The patients' perceptions were not collected. Future studies could include these topics [1,3,5,13,34].

Summary and conclusion
Our study coincides with previous research. There is a high prevalence of the presence of companion, which is present in almost one of every 4 visits served in Family Medicine. The accompanying "type" is a middle-aged adult, predominantly the couple, worker, housewife or retired, with family problems. Accompanying patients are older women, with polypharmacy, and generate hospital referrals.
The companion seems to play a secondary role, but he can be the main actor. This high prevalence of companion should remind us "make the invisible visible" and take into account the companion during assistance in individual patients [35]. Doctors should be interested increasingly in them. A second adult -usually the husband or wife or parents-accompanying the patient in consultation, or instead of him or her, is always significant and deserves the attention of the doctor. The family members are the most frequent companions of the patient consultation, and thus, it forces to a practice orientated to the family. Table 4 shows key recommendations for practice [3].
The presence of family members in the office visit creates opportunities for the family doctor: it allows talk to the patient and family about their family history and context, and this knowledge can be important for decision-making and implementation of therapeutic measures. Finally, the fact of the high prevalence of companions, leads to consider the ethical aspects of the companions in the consultation, mainly confidentiality and autonomy.