Counseling the Family: An Intern's Perspective

By Ali Maher Hassan On a busy nightshift I was the only intern available, as my supervising physician was deposed with other critical patients. I was immediately called to the triage area for a 48-year-old woman brought in by an ambulance and accompanied by her family. The patient was in acute distress and unable to speak. As soon as her children identified themselves, a panicked question arose: “What’s going on?” I inquired about their mother’s initial presentation and learned that her daughters had found her on the bathroom floor, but no one was sure of what occurred. Once the hospital staff helped shift the patient into the resuscitation bay, I immediately proceeded to check her vitals and assess her level of consciousness while asking a series of questions. In the midst of doing this, her son interrupted me to state, “there is no point in your questions.” Then, in a disgruntled done, he said something about me “being useless” and demanded that I “just give her medication.”

How many of us interns have encountered an angry or fearful family member or multiple disgruntled family members accompanying a sick relative? Physicians can sometimes be so mired into their work caring for patients that they forget to care for families, thus leaving them feeling unattended to. Family members sometimes attend the emergency department in a state of panic and/or with other strong emotions, which puts a strain on the relationship between family and physician. As we spend more and more time in the emergency department, we eventually realize that this is all too common and recurrent of a theme for which preparation and training is necessary. My encounter with this family in the ED was a steppingstone in my career during which I learned the importance of attending to the families of patients.

A family’s disposition in a situation like this one may greatly influence a physician’s professional judgment. Physicians may

"PHYSICIANS CAN SOMETIMES BE SO MIRED INTO THEIR WORK CARING FOR PATIENTS THAT THEY FORGET TO CARE FOR FAMILIES, THUS LEAVING THEM FEELING UNATTENDED TO."

feel disheartened due to negative feedback they receive during these crucial moments. On the other hand, such thoughtless comments may enhance empathy as it reminds us that the relationship between these individuals is a very personal one. As an intern, it is especially easy to put behind the oaths we took at the beginning and end of our medical school journey – to prioritize patient health, practicing beneficence, maintaining professionalism and abiding by the laws of ethics. Patient health encompasses physical, mental, emotional and psychosocial care. Although their mother lay on the bed, her children needed tending to, as well. While one may reflect on these principles with a clear mind, will you be able to put them into practice in that very instant?

Although looking up to the patient’s son took all of a second, it felt much longer when you deliberate how to best respond. How can I focus on the task at hand while being reprimanded simultaneously? I remind myself to remain patient, polite and as professional as possible. Her family is fearful of the situation at hand, and are not troubled by me, personally. It is never easy to witness your ill mother on a hospital bed. I then proceed to empathize with the patients’ relations, share their frustration, and gently emphasize my intention to do the best I can to help their mother. This seemed to calm them down, albeit temporarily, but it gives me just enough room to think clearly and manage the patient’s condition to the best of my ability.

It is already difficult as an intern to take care of such patients by ourselves due to the lack of experience, let alone counsel the family too. These encounters are going to be innumerable over the span of our careers, and my attending, Dr. Bradley, whom possessed over 30 years of experience as an emergency medicine specialist, mentions some things we can do to defuse such situations and excel while in practice: • Lend an ear; truly listen to and decipher their concerns. • Understand their relation to the patient and be as empathetic towards him/her as possible. • Even if they may appear angry at you, they are not. A family member, more often than not, does not understand what is going on and is merely afraid of what may follow. • If the scenario warrants it, do what is best for the patient. If this means asking family to evacuate a room, then ask them to do so politely.

An insightful review virtually accessible further consolidated these concepts. Dr. Thomas Baudendistel MD, FACP is an associate program director at Sutter Health’s California Pacific Medical Center, and chair of Sutter Health’s Ethics Committee. He encourages physicians to, first, avoid describing such family members as “difficult”, and instead consider them as “someone with lots of worries.” Secondly, when dealing with worried patients or family members, he advised building trust, being transparent, to “stay on the same page” by inquiring about and responding to any immediate concerns they may have, employing team resources, enhancing communication skills, avoiding assumptions and last, but not least, doing the very best you can.

I applied Dr. Bradley's and Dr. Baudendistel's advice in the weeks to come and found that a number of similar scenarios were handled in an overall improved manner due to an increased level of co-operation of patients. I also had a plan to lean back on when things didn’t go too well. Subsequently, I no longer found myself in a state of “what do I do now?” which only improved my confidence and directive approach when facing these situations.

Counseling is an integral part of practicing medicine. It requires plenty of practice and, if mindful, will only improve with time.

ABOUT THE AUTHOR: Ali Maher Hassan is an emergency medicine intern at Bellin Health, Green Bay, Wisconsin.