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Three-track care: Older patient, family member, and physician in the medical visit
THREE-TRACK CARE: Older Patient, Family Member, and Physician in the Medical Visit
BETTY RISTEEN HASSELKUS* University of Wisconsin- Madison
ABSTRACT: When older patients come to medical appointments accompanied by a family member, patterns of interaction ensue that reflect uncertainties about the capabilities and responsibilities of each person in this triad. In this study, ongoing discoursefrom 40 transcribed medical visits with an elderly patient, family caregiver, and physician were analyzed. Interactive behaviors that support patient self care capabilities and those that support dependency are identified and described, and patterns of interaction related to the patients’ cognitive or sensory impairments are explored. The presence of a family member at an older patient’s medical visit-in combination with the authoritarian traditions of medical care, assumptions about frailty and aging, and true impairment-appears to trigger behaviors that marginalize the patient and that are supportive of dependent self care. Behaviors that support independent serf care are less evident. An awareness of this tendency toward dependent supportive interactions may enable physicians, family members, andpatients to change this pattern, breaking the cycle of increasing dependence and supporting instead the patient S adult independent status in the clinic setting.
The American ideology of individualism, self-sufficiency, and productivity generates norms of behavior for adulthood that include independence. Clark (1973) summarized this ideology in the statement, “Only by being independent can an American be truly a person, self-respecting, worthy of concern and the esteem of others” (p. 82). This “independence” may encompass many dimensions of a person’s life experience, but one of the core components is independence in self care. *Direct all correspondence to: Betty Risteen Hasselkus, Occupational Therapy Program, Department Kinesiology, University of Wisconsin-Madison, I300 University Avenue, Madison, WI 53706. JOURNAL OF AGING STUDIES, Volume 8, Number 3, pages 291-307 Copyright @ 1994 by JAI Press Inc. All rights of reproduction in any form reserved. ISSN: 0890-4065.
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Seeking a physician’s help and engaging in medical clinic visits constitute forms of self care carried out by the adult individual (Levin 1977; Orem 1980). To monitor and study concepts of self care within the context of physician-patient care, structural elements of the medical interview have been identified that reflect and promote patient self-determination and partnership between doctor and client. Process components of the patient’s communication such as information seeking, information sharing, initiation of topics, and suggestions for diagnoses and treatment are considered consumer/self help behaviors (Beisecker 1988; Beisecker and Beisecker 1990; Haug and Lavin 1983; Stiles 1989). Haug and Lavin define consumerism in medicine as “challenging the physician’s ability to make unilateral decisions-demanding a share in reaching closure on diagnosis and working out treatment plans” (1983, pp. 16-17). Physician interview strategies, responsiveness to the patient’s participation, and styles of information gathering and giving that facilitate patients as care partners are also the focus of research (Bertakis et al. 1991; Miller and Oertel 1983; Roter and Frankel 1992; Roter et al. 1991; Simpson et al. 1991; Stiles 1989; Stiles and Putnam 1992). Help-seeking from physicians as a form of self care may be especially prominent in old age. Older people account for 31 percent of all expenditures for health care in the United States and more than one-fifth of these expenditures are for physician services (National Center for Health Statistics 1987). Among older patients, it is estimated that 20 to 37 percent who seek physician care are accompanied to medical visits by a family member (Adelman et al. 1987; Labrecque et al. 1991). The impact of this third person on the structure and function of the medical visit, including its self care components, has received limited research attention. One recent article (Glasser et al. 1992) focuses on the involvement of the family companion in the medical care-seeking decision. Other studies have addressed primarily the roles of the family caregiver (Adelman et al. 1987; Hasselkus 1992a, 1992b) and the interactional dynamics (Coe and Prendergast 1985; Labrecque et al. 1991; Rosow 1981) in the triadic visit. In this article, I examine the three-person clinic visit as it relates to the nature of self care independence and threats to the adult status of the older patient in the clinic setting. Data consisting of verbatim transcripts from 40 medical visits that included a physician, older patient, and family caregiver were examined for self care-related behaviors and interaction patterns. It is assumed that behaviors that support the older person’s independence and engagement in interactions during the medical encounter also support the person’s adult social status (Lowenberg 1989). The opposite is also assumed. The data are examined to gain new understandings of clinic behaviors by the physician, the family member, and the older patient as they relate to dependence and independence. Further, the relationship between these clinic behaviors and observable patient impairment is explored in this triadic medical context.
SELF CARE IN THE MEDICAL SETTING Self care independence is a phrase usually associated with nonmedical contexts and nonprofessional care. Lay care, home remedies, self help, folk medicine, and over-thecounter drugs are all terms that refer to self care traditions. Alternatively, medical care in western society takes place in a context of institutional authority wherein the “self is assumed to become dependent on the professional for the “care.” The tradition of
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authoritarian care has, perhaps, been particularly strong in physician care. Bloom and Speedling (1981) conclude that “the patient appears to be inherently dependent within the situation of doctor-patient exchanges” (p. 158). In many ways, the authoritarian model of health care has fostered an image of the doctor-patient relationship as fiduciary, most like the relationship of parent to child. Parson’s model of the sick role, first introduced in 1951, conceptualized illness as a form of deviance and doctors as experts who function to correct, and thus control, the deviance. In Arluke’s discussion of the sick-role concept, he states, “. . . the health care process portrays physicians as parentlike, strong figures who are permissive, supportive, objective, and ethical. Patients in this scheme . . . act as relatively weak, dependent, childlike figures” (Arluke 1988, p. 174). The authoritarian medical model of care, however, has undergone changes in recent decades. The social movements of the 1960s and 1970s led to new insights and recognition of the rights of people with disabilities and other minority statuses (DeJong 1979). Consumerism and lay-professional partnerships emerged as new ideals in medical care. As Haug and Lavin stated, “When the nature of symptoms and danger signs demands medical consultation, this does not mean that the value of independence is perforce abandoned” (1983, p. 193). Consumer behaviors in the medical encounter have been promoted, and strategies to support autonomy and self care described and encouraged. Investigation of older patients’ consumer behaviors inthe clinical setting has led to inconsistent findings. Some research suggests that an older patient and a health professional interact in a social context shaped by assumptions about debility and loss of function that are not present with a younger patient (Barta Kvitek et al. 1986; Becker and Kaufman 1988; Greene et al. 1986; Keller et al. 1989). In 1988, Beisecker reported less consumer behavior among her older subjects during physicians visits for outpatient rehabilitation. In a second study, however, Beisecker and Beisecker (1990) demonstrated more information seeking behaviors by older patients compared to those who were younger. In regard to physician attitudes, Revenson (1989) studied “compassionate stereotyping” of elderly patients, finding that doctors tended to rate older patients as less well adjusted, less autonomous, and in need of greater support and information. On the other hand, Fields et al (1992) reported that only seven percent of a class of medical studentspost geriatric rotation-believed that elderly patients are not able to take care of their own needs and follow treatment plans. Thus, findings related to beliefs about self care capabilities and self care behaviors of older patients in the medical encounter are mixed. The triadic visit seems to represent a third dimension of threats to the adult status of the patient, compounding those already inherent or implied by the medical milieu itself and societal views of aging. The scenario of an older person being accompanied into the medical examining room by a family member, for whatever reason, is likely to convey another strong signal of dependence. The ambiguities of the three-way division of responsibilities may increase the potential dependent status of the patient in the medical encounter. THREE-TRACK
CARE’
Discourse data from 40 outpatient clinic visits with physician, family member and older patient were analyzed for self care behaviors as markers of adult status in the older
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patient. Data were collected in the internal medicine and geriatric clinics of a midwestern university hospital. After following prescribed informed consent procedures, my research assistant or I placed an audiotape recorder in the examining room at the start of an appointment. We were not present in the room during the interview, but simply returned to retrieve the recorder when the appointment was concluded. All audiotapes were then transcribed in preparation for analysis. Study participants included 11 physicians, 27 patients, and 3 1 family members (5 clinic visits included more than one family caregiver). Patients’ ages ranged from 64 to 91 years. The caregivers included 13 daughters, 6 sons, 7 wives, 3 husbands, 1 daughter-in-law, and 1 sister. Of the eleven physicians, 5 were staff, 4 were residents, and 2 were geriatric fellows. I refer the reader to previous publications (Hasselkus 1992a, 1992b) for more detailed descriptions of the study sample, data collection, and data analysis. Previous analyses of these data have yielded two major roles for the family caregiver in the three-person clinic visit-the role of second practitioner and the role of interpreter (Hasselkus 1992a, 1992b). While my previous analyses focused on the family caregiver and physician interactions, the discussion here will address these findings as they relate to the older patient’s self care independence and adult status in the clinic setting.
Ambiguous Capabilities Baltes (1988), in her research on dependence in older people, has distinguished among three types of dependency: adaptive dependency (giving up independence in one area of daily life in order to maintain independence in another), true dependency due to impairment, and excess dependency that results from underestimations of capabilities either by the elderly person or by someone in the environment. In a way, physicians, family caregivers, and older patients must sort out these types of dependency as they carry out health care in the triadic medical visit. Clinical determinations of competency (in contrast to judicial rulings) must occur “on the spot”in the clinical setting (High 1989). High describes the need for professionals to be alert to evidence of incapacity and the need for surrogate decision-making. “Clues may emerge from conversations with the patient, from observation of behavior or from discussions with family members or others” (High 1989, p. 84). Family caregivers must be alert to the same clues, as, indeed, must the patient him or herself as each determines performance competencies. False assumptions of incapacity can lead to underestimations of competency, thereby promoting dependencies in self care behaviors that are not true or adaptive dependencies. CLUES ABOUT INCAPACITY In these clinic data, clues about incapacity were conveyed in several ways. For example, family caregivers’ behaviors were demonstrated that offered clues to the physician about the self care capabilities of the older patient. As an interpreter, the caregiver engaged in incidents of correcting, adding to, prompting, answering for, and paraphrasing-all potential signals to the physician that the patient needed assistance. The physician might then assume that incapacity was, in fact, present and might begin to direct more of the interview to the caregiver as a substitute patient. When the family
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caregiver acted as the direct source for information, and the interactions became an extended dyad between caregiver and physician, the patient was unquestionably marginalized (Rasselkus 1992b). An example of these mechanisms of margindlization is found in the data from Clinic Visit 18 in which the physician started the visit by directing questions to the patient.
Doctor:
Well now, Mrs. E., let me just ask you how you are doing?
Patient:
I don’t know. Last week was terrible in my legs and my arms. I’m so scared of falling . . .
The patient shifted at this point to talking about a different doctor whom she had recently
seen and who told her she was dehydrated. The patient then mentioned running out of medicine. The doctor continued briefly to tslk directly with the patient, trying to clarify the meaning of what she was saying, and returning to the topic of the walking difficulties. At that point the caregiver spoke up: “See, he [the other doctor] put her on this prozac,” thus interjecting new and seemingly significant information into the conversation. The caregiver and physician then engaged in an extended two-person dialogue that resembled that of two pr~titione~ discussing side effects, dosages, and recommendations regarding continuing or discontinuing medications. The remainder of the interview was dominated by caregiver-physician interactions related to medications. The pattern of interaction suggests that the caregiver initially held back from engaging in the conversation, witnessed the rather rambling and unclear presentation of concerns by the patient, and then decided that she needed to assist with the communication. Other behavioral clues that conveyed caregiver beliefs of incompetence in the patient occurred when: the caregiver explicitly questioned the truth of the patient’s statements; the caregiver disclosed information to the doctor in spite of the patient’s objections; the caregiver told the patient what to say or do; the caregiver interacted paternalistically with the patient. The following interview excerpt illustrates disclosure of information against the wishes of the patient, casting doubts about the veracity of the patient’s views of the symptoms: Caregiver [to doctor]:
She hyperventilates all the time and this morning it was much worse. [To patient]: Well, it’s the truth, you’ve got to tell them that * . You’ve got to tell him so he knows.
Patient [to caregiver]:
He knows. You don’t need to tell.
Physician [to patient]:
Well, when you were breathing like that . . . what was the reason for that?
Patient:
Well, I was out of breath . . . I do that when I walk, I walk so many times I get out of breath and I start breathing.
Physician [to caregiver]:
Okay, so you’re not agreeing, you think it’s different?
Caregiver:
I think she’s very nervous, and that’s what makes her do that. She says ‘I have to do that.’ She does it 365 days a year, all the time.
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Patient:
It isn’t that bad.
Caregiver:
Mother,
Patient:
It isn’t that bad. [Clinic Visit 61
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you do.
This subjugation of the patient’s control over what is disclosed in the clinic visit sends a strong message of the caregiver’s disbelief in the patient’s judgment capabilities and disregard for the older person’s autonomy. Older patients themselves gave evidence of incapacity in other ways such as the following: by talking to the doctor through the family member (“He’ll have to give me some new prescriptions”), thereby indicating an expectation that the caregiver would be the spokesperson; by deferring to the caregiver regarding responsibility for information (Doctor: So it would be the same number of pills a day. Patient [to caregiver]: You know how to do it now?); and by checking with the caregiver for accuracy of information being requested (Doctor: When was the last time that you threw up? Do you remember? Was that very recent at all? Patient [to caregiver]: Not very recent, was it?). Explicit deference to the bureaucratic authority of the doctor was noted in a few instances (Doctor: Let’s see, have you tried any aspirin at all? Patient: Huh uh. With your permission, I would like to.). This deference portrayed a dependency derived from the patient relinquishing decision-making power to the authority of the professional. The above examples and patterns of interaction all convey a sense of patient incapacity and seem to promote marginalization and loss of adult status in the older patient. These interactions probably represent a convergence of assumptions about the patient’s capabilities prompted by the age of the patient, the model of physician authority, and the family caregiver roles of practitioner and interpreter.
SUPPORT
FOR CAPACIN
Interactions also occurred that affirmed capacity and thus supported the patient’s adult status. These interactions seemed to represent conscious efforts on the part of the physician, family member, and patient to enable the patient to participate in the conversations. The physicians’ efforts of support are represented in behaviors such as interrupting the caregiver’s dialogue to enable the patient to respond, or deliberately turning back to the patient for information during an exchange with the caregiver. At times, physicians made a show of respect for the patient by asking “permission” to direct questions to the family member. Both the physicians and the caregivers turned to the patient to verify information being discussed. For example, after a lengthy discussion with the doctor about her mother’s medications and possible side effects of fatigue, the caregiver turned to her hearing-impaired mother to verify the complaint: Caregiver [to mother]:
You say the big thing, you’re so tired all the time. That bothers you a lot, doesn’t it?
Patient:
Well, just that you don’t like to be so tired that you can’t, you know, sometimes I feel as though I’m too tired to even get up. [Clinic Visit 131
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The caregivers also demonstrated efforts to help the patients understand what was being discussed. This was evident when a caregiver repeated or paraphrased the doctor’s questions and comments to a patient. But other incidents illustrated frankly assertive behaviors on the patient’s behalf. In the following exchange, the doctor was displaying new and old x-rays and did not address the patient’s ability to see the films: Doctor:
All right, let’s compare it to when you were at your worst.. . Okay, you can see this is when she was really sick [note shift to caregiver]. How this . . .
Caregiver [interrupts] Why don’t you get up, I don’t know if you can see this. [to mother]: Doctor [continuing]:
She gets cut off [?I right here in her lungs . . . so she’s much better than she was before, they look pretty clear. I don’t see any fluid on there. [Clinic Visit 21
It is the caregiver in this scenario who acts to enable the patient to see the x-rays, recognizing the centrality of the discussion to her mother. The caregiver’s deliberate inclusion of her mother sends a message that the mother is cognitively capable of understanding such information, thus affirming her adult capabilities as well as her rights in the clinic setting. The doctor in this incident continues to address all comments to the caregiver. Occasionally, the family member turned to the patient to include him or her in decision making. Following fairly lengthy discourse between the doctor and the caregiver about her mother’s back pain and the use of various analgesics, one caregiver summarized the recommendation succinctly for the patient and solicited her approval: Caregiver [to mother]:
That little blue pill you take, Mother, maybe they can change that, to try a different medication.
Patient:
Well, I’ve been taking that for a long time.
Doctor:
Right.
Caregiver:
Yeah, you’d be willing io change it?
Patient:
Yeah, if something’s better, well then I’d want to get it. [Clinic Visit 131
This action by the caregiver affirms the patient’s ability and right to make informed and reasonable decisions, thus also affirming her adult status. Finally, the older patients themselves exhibited behaviors that supported their own adult status. Patients interrupted doctor-caregiver dyads to ask their own questions about medication, to volunteer information, to express their own opinions about treatments and symptoms, and to remind the caregiver and doctor about concerns such as prescription needs. These self care behaviors were most evident in those interviews in which the patient did not have significant cognitive or sensory impairments. An exception was Clinic Visit 13 wherein the patient had a marked hearing impairment that severely interfered with communication. This patient, accompanied by her daughter
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caregiver, stated to the doctor early in the interview, “I have a hearing problem, you know; you’d probably know that without me telling you. That’s why I have to ask you to repeat things.” Moments later, she volunteered further explanation of the hearing impairment. “It isn’t that I don’t hear so much, it’s that I don’t understand. There’s a difference there.. . I call it a hearing problem, I suppose it is a hearing problem, but it isn’t that. Lots of times I can hear people but I can’t understand what they’re saying.” This display of initiative and sense of responsibility for self-disclosure contrasts starkly with the patients who did not offer such information and/or who turned to their caregivers to carry out this function.
Dependency and Impairment In order to examine the relationship of the patterns of interaction to functional status of the patient in these triadic interviews, the transcripts were divided into three categories of patient impairment: no apparent cognitive or sensory impairment (15 interviews), moderate or questionable impairment (15 interviews), and marked impairment (10 interviews). Categorization of marked impairment was based on diagnoses if stated (“She’s not going to understand, she’s aphasic”), evidence from the patient’s attempts at discourse (repeated incoherence, nonresponsiveness, confusion), frequent need to repeat questions, and other revealing remarks made during the interview. Interviews that reflected mild hearing impairment or that indicated mild cognitive problems in areas such as medication management were categorized as moderate impairment. Those that contained no explicit statements or other signs of impairment in the patient were categorized as no impairment. MARKED M’AIRMENT In those interviews in which the patient had a marked and obvious impairment, direct involvement of the patient was largely limited to the physical examination phase of the visit. The physician and the family caregiver tended to interact as two practitioners in an extended dyadic exchange during the history-taking and during the decision-making and instructions near the end of the interview. This pattern of interaction was particularly evident when the patient’s imp~rment was cognitive. One profoundly demented patient’s only communications in the visit were responses to questions about o~entation to time, place, and person and physical status during the examination; all other interaction took place between the physician and family caregiver. Medical visits are, it seems, very cognitive events. As Haug and Ory (1987) state, severe impairment from dementia will “virtually preclude meaningful encounters with a care provider” (p. 12). When the marked impairment was a hearing loss, efforts were made in the beginning of the visit to overcome communication difficulties. Physicians used various strategies (with varying degrees of success) of rephrasing and speaking louder to enhance the patient’s ability to contribute to the clinic process. One physician sought the input of the family caregiver regarding the patient’s hearing, asking “Am I talking into the wrong ear, do you think?” In this case, a subsequent shift to the other ear did help the patient’s hearing. The caregivers, too, volunteered suggestions to the physicians regarding strategies to overcome the hearing problems (“When you’re speaking to him, it’s much easier if you look at him”). In Clinic Visit 13 (the above excerpt of the patient who
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explained her hearing problem to the doctor), the caregiver made concerted efforts throughout the visit to support her mother’s participation in the clinic visit, despite the severe hearing impairment. This daughter repeatedly sought her mother’s opinions, inquired about what she understood, sought further information and facts from her mother, deferred to her mother to provide information, and reminded her of concerns to bring up.
MODERATE
IMPAIRMENT
When a cognitive or sensory impairment was present, but only to a more moderate extent, the uncertainties of the situation became a pervasive force. The interviews in this category were largely represented by triads that included patients with mild cognitive deficits. Each physician was faced with the “on the spot” task of sorting out the ambiguous capabilities of the patient and caregiver. As High (1989) has discussed, no clear definition of capacity and incapacity exists, nor is there a uniform set of criteria for making such determinations. The physician must define and redefine the situation, being ever alert to ongoing evidence regarding the patient’s ability to comprehend information, to ask and answer questions, and to engage in decision-making (Glasser et al. 1990; High 1989). In these interviews, physicians struggled with dilemmas of whom to address in the history-taking and whom to address in the explanation of diagnoses and treatment. Caregivers struggled with how best to interact with the patient and physician in the clinic setting in the presence of uncertain impairment. Physicians seemed usually to give the patient the benefit of the doubt at the beginning of the interview-addressing opening comments and questions directly to him or her and listening, then, for clues from the patient and caregiver about what capabilities to expect. These direct physicianpatient interactions, however, were usually brief, and the caregiver played a prominent role as the dialogue continued. As evidence of this uncertainty about capabilities, it was not uncommon for the physician to shift back and forth repeatedly between the caregiver and the patient during discussions and explanations of health issues: Physician [to caregiver regarding medication]:
. we’ll see if 50 is enough. If 50 is not enough and she gets another infection then we’ll go back up and have her take the 100. But I’d like her to be on the lowest possible dose that she can be on . . and then we’ll try that for a few months and then maybe we’ll stop it and see what happens.
Caregiver:
Okay.
Physician [shift to patient]:
. . . and then based on your blood test, we’ll tell you if you have to make any changes in the other [medication] . . since you’re not waking up at night as much . . I mean that’s why I had you go up on that to see if your breathing would be better at night, so you weren’t getting up and feeling like you needed to sit in the chair as much. [shift back to caregiver] And if she’s tolerating taking 3 doxepin and maybe there’s been some change, I think we should go ahead and have her stay on 3 for a while.. . [Clinic Visit 301.
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Much of the discourse in these interviews represented protective caregiving as discussed by Bowers (1987). Protective caregiving occurs when the caregiver attempts to protect the older person from being aware that he or she is being cared for. By inference, this also means protecting the older person from being aware that he or she is perceived by others as needing to be cared for. This sense of the need to protect the patient from “knowing” in these triadic interviews meant that negotiations about capabilities had to be carried out silently or dealt with very obliquely by the physician and family caregiver. In keeping with Bowers’ findings, protective caregiving in this study was most intense when the older patient had a moderate cognitive impairment. These caregivers used many strategies to provide their caregiving services in ways that were not explicitly recognizable as such. Additionally, the physicians carried out their caregiving tasks in ways that masked their knowledge of the patient’s incapacity from the patient. Whatever signals and negotiations took place to establish this as a modus operandi were silent, unspoken. Much of the interpreter behaviors of the caregiver served as protective caregiving. These were the incidents when the caregiver sought to include the patient in the conversation in a way that supported the patient’s ability to actively participate as a competent adult-prompting the patient to respond, clarifying meanings for the patient, suggesting topics for the patient to bring up, seeking the patient’s opinion. In the practitioner role, when care needs were being more directly addressed by the family member, the caregiver used other subtle strategies to avoid explicit statements of the patient’s marginal capacity but at the same time to signal to the physician that the patient’s capabilities were questionable as in the following example: Patient [to doctor]:
What do you mean by one dose?
Doctor:
One dose.
Patient:
Two?
Doctor:
Just, uh, two, two aspirin pills.
Patient:
Two, two makes a dose.
Doctor:
How does that sound to you?
Patient:
Good.
Caregiver:
Now one concern that I have is that, urn, Mother has a tendency to take things [carefully choosing words], she’s almost compulsive.
Doctor:
Uh huh.
Caregiver:
You know, she gets a thought in her mind, she takes them. One of the nice things about having a pill dispenser is that it regulates her. Although I came this morning, at seven-thirty this morning to pick her up and she had already taken her noon medication.
Doctor:
Uh huh.
Patient:
(laughs)
Caregiver:
So, but then I, she got up at four o’clock this morning so her body clock probably was noon (slight laugh). . . I’m concerned that she have aspirin in her apartment.
Three-Track Care: O/der Patient, Family Member, and Physician Doctor:
Oh, I think we can use it in the context of the pill dispenser.
Caregiver:
Okay, that was my concern. [Clinic Visit 011
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about the patient’s capabilities, but to do it in such a way that the patient is protected from direct awareness of incapacity and that his or her adult status and dignity is somehow also upheld (“her body clock probably was noon”), further compounds the obscurities of the situation and heightens the physician’s need to be ever alert to clues about the patient’s status. It seems apparent that the uncertainty of capabilities entails a corollary uncertainty of responsibilities, Ambiguous responsibility has been explored in the context of the physician-patient relationship (Becker and Nachtigall 1991; Lowenberg 1989). In the triadic clinic visit, I use the term ambiguous responsibility to refer to the uncertainties about individuai health care responsibility that are present throughout the visit. The caregivers and patients struggled to determine where their respective responsibilities began and ended in relation to each other and to the physician. Caregivers were clearly attributing responsibility to themselves when they told the patients what to say, when they prompted patients to bring up certain topics, when they paraphrased the doctors’ questions to help the patients understand, when they explained to the doctors what the patients were trying to say, when they suggested diagnoses and treatments. Patients demonstrated self-responsibility when they asserted their own viewpoints, brought up concerns, expanded on answers given by the caregivers, or corrected misinformation given by the doctors or caregivers. Patients and caregivers attributed responsibility to the other when they deferred to each other to answer questions. The subtleties and complexities of these interactions are illustrated in the following opening exchange in Clinic Visit 38 with a physician, patient, and daughter caregiver:
These efforts to convey isolation
Doctor [upon entering the room]:
How are you two?
Caregiver:
Well, pretty good. [shift to patient] Tell him how you are.
Patient:
About the same as usual, only a little worse.
Doctor:
Okay.
Patient:
[mumbles] . . . sore heels.
Doctor:
You have sore heels?
Patient:
Yeah. [shift to caregiver] I want him to look at my heel.
The physician’s opening greeting jointly addresses both patient and caregiver. This approach could be a signal of the doctor’s recognition of the family context of the care, it could be a sign of his perplexity about whom to address in this visit, or it could reflect an attempt to be neutral about which person was the primary spokesperson, giving them both a chance for the role and giving himself a chance to see how the interactions evolve. The caregiver sends a strong signal of primacy both when she responds to the doctor’s question (att~buting responsibility to herself to be the respondent) and when she follows her response with a directive to the patient (implying
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that the patient is unable to respond without her help and feeling responsibility to offer that help). The patient attempts to follow the caregiver’s directive by bringing up her concerns about her sore heels. The patient soon shifts, however, to express her concern through the caregiver (“I want him to look at my heel”), thus sending another strong signal that the caregiver is the primary spokesperson. Throughout this example, the physician, patient, and caregiver continued to sort out the capabilities and responsibilities of each other, Clinic Visit 38 typifies those ill-defined situations in which the patient’s impairment is moderate. In such instances, it is difficult to distinguish true dependency needs from false assumptions about dependency derived from idiosyncratic characteristics, long~stablished family relationships, ageist attitudes, and the traditional asymmet~ of the physician-patient situation. When the caregiver and patient presented opposing information, the physician was caught in an uncomfortable dilemma of having to “choose” one view over the other. Because the capabilities of the patient were not explicitly defined, the sense of being forced to choose was particularly awkward. Such a situation occurred in the transcript of Clinic Visit 06 in the dialogue about the patient hyperventilating. Patient:
It isn’t that bad.
Caregiver:
Mother, you do.
Patient:
It isn’t that bad.
Doctor [to caregiver]: Okay. So, well I think I have to, you know, believe her. Caregiver [to doctor]: Yeah, that’s right. Doctor:
You know, she’s saying it’s not that bad.
Caregiver:
Yeah.
Doctor:
Urn, it, hyperventilating is normal with exercise, but at other times it can be due to nervousness.
Caregiver:
Yeah, right, she’s very nervous, yeah.
This doctor seemed to diplomatically support both the patient’s and the caregiver’s views, thus avoiding a total negation of either’s statements. A small number of clinic visits in the categories of marked and moderate impairment included more than one family caregiver. The same ongoing efforts to define and redefine the situation took place, obviously compounded, however, by the extra people. Responsibilities were even more ambiguous as each person’s sphere of influence became increasingly difficult to delineate. As Glasser et al. (1990) concluded, additional people in the medical encounter have more than simply an additive effect on the social processes; rather, the impact is one of increased complexity derived from the competing roles and necessary redefinitions of control and capability. The negotiations for responsibility in situations with multiple family caregivers led in one instance to an obvious marginalization of the doctor, Two caregivers were discussing the merits of ‘*multiple vitamins.” After a fairly lengthy exchange between themselves and the patient, the physician interjected his agreement with their suggestion
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for daily vitamins (,,I think that’s a good idea”), although, in fact, no one had actually even asked for his opinion! Iv0 /~PA~~~~~ Patient self care behaviors were most integral to those clinic visits in which the patient exhibited no obvious cognitive or sensory impairment. It was in some of these interviews that the patient’s comments and responses flowed smoothly in and out of the interactions, enmeshed in ongoing discourse among all three people. In such visits, the patient sometimes acted as a primary spokesperson for him or herself throughout the visit, and it was the caregiver who interjected comments in a secondary and supplementary manner. In these interviews, patients’ behaviors reflected increasing amounts of selfresponsibility and autonomy. Patients exhibited some control over the agenda of the visit by assertively stating their concerns in the beginning of the visit, by bringing up new topics, by redirecting the conversation back to topics of their priority, by telling the physician what should be done. In interactions with the doctors, they offered opinions on diagnoses and treatments, asked questions about the medications, asked for clarification about points not understood, disagreed with physicians’ views, and disclosed feelings about their illness experiences. This is not to imply that the engagement of these unimpaired older patients in the clinic visit reflected equity of interaction and authority. The family caregivers and physicians often continued to dominate the interactions, though not as much to the exclusion of the patients as occurred in the visits with markedly or moderately impaired patients. Parallels can be drawn with Sankar’s (1986) compa~sons of physician experiences on home visits and in the clinic. Sankar’s findings reveal that the home visit yields an increased intimacy of information, potentially providing the physician with useful information and insight into the complexity of the patient’s life not otherwise readily accessible. The triadic visit of older patient, family member and physician may be another situations context that increases the intimacy of information available to the physician. Yet, ironically, the additional contextual family information, the ambiguities of capabilities and responsibilities, and the awkwardness of three-way discourse may interact to potentiate a context of uncertainty that many physicians do not find comfortable. Whether or not a physician actually embraces the family context in the clinic visit may depend partly on her or his ability to be comfortable with such uncertainties. An interesting example of adaptive dependency seems to be present in the interviews in this category of no impairment. Patients were observed at times to feel responsibility for their famiIy caregiver’s behavior. When a patient asked the caregiver, “Did you find out everything you wanted to know?” or “Do you have any questions?“, the patient was deferring a certain amount of responsibility (the responsibility to ask questions) to the caregiver. At the same time, however, the patient is m~ntaining set-responsibility for helping that family member be a competent question asker. As another example, one patient informed the doctor that the caregiver would be responsible for calling to schedule the next appointment (“She would do that”), reflecting her own sense of responsibility to be the source of i~ormation to the doctor about the caregiver. Such behaviors are similar to care management tasks and represent a patient’s self-reliance in defining the role of the caregiver.
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CONCLUSIONS When older patients come to medical appointments accompanied by a family member, patterns of interaction ensue that reflect uncertainties about the capabilities and responsibilities of each person in this triad. The traditional authoritarian role of the medical professional, the family caregiver’s roles of lay practitioner and interpreter, and overriding assumptions about frailty and dependency in older people combine with the patient’s true impairment to shape the medical encounter. Ambiguities of the situation lead to a largely silent negotiation of capabilities and responsibilities by the actors in this three-track care. Marginalization of the elderly patient may lead to the loss of normative adult participation in the self care aspects of the medical visit. In this study, interactive behaviors that support patient self care capabilities and those that support dependency in medical encounters were identified and described. Categorization of the clinic visits into three levels of patient impairment revealed shifting patterns of interaction, with the most ambiguities about capacity and responsibility reflected in those visits that included a patient with mild to moderate impairment. In such situations, the uncertainties of the situation led to strategies such as protective caregiving. Initial efforts by the physician and caregiver to facilitate the patient’s meanin~ul involvement in the interactions soon gave way to extended dyadic exchanges with periodic reengagement of the patient, Marked impairment in the patient was accompanied by a strong pattern of interactions between the physician and caregiver, sometimes to the almost total exclusion of the patient. When the patient had no noticeable cognitive or sensory impairment, the discourse tended to be more equitably divided among the physician, family member, and patient. In this circumstance, health care capabilities and responsibilities were treated as properties that were sometimes avidly negotiated by all three people; yet an inexplicable tendency for the physician and caregiver to address each other instead of the patient was often still present. It appears from these clinic data that the presence of a family member at an older patient’s medical visit triggers assumptions about self care dependencies and responsibilities that constitute threats to the patient’s adult status. Depending on the ambi~ities of the situation, the physician, family caregiver, and patient him or herself demonstrate relatively limited efforts to engage the patient in the interactions. As Beisecker (1988) has commented, the third person tends to become the pivotal person in the interview and consumer behaviors by the patient are decreased. The patient’s sphere of influence shrinks and, hence, his or her power or control in the situation is also diminished. This shift of influence and responsibility away from the patient does not always reflect true impudent. Rather, much of the dependency behavior of the older patients in these triadic medical encounters took place in situations of moderate or unappa~nt impairment. I would conclude that such behavior is derived from underestimations of capacity-by the physicians, family caregivers, and patientsrelated to situational variables such as age, medical traditions of authority, and the presence of a family member at the visit. In Baltes’ model of dependency, such underestimations of ability results in excess care and can “begin a vicious cycle accelerating decline, and, in turn, increase dependency” (1988, p. 316). The need for on-the-spot calculations of each other’s capabilities and responsibilities by all three people in the triadic medical encounter-z~ro#g~o~f the medical visit-
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seems paramount to appropriate support of the older patient as an adult member of the group. Ongoing definitions and redefinitions of the situation must take place, especially when the patient’s capabilities are poorly defined. Continuing alertness to the clues of capacity and responsibility that are contained in the flow of interaction can help to establish a working definition of the patient’s self care capacities. In this way, satisfactions with the medical visit may be better realized for all participants in the medical event, and the older patient’s self care capacity and adult status will be supported.
NOTE 1. The concept for the term “three-track 1991. “The Therapist with the Three-track 45:1007-1014).
care”is borrowed from Fleming (Fleming, Maureen. Mind.” American Journal of Occupational Therapy
REFERENCES Adelman, R.D., M.G. Greene, and R. Charon. 1987. “The Physician-Elderly Patient-Companion Triad in the Medical Encounter: The Development of a Conceptual Framework and Research Agenda.” Gerontologist 271729-734. Arluke, A. 1988. “The Sick-Role Concept.“Pp. 169-180 in Health Behavior: Emerging Research Perspectives, edited by D.S. Gochman. New York: Plenum. Baltes, M.M. 1988. “The Etiology and Maintenance of Dependency in the Elderly: Three Phases of Operant Research.” Behavior Therapy 19:301-319. Barta Kvitek, S.D., B.J. Shaver, H. Blood, and K.F. Shepard. 1986. “Age Bias: Physical Therapists and Older Patients.” Journal of Gerontology 41:706-709. Becker, G. and R.D. Nachtigall. 1991. “Ambiguous Responsibility in the Doctor-Patient Relationship: The Case of Infertility.” Social Science and Medicine 32:875-885. Becker, G. and S. Kaufman. 1988. “Old Age, Rehabilitation and Research: A Review of the Issues.” The Gerontologist 28:459-468. Beisecker, A.E. 1988. “Aging and the Desire for Information and Input in Medical Decisions: Patient Consumerism in Medical Encounters.” Gerontologist 28:330-335. Beisecker, A.E. and T.D. Beisecker. 1990. “Patient Information-Seeking Behaviors when Communicating with Doctors.” Medical Care 28: 19-28. Bertakis, K.D., D. Roter, and S.M. Putnam. 1991. “The Relationship of Physician Medical Interview Style to Patient Satisfaction.” Journal of Family Practice 32:175-181. Bloom, S.W. and E.J. Speedling. 1981. “Strategies of Power and Dependence in Doctor-Patient Exchanges.” Pp. 157-170 in Elderly Patients and their Doctors, edited by M.L. Haug. New York: Springer. Bowers, B.J. 1987. “Intergenerational Caregiving: Adult Caregivers and Their Aging Parents.” Advances in Nursing Science 9(2):20-3 1. Clark, M.M. 1973. “Contributions of Cultural Anthropology to the Study of the Aged.” Pp. 78-88 in Cultural Illness and Health, edited by L. Nader and T. W. Maretzki. Washington, DC: American Anthropological Association. Coe, R.M. and C. Prendergast. 1985. “The Formation of Coalitions: Interaction Strategies in Triads.” Sociology of Health and Illness 71236-247. DeJong, G. 1979. “Independent Living: From Social Movement to Analytic Paradigm.” Archives of Physical Medicine and Rehabilitation 601435446.
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Fields, SD., R. Jutagir, R.D. Adelman, R. Tideiksarr, and E. Olson, 1992. “Geriatric Education Part I: Efficacy of a Mandatory Clinical Rotation for Fourth Year Medical Students.” Journal of the American Geriatrics Society 401964969.
Glasser, M., S. Rubin, and M. Dickover. 1990. “The Caregiver Role: Review of Family CaregiverPhysician Relations and Dementing Disorders.” Pp. 321-337 in The kgacy of Longevity, edited by S.M. Stahl. Newbury Park: Sage. Glasser, M., T. Prohaska, and 3. Roska. 1992. “The Role of the Family in Medical Care-seeking Decisions of Older Adults.” Farnib and community Health 1559-70. Greene, M.G., R. Adelman, R. Charon, and S. Hoffman. 1986. “Ageism in the Medical Encounter: An Exploratory Study of the Doctor-Elderly Patient Relationship.” Language & Communication 6: 113-124. Hasselkus, B.R. 1992a. “Physician and Family Caregiver in the Medical Setting: Negotiation of Care?” Journal qf Aging Studies 6:67-80. -. 1992b. “The Family Caregiver as Interpreter in the Geriatric Medical Interview.” Medical Anthropology
Quurterfy 6:288-304.
Haug, M.R. and B. Lavin. 1983. Consumerism in Medicine: Chailenging Physician Authority. Beverly Hills: Sage. Haug, M.R. and M.G. Ory. 1987. “Issues in Elderly Patient-Provider Interactions.” Research on Aging 9:3-44.
High, D.M. 1989. “Caring for ~ecisionally Incapacitated Elderly.” ~eoret~caZ Medicine 10:8396.
Keller, M.L., H. Leventhal, T.R. Prohaska, and E.A. Leventhal. 1989. “Beliefs about Aging and Illness in a Community Sample.” Research in Nursing and Health 12~247-255. Labrecque, M.S., C.G. Blanchard, J.C. Ruckdeschel, and E.B. Blanchard. 1991. “The Impact of Family Presence on the Physician-Cancer Patient Interaction.” Social Science and medicine 33:1253-1261.
Levin, L.S. 1977. “Forces and Issues in the Revival of Interest in Self-care: Impetus for Redirection in Health.” Health Fducation Monographs 5: I 15-120. Lowenberg, J.S. 1989. Caring and Responsibility. Philadelphia: University of Pennsylvania Press. Miller, J.F. and C.B. Oertel. 1983. “Powerlessness in the Elderly: Preventing Hopelessness.” Pp. 109-l 3 1 in Coping with Chronic Illness: Overcoming Powerlessness, edited by J.F. Miller. Philadelphia: F.A. Davis. National Center for Health Statistics. 1987. “Health Statistics on Older Persons, United States, 1986.” Vitaland Hearth Statjst~cs, Series 3, No. 25, DHHS Pub. No. (PHS) 87-1409. Public Health Service. Washington, DC: U.S. Government Printing Office. Orem, D.E. 1980. “Nursing and Self-care.” Pp. 35-54 in Nursing: Concepts of Practice, 2nd edition. New York: McGraw-Hill. Parsons, T. 19.51. The Sociaf System. Glencoe, IL: Free Press. Revenson, T.A. 1989. “Compassionate Stereotyping of Elderly Patients by Physicians: Revising the Social Contact Hypothesis.” Psychology and Aging 4:230-234. Rosow, I. 1981. “‘Coalitions in Geriatric Medicine.” Pp. 137-146 in Elderly Patients and Their Doctors, edited by M.R. Haug. New York: Springer. Roter, D., M. Lipkin, and A. Korsgaard. 1991. “Sex Differences in Patients’ and Physicians’ Communication During Primary Care Medical Visits. ” Medical Care 29: 1083-1093. Roter, D. and R. Frankel. 1992. “Quantitative and Qualitative Approaches to the Evaluation of the Medical Dialogue.” Social Science and Medicine 34: 1097-l 103. Sankar, A. 1986. “Out of the Clinic tnto the Home: Control and Patient-Physician Communication.” Social Science and Medjcjne 22973-982.
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Simpson, M., R. Buckman, M. Stewart, P. Ma~u~re, M. Lipkin, D. Novack, and J. Till. 1991. “Doctor-Patient Communication: The Toronto Consensus Statement.” British medical JournaZ 303: 13851387. Stiles, W.B. 1989. “Evaluating Medical Interview Process Components.” Medical Cure 27:212220. Stiles, W.B. and S.M. Putnam. 1992. “Verbal Exchanges in Medical Interviews: Concepts and Measurement.” Social Science and Medicine 35:347-355.
BETTY RISTEEN HASSELKUS* University of Wisconsin- Madison
ABSTRACT: When older patients come to medical appointments accompanied by a family member, patterns of interaction ensue that reflect uncertainties about the capabilities and responsibilities of each person in this triad. In this study, ongoing discoursefrom 40 transcribed medical visits with an elderly patient, family caregiver, and physician were analyzed. Interactive behaviors that support patient self care capabilities and those that support dependency are identified and described, and patterns of interaction related to the patients’ cognitive or sensory impairments are explored. The presence of a family member at an older patient’s medical visit-in combination with the authoritarian traditions of medical care, assumptions about frailty and aging, and true impairment-appears to trigger behaviors that marginalize the patient and that are supportive of dependent self care. Behaviors that support independent serf care are less evident. An awareness of this tendency toward dependent supportive interactions may enable physicians, family members, andpatients to change this pattern, breaking the cycle of increasing dependence and supporting instead the patient S adult independent status in the clinic setting.
The American ideology of individualism, self-sufficiency, and productivity generates norms of behavior for adulthood that include independence. Clark (1973) summarized this ideology in the statement, “Only by being independent can an American be truly a person, self-respecting, worthy of concern and the esteem of others” (p. 82). This “independence” may encompass many dimensions of a person’s life experience, but one of the core components is independence in self care. *Direct all correspondence to: Betty Risteen Hasselkus, Occupational Therapy Program, Department Kinesiology, University of Wisconsin-Madison, I300 University Avenue, Madison, WI 53706. JOURNAL OF AGING STUDIES, Volume 8, Number 3, pages 291-307 Copyright @ 1994 by JAI Press Inc. All rights of reproduction in any form reserved. ISSN: 0890-4065.
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Seeking a physician’s help and engaging in medical clinic visits constitute forms of self care carried out by the adult individual (Levin 1977; Orem 1980). To monitor and study concepts of self care within the context of physician-patient care, structural elements of the medical interview have been identified that reflect and promote patient self-determination and partnership between doctor and client. Process components of the patient’s communication such as information seeking, information sharing, initiation of topics, and suggestions for diagnoses and treatment are considered consumer/self help behaviors (Beisecker 1988; Beisecker and Beisecker 1990; Haug and Lavin 1983; Stiles 1989). Haug and Lavin define consumerism in medicine as “challenging the physician’s ability to make unilateral decisions-demanding a share in reaching closure on diagnosis and working out treatment plans” (1983, pp. 16-17). Physician interview strategies, responsiveness to the patient’s participation, and styles of information gathering and giving that facilitate patients as care partners are also the focus of research (Bertakis et al. 1991; Miller and Oertel 1983; Roter and Frankel 1992; Roter et al. 1991; Simpson et al. 1991; Stiles 1989; Stiles and Putnam 1992). Help-seeking from physicians as a form of self care may be especially prominent in old age. Older people account for 31 percent of all expenditures for health care in the United States and more than one-fifth of these expenditures are for physician services (National Center for Health Statistics 1987). Among older patients, it is estimated that 20 to 37 percent who seek physician care are accompanied to medical visits by a family member (Adelman et al. 1987; Labrecque et al. 1991). The impact of this third person on the structure and function of the medical visit, including its self care components, has received limited research attention. One recent article (Glasser et al. 1992) focuses on the involvement of the family companion in the medical care-seeking decision. Other studies have addressed primarily the roles of the family caregiver (Adelman et al. 1987; Hasselkus 1992a, 1992b) and the interactional dynamics (Coe and Prendergast 1985; Labrecque et al. 1991; Rosow 1981) in the triadic visit. In this article, I examine the three-person clinic visit as it relates to the nature of self care independence and threats to the adult status of the older patient in the clinic setting. Data consisting of verbatim transcripts from 40 medical visits that included a physician, older patient, and family caregiver were examined for self care-related behaviors and interaction patterns. It is assumed that behaviors that support the older person’s independence and engagement in interactions during the medical encounter also support the person’s adult social status (Lowenberg 1989). The opposite is also assumed. The data are examined to gain new understandings of clinic behaviors by the physician, the family member, and the older patient as they relate to dependence and independence. Further, the relationship between these clinic behaviors and observable patient impairment is explored in this triadic medical context.
SELF CARE IN THE MEDICAL SETTING Self care independence is a phrase usually associated with nonmedical contexts and nonprofessional care. Lay care, home remedies, self help, folk medicine, and over-thecounter drugs are all terms that refer to self care traditions. Alternatively, medical care in western society takes place in a context of institutional authority wherein the “self is assumed to become dependent on the professional for the “care.” The tradition of
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authoritarian care has, perhaps, been particularly strong in physician care. Bloom and Speedling (1981) conclude that “the patient appears to be inherently dependent within the situation of doctor-patient exchanges” (p. 158). In many ways, the authoritarian model of health care has fostered an image of the doctor-patient relationship as fiduciary, most like the relationship of parent to child. Parson’s model of the sick role, first introduced in 1951, conceptualized illness as a form of deviance and doctors as experts who function to correct, and thus control, the deviance. In Arluke’s discussion of the sick-role concept, he states, “. . . the health care process portrays physicians as parentlike, strong figures who are permissive, supportive, objective, and ethical. Patients in this scheme . . . act as relatively weak, dependent, childlike figures” (Arluke 1988, p. 174). The authoritarian medical model of care, however, has undergone changes in recent decades. The social movements of the 1960s and 1970s led to new insights and recognition of the rights of people with disabilities and other minority statuses (DeJong 1979). Consumerism and lay-professional partnerships emerged as new ideals in medical care. As Haug and Lavin stated, “When the nature of symptoms and danger signs demands medical consultation, this does not mean that the value of independence is perforce abandoned” (1983, p. 193). Consumer behaviors in the medical encounter have been promoted, and strategies to support autonomy and self care described and encouraged. Investigation of older patients’ consumer behaviors inthe clinical setting has led to inconsistent findings. Some research suggests that an older patient and a health professional interact in a social context shaped by assumptions about debility and loss of function that are not present with a younger patient (Barta Kvitek et al. 1986; Becker and Kaufman 1988; Greene et al. 1986; Keller et al. 1989). In 1988, Beisecker reported less consumer behavior among her older subjects during physicians visits for outpatient rehabilitation. In a second study, however, Beisecker and Beisecker (1990) demonstrated more information seeking behaviors by older patients compared to those who were younger. In regard to physician attitudes, Revenson (1989) studied “compassionate stereotyping” of elderly patients, finding that doctors tended to rate older patients as less well adjusted, less autonomous, and in need of greater support and information. On the other hand, Fields et al (1992) reported that only seven percent of a class of medical studentspost geriatric rotation-believed that elderly patients are not able to take care of their own needs and follow treatment plans. Thus, findings related to beliefs about self care capabilities and self care behaviors of older patients in the medical encounter are mixed. The triadic visit seems to represent a third dimension of threats to the adult status of the patient, compounding those already inherent or implied by the medical milieu itself and societal views of aging. The scenario of an older person being accompanied into the medical examining room by a family member, for whatever reason, is likely to convey another strong signal of dependence. The ambiguities of the three-way division of responsibilities may increase the potential dependent status of the patient in the medical encounter. THREE-TRACK
CARE’
Discourse data from 40 outpatient clinic visits with physician, family member and older patient were analyzed for self care behaviors as markers of adult status in the older
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patient. Data were collected in the internal medicine and geriatric clinics of a midwestern university hospital. After following prescribed informed consent procedures, my research assistant or I placed an audiotape recorder in the examining room at the start of an appointment. We were not present in the room during the interview, but simply returned to retrieve the recorder when the appointment was concluded. All audiotapes were then transcribed in preparation for analysis. Study participants included 11 physicians, 27 patients, and 3 1 family members (5 clinic visits included more than one family caregiver). Patients’ ages ranged from 64 to 91 years. The caregivers included 13 daughters, 6 sons, 7 wives, 3 husbands, 1 daughter-in-law, and 1 sister. Of the eleven physicians, 5 were staff, 4 were residents, and 2 were geriatric fellows. I refer the reader to previous publications (Hasselkus 1992a, 1992b) for more detailed descriptions of the study sample, data collection, and data analysis. Previous analyses of these data have yielded two major roles for the family caregiver in the three-person clinic visit-the role of second practitioner and the role of interpreter (Hasselkus 1992a, 1992b). While my previous analyses focused on the family caregiver and physician interactions, the discussion here will address these findings as they relate to the older patient’s self care independence and adult status in the clinic setting.
Ambiguous Capabilities Baltes (1988), in her research on dependence in older people, has distinguished among three types of dependency: adaptive dependency (giving up independence in one area of daily life in order to maintain independence in another), true dependency due to impairment, and excess dependency that results from underestimations of capabilities either by the elderly person or by someone in the environment. In a way, physicians, family caregivers, and older patients must sort out these types of dependency as they carry out health care in the triadic medical visit. Clinical determinations of competency (in contrast to judicial rulings) must occur “on the spot”in the clinical setting (High 1989). High describes the need for professionals to be alert to evidence of incapacity and the need for surrogate decision-making. “Clues may emerge from conversations with the patient, from observation of behavior or from discussions with family members or others” (High 1989, p. 84). Family caregivers must be alert to the same clues, as, indeed, must the patient him or herself as each determines performance competencies. False assumptions of incapacity can lead to underestimations of competency, thereby promoting dependencies in self care behaviors that are not true or adaptive dependencies. CLUES ABOUT INCAPACITY In these clinic data, clues about incapacity were conveyed in several ways. For example, family caregivers’ behaviors were demonstrated that offered clues to the physician about the self care capabilities of the older patient. As an interpreter, the caregiver engaged in incidents of correcting, adding to, prompting, answering for, and paraphrasing-all potential signals to the physician that the patient needed assistance. The physician might then assume that incapacity was, in fact, present and might begin to direct more of the interview to the caregiver as a substitute patient. When the family
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caregiver acted as the direct source for information, and the interactions became an extended dyad between caregiver and physician, the patient was unquestionably marginalized (Rasselkus 1992b). An example of these mechanisms of margindlization is found in the data from Clinic Visit 18 in which the physician started the visit by directing questions to the patient.
Doctor:
Well now, Mrs. E., let me just ask you how you are doing?
Patient:
I don’t know. Last week was terrible in my legs and my arms. I’m so scared of falling . . .
The patient shifted at this point to talking about a different doctor whom she had recently
seen and who told her she was dehydrated. The patient then mentioned running out of medicine. The doctor continued briefly to tslk directly with the patient, trying to clarify the meaning of what she was saying, and returning to the topic of the walking difficulties. At that point the caregiver spoke up: “See, he [the other doctor] put her on this prozac,” thus interjecting new and seemingly significant information into the conversation. The caregiver and physician then engaged in an extended two-person dialogue that resembled that of two pr~titione~ discussing side effects, dosages, and recommendations regarding continuing or discontinuing medications. The remainder of the interview was dominated by caregiver-physician interactions related to medications. The pattern of interaction suggests that the caregiver initially held back from engaging in the conversation, witnessed the rather rambling and unclear presentation of concerns by the patient, and then decided that she needed to assist with the communication. Other behavioral clues that conveyed caregiver beliefs of incompetence in the patient occurred when: the caregiver explicitly questioned the truth of the patient’s statements; the caregiver disclosed information to the doctor in spite of the patient’s objections; the caregiver told the patient what to say or do; the caregiver interacted paternalistically with the patient. The following interview excerpt illustrates disclosure of information against the wishes of the patient, casting doubts about the veracity of the patient’s views of the symptoms: Caregiver [to doctor]:
She hyperventilates all the time and this morning it was much worse. [To patient]: Well, it’s the truth, you’ve got to tell them that * . You’ve got to tell him so he knows.
Patient [to caregiver]:
He knows. You don’t need to tell.
Physician [to patient]:
Well, when you were breathing like that . . . what was the reason for that?
Patient:
Well, I was out of breath . . . I do that when I walk, I walk so many times I get out of breath and I start breathing.
Physician [to caregiver]:
Okay, so you’re not agreeing, you think it’s different?
Caregiver:
I think she’s very nervous, and that’s what makes her do that. She says ‘I have to do that.’ She does it 365 days a year, all the time.
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Patient:
It isn’t that bad.
Caregiver:
Mother,
Patient:
It isn’t that bad. [Clinic Visit 61
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you do.
This subjugation of the patient’s control over what is disclosed in the clinic visit sends a strong message of the caregiver’s disbelief in the patient’s judgment capabilities and disregard for the older person’s autonomy. Older patients themselves gave evidence of incapacity in other ways such as the following: by talking to the doctor through the family member (“He’ll have to give me some new prescriptions”), thereby indicating an expectation that the caregiver would be the spokesperson; by deferring to the caregiver regarding responsibility for information (Doctor: So it would be the same number of pills a day. Patient [to caregiver]: You know how to do it now?); and by checking with the caregiver for accuracy of information being requested (Doctor: When was the last time that you threw up? Do you remember? Was that very recent at all? Patient [to caregiver]: Not very recent, was it?). Explicit deference to the bureaucratic authority of the doctor was noted in a few instances (Doctor: Let’s see, have you tried any aspirin at all? Patient: Huh uh. With your permission, I would like to.). This deference portrayed a dependency derived from the patient relinquishing decision-making power to the authority of the professional. The above examples and patterns of interaction all convey a sense of patient incapacity and seem to promote marginalization and loss of adult status in the older patient. These interactions probably represent a convergence of assumptions about the patient’s capabilities prompted by the age of the patient, the model of physician authority, and the family caregiver roles of practitioner and interpreter.
SUPPORT
FOR CAPACIN
Interactions also occurred that affirmed capacity and thus supported the patient’s adult status. These interactions seemed to represent conscious efforts on the part of the physician, family member, and patient to enable the patient to participate in the conversations. The physicians’ efforts of support are represented in behaviors such as interrupting the caregiver’s dialogue to enable the patient to respond, or deliberately turning back to the patient for information during an exchange with the caregiver. At times, physicians made a show of respect for the patient by asking “permission” to direct questions to the family member. Both the physicians and the caregivers turned to the patient to verify information being discussed. For example, after a lengthy discussion with the doctor about her mother’s medications and possible side effects of fatigue, the caregiver turned to her hearing-impaired mother to verify the complaint: Caregiver [to mother]:
You say the big thing, you’re so tired all the time. That bothers you a lot, doesn’t it?
Patient:
Well, just that you don’t like to be so tired that you can’t, you know, sometimes I feel as though I’m too tired to even get up. [Clinic Visit 131
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The caregivers also demonstrated efforts to help the patients understand what was being discussed. This was evident when a caregiver repeated or paraphrased the doctor’s questions and comments to a patient. But other incidents illustrated frankly assertive behaviors on the patient’s behalf. In the following exchange, the doctor was displaying new and old x-rays and did not address the patient’s ability to see the films: Doctor:
All right, let’s compare it to when you were at your worst.. . Okay, you can see this is when she was really sick [note shift to caregiver]. How this . . .
Caregiver [interrupts] Why don’t you get up, I don’t know if you can see this. [to mother]: Doctor [continuing]:
She gets cut off [?I right here in her lungs . . . so she’s much better than she was before, they look pretty clear. I don’t see any fluid on there. [Clinic Visit 21
It is the caregiver in this scenario who acts to enable the patient to see the x-rays, recognizing the centrality of the discussion to her mother. The caregiver’s deliberate inclusion of her mother sends a message that the mother is cognitively capable of understanding such information, thus affirming her adult capabilities as well as her rights in the clinic setting. The doctor in this incident continues to address all comments to the caregiver. Occasionally, the family member turned to the patient to include him or her in decision making. Following fairly lengthy discourse between the doctor and the caregiver about her mother’s back pain and the use of various analgesics, one caregiver summarized the recommendation succinctly for the patient and solicited her approval: Caregiver [to mother]:
That little blue pill you take, Mother, maybe they can change that, to try a different medication.
Patient:
Well, I’ve been taking that for a long time.
Doctor:
Right.
Caregiver:
Yeah, you’d be willing io change it?
Patient:
Yeah, if something’s better, well then I’d want to get it. [Clinic Visit 131
This action by the caregiver affirms the patient’s ability and right to make informed and reasonable decisions, thus also affirming her adult status. Finally, the older patients themselves exhibited behaviors that supported their own adult status. Patients interrupted doctor-caregiver dyads to ask their own questions about medication, to volunteer information, to express their own opinions about treatments and symptoms, and to remind the caregiver and doctor about concerns such as prescription needs. These self care behaviors were most evident in those interviews in which the patient did not have significant cognitive or sensory impairments. An exception was Clinic Visit 13 wherein the patient had a marked hearing impairment that severely interfered with communication. This patient, accompanied by her daughter
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caregiver, stated to the doctor early in the interview, “I have a hearing problem, you know; you’d probably know that without me telling you. That’s why I have to ask you to repeat things.” Moments later, she volunteered further explanation of the hearing impairment. “It isn’t that I don’t hear so much, it’s that I don’t understand. There’s a difference there.. . I call it a hearing problem, I suppose it is a hearing problem, but it isn’t that. Lots of times I can hear people but I can’t understand what they’re saying.” This display of initiative and sense of responsibility for self-disclosure contrasts starkly with the patients who did not offer such information and/or who turned to their caregivers to carry out this function.
Dependency and Impairment In order to examine the relationship of the patterns of interaction to functional status of the patient in these triadic interviews, the transcripts were divided into three categories of patient impairment: no apparent cognitive or sensory impairment (15 interviews), moderate or questionable impairment (15 interviews), and marked impairment (10 interviews). Categorization of marked impairment was based on diagnoses if stated (“She’s not going to understand, she’s aphasic”), evidence from the patient’s attempts at discourse (repeated incoherence, nonresponsiveness, confusion), frequent need to repeat questions, and other revealing remarks made during the interview. Interviews that reflected mild hearing impairment or that indicated mild cognitive problems in areas such as medication management were categorized as moderate impairment. Those that contained no explicit statements or other signs of impairment in the patient were categorized as no impairment. MARKED M’AIRMENT In those interviews in which the patient had a marked and obvious impairment, direct involvement of the patient was largely limited to the physical examination phase of the visit. The physician and the family caregiver tended to interact as two practitioners in an extended dyadic exchange during the history-taking and during the decision-making and instructions near the end of the interview. This pattern of interaction was particularly evident when the patient’s imp~rment was cognitive. One profoundly demented patient’s only communications in the visit were responses to questions about o~entation to time, place, and person and physical status during the examination; all other interaction took place between the physician and family caregiver. Medical visits are, it seems, very cognitive events. As Haug and Ory (1987) state, severe impairment from dementia will “virtually preclude meaningful encounters with a care provider” (p. 12). When the marked impairment was a hearing loss, efforts were made in the beginning of the visit to overcome communication difficulties. Physicians used various strategies (with varying degrees of success) of rephrasing and speaking louder to enhance the patient’s ability to contribute to the clinic process. One physician sought the input of the family caregiver regarding the patient’s hearing, asking “Am I talking into the wrong ear, do you think?” In this case, a subsequent shift to the other ear did help the patient’s hearing. The caregivers, too, volunteered suggestions to the physicians regarding strategies to overcome the hearing problems (“When you’re speaking to him, it’s much easier if you look at him”). In Clinic Visit 13 (the above excerpt of the patient who
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explained her hearing problem to the doctor), the caregiver made concerted efforts throughout the visit to support her mother’s participation in the clinic visit, despite the severe hearing impairment. This daughter repeatedly sought her mother’s opinions, inquired about what she understood, sought further information and facts from her mother, deferred to her mother to provide information, and reminded her of concerns to bring up.
MODERATE
IMPAIRMENT
When a cognitive or sensory impairment was present, but only to a more moderate extent, the uncertainties of the situation became a pervasive force. The interviews in this category were largely represented by triads that included patients with mild cognitive deficits. Each physician was faced with the “on the spot” task of sorting out the ambiguous capabilities of the patient and caregiver. As High (1989) has discussed, no clear definition of capacity and incapacity exists, nor is there a uniform set of criteria for making such determinations. The physician must define and redefine the situation, being ever alert to ongoing evidence regarding the patient’s ability to comprehend information, to ask and answer questions, and to engage in decision-making (Glasser et al. 1990; High 1989). In these interviews, physicians struggled with dilemmas of whom to address in the history-taking and whom to address in the explanation of diagnoses and treatment. Caregivers struggled with how best to interact with the patient and physician in the clinic setting in the presence of uncertain impairment. Physicians seemed usually to give the patient the benefit of the doubt at the beginning of the interview-addressing opening comments and questions directly to him or her and listening, then, for clues from the patient and caregiver about what capabilities to expect. These direct physicianpatient interactions, however, were usually brief, and the caregiver played a prominent role as the dialogue continued. As evidence of this uncertainty about capabilities, it was not uncommon for the physician to shift back and forth repeatedly between the caregiver and the patient during discussions and explanations of health issues: Physician [to caregiver regarding medication]:
. we’ll see if 50 is enough. If 50 is not enough and she gets another infection then we’ll go back up and have her take the 100. But I’d like her to be on the lowest possible dose that she can be on . . and then we’ll try that for a few months and then maybe we’ll stop it and see what happens.
Caregiver:
Okay.
Physician [shift to patient]:
. . . and then based on your blood test, we’ll tell you if you have to make any changes in the other [medication] . . since you’re not waking up at night as much . . I mean that’s why I had you go up on that to see if your breathing would be better at night, so you weren’t getting up and feeling like you needed to sit in the chair as much. [shift back to caregiver] And if she’s tolerating taking 3 doxepin and maybe there’s been some change, I think we should go ahead and have her stay on 3 for a while.. . [Clinic Visit 301.
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Much of the discourse in these interviews represented protective caregiving as discussed by Bowers (1987). Protective caregiving occurs when the caregiver attempts to protect the older person from being aware that he or she is being cared for. By inference, this also means protecting the older person from being aware that he or she is perceived by others as needing to be cared for. This sense of the need to protect the patient from “knowing” in these triadic interviews meant that negotiations about capabilities had to be carried out silently or dealt with very obliquely by the physician and family caregiver. In keeping with Bowers’ findings, protective caregiving in this study was most intense when the older patient had a moderate cognitive impairment. These caregivers used many strategies to provide their caregiving services in ways that were not explicitly recognizable as such. Additionally, the physicians carried out their caregiving tasks in ways that masked their knowledge of the patient’s incapacity from the patient. Whatever signals and negotiations took place to establish this as a modus operandi were silent, unspoken. Much of the interpreter behaviors of the caregiver served as protective caregiving. These were the incidents when the caregiver sought to include the patient in the conversation in a way that supported the patient’s ability to actively participate as a competent adult-prompting the patient to respond, clarifying meanings for the patient, suggesting topics for the patient to bring up, seeking the patient’s opinion. In the practitioner role, when care needs were being more directly addressed by the family member, the caregiver used other subtle strategies to avoid explicit statements of the patient’s marginal capacity but at the same time to signal to the physician that the patient’s capabilities were questionable as in the following example: Patient [to doctor]:
What do you mean by one dose?
Doctor:
One dose.
Patient:
Two?
Doctor:
Just, uh, two, two aspirin pills.
Patient:
Two, two makes a dose.
Doctor:
How does that sound to you?
Patient:
Good.
Caregiver:
Now one concern that I have is that, urn, Mother has a tendency to take things [carefully choosing words], she’s almost compulsive.
Doctor:
Uh huh.
Caregiver:
You know, she gets a thought in her mind, she takes them. One of the nice things about having a pill dispenser is that it regulates her. Although I came this morning, at seven-thirty this morning to pick her up and she had already taken her noon medication.
Doctor:
Uh huh.
Patient:
(laughs)
Caregiver:
So, but then I, she got up at four o’clock this morning so her body clock probably was noon (slight laugh). . . I’m concerned that she have aspirin in her apartment.
Three-Track Care: O/der Patient, Family Member, and Physician Doctor:
Oh, I think we can use it in the context of the pill dispenser.
Caregiver:
Okay, that was my concern. [Clinic Visit 011
301
about the patient’s capabilities, but to do it in such a way that the patient is protected from direct awareness of incapacity and that his or her adult status and dignity is somehow also upheld (“her body clock probably was noon”), further compounds the obscurities of the situation and heightens the physician’s need to be ever alert to clues about the patient’s status. It seems apparent that the uncertainty of capabilities entails a corollary uncertainty of responsibilities, Ambiguous responsibility has been explored in the context of the physician-patient relationship (Becker and Nachtigall 1991; Lowenberg 1989). In the triadic clinic visit, I use the term ambiguous responsibility to refer to the uncertainties about individuai health care responsibility that are present throughout the visit. The caregivers and patients struggled to determine where their respective responsibilities began and ended in relation to each other and to the physician. Caregivers were clearly attributing responsibility to themselves when they told the patients what to say, when they prompted patients to bring up certain topics, when they paraphrased the doctors’ questions to help the patients understand, when they explained to the doctors what the patients were trying to say, when they suggested diagnoses and treatments. Patients demonstrated self-responsibility when they asserted their own viewpoints, brought up concerns, expanded on answers given by the caregivers, or corrected misinformation given by the doctors or caregivers. Patients and caregivers attributed responsibility to the other when they deferred to each other to answer questions. The subtleties and complexities of these interactions are illustrated in the following opening exchange in Clinic Visit 38 with a physician, patient, and daughter caregiver:
These efforts to convey isolation
Doctor [upon entering the room]:
How are you two?
Caregiver:
Well, pretty good. [shift to patient] Tell him how you are.
Patient:
About the same as usual, only a little worse.
Doctor:
Okay.
Patient:
[mumbles] . . . sore heels.
Doctor:
You have sore heels?
Patient:
Yeah. [shift to caregiver] I want him to look at my heel.
The physician’s opening greeting jointly addresses both patient and caregiver. This approach could be a signal of the doctor’s recognition of the family context of the care, it could be a sign of his perplexity about whom to address in this visit, or it could reflect an attempt to be neutral about which person was the primary spokesperson, giving them both a chance for the role and giving himself a chance to see how the interactions evolve. The caregiver sends a strong signal of primacy both when she responds to the doctor’s question (att~buting responsibility to herself to be the respondent) and when she follows her response with a directive to the patient (implying
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that the patient is unable to respond without her help and feeling responsibility to offer that help). The patient attempts to follow the caregiver’s directive by bringing up her concerns about her sore heels. The patient soon shifts, however, to express her concern through the caregiver (“I want him to look at my heel”), thus sending another strong signal that the caregiver is the primary spokesperson. Throughout this example, the physician, patient, and caregiver continued to sort out the capabilities and responsibilities of each other, Clinic Visit 38 typifies those ill-defined situations in which the patient’s impairment is moderate. In such instances, it is difficult to distinguish true dependency needs from false assumptions about dependency derived from idiosyncratic characteristics, long~stablished family relationships, ageist attitudes, and the traditional asymmet~ of the physician-patient situation. When the caregiver and patient presented opposing information, the physician was caught in an uncomfortable dilemma of having to “choose” one view over the other. Because the capabilities of the patient were not explicitly defined, the sense of being forced to choose was particularly awkward. Such a situation occurred in the transcript of Clinic Visit 06 in the dialogue about the patient hyperventilating. Patient:
It isn’t that bad.
Caregiver:
Mother, you do.
Patient:
It isn’t that bad.
Doctor [to caregiver]: Okay. So, well I think I have to, you know, believe her. Caregiver [to doctor]: Yeah, that’s right. Doctor:
You know, she’s saying it’s not that bad.
Caregiver:
Yeah.
Doctor:
Urn, it, hyperventilating is normal with exercise, but at other times it can be due to nervousness.
Caregiver:
Yeah, right, she’s very nervous, yeah.
This doctor seemed to diplomatically support both the patient’s and the caregiver’s views, thus avoiding a total negation of either’s statements. A small number of clinic visits in the categories of marked and moderate impairment included more than one family caregiver. The same ongoing efforts to define and redefine the situation took place, obviously compounded, however, by the extra people. Responsibilities were even more ambiguous as each person’s sphere of influence became increasingly difficult to delineate. As Glasser et al. (1990) concluded, additional people in the medical encounter have more than simply an additive effect on the social processes; rather, the impact is one of increased complexity derived from the competing roles and necessary redefinitions of control and capability. The negotiations for responsibility in situations with multiple family caregivers led in one instance to an obvious marginalization of the doctor, Two caregivers were discussing the merits of ‘*multiple vitamins.” After a fairly lengthy exchange between themselves and the patient, the physician interjected his agreement with their suggestion
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for daily vitamins (,,I think that’s a good idea”), although, in fact, no one had actually even asked for his opinion! Iv0 /~PA~~~~~ Patient self care behaviors were most integral to those clinic visits in which the patient exhibited no obvious cognitive or sensory impairment. It was in some of these interviews that the patient’s comments and responses flowed smoothly in and out of the interactions, enmeshed in ongoing discourse among all three people. In such visits, the patient sometimes acted as a primary spokesperson for him or herself throughout the visit, and it was the caregiver who interjected comments in a secondary and supplementary manner. In these interviews, patients’ behaviors reflected increasing amounts of selfresponsibility and autonomy. Patients exhibited some control over the agenda of the visit by assertively stating their concerns in the beginning of the visit, by bringing up new topics, by redirecting the conversation back to topics of their priority, by telling the physician what should be done. In interactions with the doctors, they offered opinions on diagnoses and treatments, asked questions about the medications, asked for clarification about points not understood, disagreed with physicians’ views, and disclosed feelings about their illness experiences. This is not to imply that the engagement of these unimpaired older patients in the clinic visit reflected equity of interaction and authority. The family caregivers and physicians often continued to dominate the interactions, though not as much to the exclusion of the patients as occurred in the visits with markedly or moderately impaired patients. Parallels can be drawn with Sankar’s (1986) compa~sons of physician experiences on home visits and in the clinic. Sankar’s findings reveal that the home visit yields an increased intimacy of information, potentially providing the physician with useful information and insight into the complexity of the patient’s life not otherwise readily accessible. The triadic visit of older patient, family member and physician may be another situations context that increases the intimacy of information available to the physician. Yet, ironically, the additional contextual family information, the ambiguities of capabilities and responsibilities, and the awkwardness of three-way discourse may interact to potentiate a context of uncertainty that many physicians do not find comfortable. Whether or not a physician actually embraces the family context in the clinic visit may depend partly on her or his ability to be comfortable with such uncertainties. An interesting example of adaptive dependency seems to be present in the interviews in this category of no impairment. Patients were observed at times to feel responsibility for their famiIy caregiver’s behavior. When a patient asked the caregiver, “Did you find out everything you wanted to know?” or “Do you have any questions?“, the patient was deferring a certain amount of responsibility (the responsibility to ask questions) to the caregiver. At the same time, however, the patient is m~ntaining set-responsibility for helping that family member be a competent question asker. As another example, one patient informed the doctor that the caregiver would be responsible for calling to schedule the next appointment (“She would do that”), reflecting her own sense of responsibility to be the source of i~ormation to the doctor about the caregiver. Such behaviors are similar to care management tasks and represent a patient’s self-reliance in defining the role of the caregiver.
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CONCLUSIONS When older patients come to medical appointments accompanied by a family member, patterns of interaction ensue that reflect uncertainties about the capabilities and responsibilities of each person in this triad. The traditional authoritarian role of the medical professional, the family caregiver’s roles of lay practitioner and interpreter, and overriding assumptions about frailty and dependency in older people combine with the patient’s true impairment to shape the medical encounter. Ambiguities of the situation lead to a largely silent negotiation of capabilities and responsibilities by the actors in this three-track care. Marginalization of the elderly patient may lead to the loss of normative adult participation in the self care aspects of the medical visit. In this study, interactive behaviors that support patient self care capabilities and those that support dependency in medical encounters were identified and described. Categorization of the clinic visits into three levels of patient impairment revealed shifting patterns of interaction, with the most ambiguities about capacity and responsibility reflected in those visits that included a patient with mild to moderate impairment. In such situations, the uncertainties of the situation led to strategies such as protective caregiving. Initial efforts by the physician and caregiver to facilitate the patient’s meanin~ul involvement in the interactions soon gave way to extended dyadic exchanges with periodic reengagement of the patient, Marked impairment in the patient was accompanied by a strong pattern of interactions between the physician and caregiver, sometimes to the almost total exclusion of the patient. When the patient had no noticeable cognitive or sensory impairment, the discourse tended to be more equitably divided among the physician, family member, and patient. In this circumstance, health care capabilities and responsibilities were treated as properties that were sometimes avidly negotiated by all three people; yet an inexplicable tendency for the physician and caregiver to address each other instead of the patient was often still present. It appears from these clinic data that the presence of a family member at an older patient’s medical visit triggers assumptions about self care dependencies and responsibilities that constitute threats to the patient’s adult status. Depending on the ambi~ities of the situation, the physician, family caregiver, and patient him or herself demonstrate relatively limited efforts to engage the patient in the interactions. As Beisecker (1988) has commented, the third person tends to become the pivotal person in the interview and consumer behaviors by the patient are decreased. The patient’s sphere of influence shrinks and, hence, his or her power or control in the situation is also diminished. This shift of influence and responsibility away from the patient does not always reflect true impudent. Rather, much of the dependency behavior of the older patients in these triadic medical encounters took place in situations of moderate or unappa~nt impairment. I would conclude that such behavior is derived from underestimations of capacity-by the physicians, family caregivers, and patientsrelated to situational variables such as age, medical traditions of authority, and the presence of a family member at the visit. In Baltes’ model of dependency, such underestimations of ability results in excess care and can “begin a vicious cycle accelerating decline, and, in turn, increase dependency” (1988, p. 316). The need for on-the-spot calculations of each other’s capabilities and responsibilities by all three people in the triadic medical encounter-z~ro#g~o~f the medical visit-
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seems paramount to appropriate support of the older patient as an adult member of the group. Ongoing definitions and redefinitions of the situation must take place, especially when the patient’s capabilities are poorly defined. Continuing alertness to the clues of capacity and responsibility that are contained in the flow of interaction can help to establish a working definition of the patient’s self care capacities. In this way, satisfactions with the medical visit may be better realized for all participants in the medical event, and the older patient’s self care capacity and adult status will be supported.
NOTE 1. The concept for the term “three-track 1991. “The Therapist with the Three-track 45:1007-1014).
care”is borrowed from Fleming (Fleming, Maureen. Mind.” American Journal of Occupational Therapy
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