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![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Is the level of medical care use an acquired behavior during childhood, which determines health behavior throughout adulthood?
Family consultation patterns - continued
Questions begging for an answer
Consultation Patterns in Families: Public Health Enters the FP’s Office
Archie Bunker and the family physician
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Amnon Lahad, Jerusalem, Israel Chairman, Department of Family Medicine, Hebrew University, Jerusalem, Israel, Avraham Friedman
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The article by Cardol et al tries to explore why some people come to the doctor for minor illnesses while others do not. This question has been previously investigated by White in his 1961 article, in which 750 out of 1000 adults suffered from some illness during a given month, but only 250 visited the doctor [1]. An individual’s health-related decisions are made within the context of his/her household [2]. Few researchers have focused on the range of influences that family members exert upon one another, focusing primarily on the effect of a mother's health behavior on that of her young children [3]. Minors visit the physician according to their mothers’ care-seeking behavior, but little is known whether parental effects continue to influence grown offspring into adult life. The reason one visits a physician is related not only to the biological severity of the disease, but also to the patient’s concept of illness, as described by Engel in a 1977 article [4]. Cardol et al shows a family pattern of behavior with high correlation of medical care use for insignificant illnesses when the offspring were still minors. But is this true later in life? Is the level of medical care use an acquired behavior? We are lacking evidence for the same association between adult offspring and their parents. In our own study [5] we found unique evidence for a maternal health behavior effect on grown children, in the setting of a kibbutz in Israel, in which there was a correlation between maternal and adult offspring number of visits for primary care, even after controlling for chronic medical diagnosis. These findings support the observation that healthcare utilization should be viewed within the context of the family unit. There is an opportunity to institute educational programs to change healthcare-seeking behavior. Such intervention is best aimed at affecting mothers’ attitudes concerning their own use of health services, where this is possible. 1. White KL, Williams F, Greenberg B. Ecology of medical care. N Engl J Med 1961:265;885. 2. Litman TJ. The family as a basic unit in health and medical care: a social-behavioral overview. Soc Sci Med. 1974;8:495–560. 3. Newacheck PW, Halfon N. The association between mother's and children's use of physician services. Med Care 1986;24:30–8. 4. Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977;196:129-136 5. Friedman A, Lahad A. Association between Maternal and Adult Offspring Primary Healthcare Utilization. IMAJ 2007 in press Competing interests: None declared |
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Mieke Cardol, Netherlands NIVEL
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We are glad our article about family similarity in consultation rates evoked discussion; it shows the subject of family medicine is alive and still of importance. All participants of the online discussion are univocal about the influence of families on the use of health care facilities. It exists and FP’s should be aware of it. Indeed, Huygen already learned us about the influence of the family on individual consultation rates. Research on the role of the family, however, mostly dates from the 1970s and 1980s and the family is scarcely mentioned after in publications, let alone used in statistical analyses. So, it will not harm to root up the subject more often. Moreover, changes have taken place in society, families and general practices, that have raised questions about the actuality and the mechanism behind family resemblances in consulting patterns. Our goal was to further explore family influences by questions such as: why does resemblance in consultation patterns exist in families, and does family similarity exists as much with regard to minor complaints as with regard to chronic illness? The last question is answered in this paper. This paper, as opposed to the impression of Van der Wouden, focusses mainly on similarities in the type of new health complaints. We agree with Van der Wouden that health beliefs partly explain consultation rates. However, in this study we did not want to explain consultation behaviour. We wanted to investigate family resemblance in health complaints that were perceived to be seriously enough to consult a FP. After all, these are the health complaints FPs have to deal with. As a matter of fact, we explored the health beliefs in a recently published article (1). Both Zaat and Van der Wouden wonder how the knowledge of our study can be used in daily practice. In our opinion, the message of this paper goes beyond the old message – be aware of family ties. It shows that family influence is especially present in minor complaints and that father’s role is specific and more important than presumed. In the consultation room, FPs can discuss striking family patterns with members of the family at times they consult and they can provide family tailored health information related to (minor) health complaints. To use family information effectively, family doctors do not need to invite the whole family as suggested by Van der Wouden. We agree with Van Weel that FPs are largely unaware of their influence on the family shaping of health beliefs. Pro-active use of family mechanisms can be used more often. Strikingly, questions about chronic illnesses in families always are part of the family anamneses, but family beliefs about illness or socialisation conditions are so to a much lesser extent. Likewise, in the Dutch guidelines for general practitioners, related to family medicine little research or advise can be found. 1. BMC Family Practice 2007, 8:4. Striking variations in consultation rates with general practice reveal family influence. Competing interests: None declared |
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Johannes C van der Wouden, Rotterdam, The Netherlands senior lecturer, Erasmus MC - University Medical Center Rotterdam, D. Margriet Noordzij
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Cardol et al have done a remarkable job, by combining a huge database with sophisticated statistical methods. Before being able to interpret their findings, we would like to have several questions answered. The age range of children that were included seems to be 0-12 years. We assume this from the range given in table 1, although this inclusion criterion is not stated explicitly. However, how much freedom do children up to 12 years of age have to seek medical care? It is not only a matter of putting words to perceived symptoms, but also, and much more important for this paper, the decision to consult the family doctor. Furthermore, the denominator of (perceived) illness seems to be neglected by the authors: in order to consult a doctor, people usually have to be aware of some health problem. Differences in consultation patterns may, at least to some extent, be explained by differences in perceived health problems. The category of minor ailments and of chronic illnesses both seem ragbags of several diseases and symptoms. Given the large number of children that had consultations thus categorized, it is surprising that the authors did not subdivide these groups further into smaller, and more homogeneous, groups. Their (unexpected) finding that the clustering of consultation behavior within families was not clearly related to minor ailments may be the result of this choice. Finally, we wondered in what way the results might be beneficial for either the family doctor or the patients. We don’t believe that the family doctor can intervene in the development of a copied consultation pattern or for example, prevent headache in youngsters when (one of) the parents suffer from chronic illnesses. Firstly, the youngsters only visit the family doctor when the complaint exists already. Secondly, to prevent family-claiming side effects of an illness, the whole family system would have to understand how this process works and why it is not wanted. This seems to be too much for a family doctor to deal with during the consultation. Competing interests: None declared |
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Chris van Weel, Nijmegen, The Netherlands Professor of Family Medicine, Radboud University Medical Centre
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The analysis of the Dutch National Study of General Practice database by Cardol et al confirms the role of socialization in accessing health care: the use of family practice for self-limiting health problems by children resembles that of their parents. The most profound observations in this respect had been made nearly 30 before by Frans Huygen, in his classical qualitative and quantitative reach of his practice [1]. From his study could be inferred that expectations of medical care and self- efficacy in dealing with stress were important mechanisms behind the family consistency in practice visits. Later studies demonstrated the extent of this effect that was still present in siblings’ at their age of 20 years [2]. It is likely that contacts with medical professionals – and in particular with family physicians (FP) – shape use of health care, so the observations must reflect at the same time the outcome of this process. The importance of the study of Cardol et al next to this existing body of knowledge collected in the 1950s and 60s, is in confirming the influence of families on the use of health care facilities, in an era in which the social role of family life is in decline. With the socio- cultural changes came as well essential changes in family size, resulting of in a decline of family size to 2.30 persons per household in 1997 [3]. Another importance of the study of Cardol is that this downward trend still enables analysis of family patterns, provided the database is rich enough. For family practice it signals that with the patient the ‘family’ enters the office, with its health beliefs and health-related behaviors. In other words, the micro-society is present in the patient’s consultation and FPs’ advice and support offered is likely to transpire back to family members, irrespective of their actual presence in the consulting room. Thus far, FPs are largely unaware of their influence on the family shaping of health beliefs. Pro-active use of family mechanisms can be applied for important public health objectives like patient empowerment and in protecting patients against over-medicalisation and undue use of medical interventions. At least it is time to assess these effects in a prospective approach. Family patterns can be identified the logical question is after its determination. And although learning is seen as its most likely mechanism, genetic constitution cannot be excluded. It is safe to predict that soon research on health and health related behavior will be linked to its genetic determinants. Such research might enable better interventions, provided social determinants of behavior will be included in the equation of gene-environment interaction. In that respect, the study of Cardol et al is relevant, in that family medicine databases will be able to contribute to this with robust data. References
Competing interests: None declared |
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Joost O Zaat, Purmerend, The Netherlands general practitioner, former editor of Huisarts & Wetenschap
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Cardol et al have investigated an intriguing phenomenon: the pattern of visiting family doctors within families. Their research questions are loosely based on Frans Huygen’s Family Medicine.1 We all know that some families do visits extremely often for minor somatic problems, but also for minor ‘life associated problems’. The same authors published an interesting article in the BMJ last year of the same research database. Quite a lot of the statistical variation of visiting was explained by family patterns (22%), a small part by the family doctor (6%) and the largest part by individual differences.2 For me, that’s a good old message: see families as a complex system and try to act according this knowledge. In this article about indicators they choose another view: they tried to formulate indicators of family patterns and find that only headaches and abdominal pain have sufficient statistical power to act as such an indicator. There are some problems here. The time span of the whole project was only one year. That can be too short to investigate complex patterns. Many unexplained physical symptoms change in time: sometimes people suffer of headache, another time they have belly pain, low back pain, dizziness, fatigue or a dozen other complaints. Families grow their patterns much more slowly than during one year, Huygen told us long ago. The results that only abdominal pain and headache are indicators, could be misleading. The unexpected result that there was no relation between minor ailments and clustering of consultation can easily be a fault of the second order. The practical question of this kind of research is, how could you use this knowledge in daily practice? I really don’t know. Should I count the abdominal complaints of little Mary and be less surprised that she is here again, because of her mum has frequently headaches? Many older doctors will remember Archie Bunker in the tv soap All in the family in the seventies as a grumble old man who utters platitudes all the time. Although the authors aren’t old and surely not grumble and reactionary, they described here nothing new and nothing really handy for daily practice. The old message - be aware of families ties - stays true for all complaints and all families, as the authors conclude in the end. 1. Huygen FJA . Family medicine, the medical life history of families. Nijmegen: Dekker & Van de Vegt, 1978. 2. Cardol M, Groenewegen PP, De Bakker DH, Spreeuwenberg P, Van Dijk L, Van den Bosch W. Shared help seeking behavior within families: a retrospective cohort study. BMJ 2005;330:882-; doi:10.1136/bmj.38411.378229.E0 Competing interests: None declared |
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