Levels of Physician Involvement with

the Family
By JOHN D. CALUNSAG, M.D.
Family Physician as Specialists

 Must have knowledge and skills in a certain field that others have less of, such that they
are depended on for these skills and knowledge..
 Area of expertise – Family
 Should be aware of how illness affects the family and how families affect an illness..
 Must be able to intervene in the family system to keep the family functional in the midst of
illness, and to bring family resources, both physical and emotional, to solve the problem
and heal the patient
Levels of Family Involvement

 5 - level hierarchical model

 developed - Doherty & Baird, 1987
 training tool for family physicians - adequately prepare them for dealing with the
psychosocial concerns accompanying illness for patients and family members, alike
 describes how professionals may address concerns of families with whom they are working
Levels of Physician Involvement

 Levels of Physician Involvement with Individual Patients

 Marvel et al (1993)
 modified the family levels model to describe physician involvement with the psychosocial
concerns of individual patients
Levels of Physician Involvement

 The Integrated LPI Model

 Marvel et al (1994)
 integrate the level of physician involvement with families and individual patients into one
hierarchy
 improves on the two earlier LPI models that focused on involvement with either the
family or individual patients
Level 1 - Medical issues: Physician-centered /
Minimal Emphasis on the Family

 The physician often has no direct contact with the family.

 The primary interest - gaining information which is useful for diagnosis and treatment
 At this level , physicians consider dealing with families as necessary only for practical and
medico-legal purposes
 There is no active effort by the physician to obtain the patient’s and patient’s family views
of the problem or treatment plan
 Little attention tends to be given to the patient’s or family’s response to an illness
Level 1 - Medical issues: Physician-centered /
Minimal Emphasis on the Family
 If present, family members are minimally involved and their participation is not actively
sought, except when necessary' because of the patient’s age or impaired function
 Psychosocial concerns or feelings spontaneously expressed by the patient either are not
addressed or receive only a minimal response from the physician
 Intended to benefit the organization or professional rather than the family
 Characterizes most medical school training which focuses solely on biomedical problems.
 A medical emergency is an example of appropriate level 1 physician involvement
 Individual Psychosocial Intervention

 Individual interventions limited to advice on medico-legal issues

Level 2 - Collaborative Information Exchange/
Cognitive Level / Providing Ongoing Medical
Information and Advice

 Primarily cognitive in nature

 Physicians understand the triangular nature of the doctor-patient-family relationship and
regularly communicating with families about medical issues
 The professional seeks to provide information to families that will help them address their
concerns
 The physician, patient, and family are co-participants in the exchange of information on a
cognitive level
Level 2 - Collaborative Information Exchange/
Cognitive Level / Providing Ongoing Medical
Information and Advice

 The physician interacts with the family, seeking and providing medical information as well
as dispensing advice regarding the patient and the illness
 The professional operates in an expert role at this level, providing content that is of
practical value to family members
 For example, a pediatrician may interact with a parent of a sick child by inquiring about
symptoms of the child’s illness, discussing ramifications of the illness, and reviewing
options regarding the child’s care
Individual Psychosocial Intervention

 Individual interventions involving the provision of ongoing medical

information and advice but focusing mainly on biomedical issues
and minimally on emotional support.
Level 3 -Dealing with Affect / Eliciting Feelings
and Providing Emotional Support

 This level requires physicians to have an understanding of normal family development and
responses to stress.
 The professional operating at this level needs to listen with an empathic ear, invite
expression of emotions from family members, and normalize feelings and reactions related
to stressful events.
 The professional may also provide information and advice, but he or she is primarily
concerned with helping family members experience, manage, and communicate emotional
issues related to their concerns.
Level 3 -Dealing with Affect / Eliciting Feelings
and Providing Emotional Support

 The focus of this level is not to generate solutions, but to create an environment of
support and encouragement wherein family members will have a safe avenue to explore
the emotional aspects of their concerns
 For example, an oncologist who is working with a patient recently diagnosed with cancer
can inquire about how the family is coping with this news, opening the door for them to
vent feelings of frustration or grief
Individual Psychosocial Intervention

 Interventions that involve both health education and emotional

support to deal with the psychosocial impact of illness, but stops
short of psychological therapy. (Catharsis-Education-Action model
for Individual health education)
Level 4 - Basic Psychosocial Intervention / Systematic
Family Assessment and Planned Intervention
 Involves the development of brief, focused solutions to problems experienced by family
members.
 This is done with the permission of family members and is limited to a specific concern
they are addressing.
 This level calls for the professional to have a basic understanding of Family Systems
Theory and to have the ability to ask questions which will provide a detailed description
of the family dynamics surrounding the presented problem
Level 4 - Basic Psychosocial Intervention / Systematic
Family Assessment and Planned Intervention

 The physician works with the family around a specific issue to systematically assess the
problem and to develop a treatment plan.
 The physician meets with the patient (and family, if appropriate) for one or more sessions
to find new ways to make desired changes related to health problems.
 The physician also applies recognizable counseling models or techniques, such as family
systems or Rogerian client-centered counseling, toward an identified goal.
Level 4 - Basic Psychosocial Intervention / Systematic
Family Assessment and Planned Intervention

 Working together, the family and the professional may develop a hypothesis about the
family dynamics contributing to the problem and strategies for addressing it.
 If it appears that the problem is too complex to be addressed through brief problem
solving, or if the targeted intervention is unsuccessful, the professional may need to guide
the family to a referral source.
 For example, a child’s chronic illness may alter the roles of family members and place
strain on his parents’ marital relationship. Their family physician can meet with the parents
on one or more occasions to discuss the effects of the illness on their relationship and to
develop a plan to restructure roles within the family in response to their child’s illness.
Individual Psychosocial Intervention

 Interventions requiring systematic assessment and structured brief

models of therapy that can be handled at the primary care level and
taught in FamMed Residency Training. (Rogerian Counseling)
Level 5 - Individual or Family Therapy

 This involves working with a complex web of issues affecting multiple family members,
sometimes over a lengthy period of time.
 The physician meets with a patient or family over an extended number of sessions to
improve individual or family functioning
 The issues discussed may be independent of the patient’s medical concerns.
Level 5 - Family Therapy

 This level entails planning an organized therapeutic approach to bring about major changes
in the family system
 However, more typically the family is referred to a professional specializing in this area if a
need for extended therapy is seen.
 Family therapy calls for specialized training and is outside the scope or interest of many
professionals who work with families in a capacity other than therapeutic.
 Competence - usually requires fellowship training and continued access to supervision or
consultation from therapists.
Individual Psychosocial Intervention

 Interventions involving deep therapy that require additional formal

training.
and GOOD DAY everyone!