E#8: Communicating with Patients(Part2): Uncovering Issues with Questions
In this episode I deal with the middle of the interview, and how do we start the in depth conversations to get to a common shared solutions. How to ask the right questions and when to ask them.
(This is the core of the transcript from the podcast. The Intro has been removed and some areas improved for reading ease.)
I’ll tell you a story about a true event that would have scared me terribly when I was a newly licensed physician. The truth is, even when it happened to me as a seasoned veteran doctor, it caught me slightly off guard.
A nurse came to me and said “Dr. Chawla, a patient has come into the office crying very badly and she wants to see you.”
I asked the nurse, “Why is she crying so much? What happened?”
The nurse replied “I don’t know, she just keeps crying and wants to talk to you. She said she won’t leave until she sees you, so I put her in an exam room, I hope you don’t mind.”
Kelly was sobbing uncontrollably and loudly behind the closed exam room door...“Why is she crying so much? What happened?”
Those few simple sentences I asked her were simply good quality questions.
Those good questions were what I had developed over years of trial and error from so many successful and unsuccessful dialogues.
Questions, particularly good questions at the right time are the key to opening the ‘clinical conversation door,’ especially when it comes to social and personal issues where there are so many people involved, with so much information to gather and so often a lot of variables.
Questions help provide clarity, identify needs, create options and helps reframe, re-construct and re-evaluate situations.
In the past, when I was a young and an inexperienced physician, the questions I asked were less effective and would produce slow results. But over time, I learned how to ask more effective questions, and the results were not just quicker, but also clearer for both me and the patient.
If there is one thing I’ve learned over the years of practicing medicine, is that the quality of the answers I receive really depends on the quality of the questions that I ask. Learning this skill of asking quality questions is not as difficult as people may think it is. It is a learnable skill. You don’t need to spend many years, like I did, learning through trial and error, from so many successful and unsuccessful dialogues. There are many resources that you can use to help make your questions more effective.
The quality of the answers I receive really depends on the quality of the questions that I ask.
Why are questions so important? The reality is that questions are the cornerstone of discovery in everything we do, from the realm of innovative ideas and designs, to uncovering what’s happening in a person’s world, including our own. In fact, the whole premise of science is based on a hypothesis, which is essentially a question.
On any given day, clinicians spend over 40% of their time asking questions. We try to uncover what’s happening with a person’s health and life situation. The better questions we ask as clinicians, the better understanding we have of our patient’s situation. In medicine, as you already know, it’s called getting a history from the patient. Perhaps that’s how the term was coined: “his-story” or her story.
Questions help provide clarity, identify needs, create options and helps re-frame, re-construct and re-evaluate situations.
A good clinical history removes ambiguity and gives the healthcare practitioner knowledge and clarity. The healthcare practitioner then carries out a physical exam and orders tests to narrow down the many possible diagnoses (differential diagnosis) that could be ailing the patient and then narrowing it down to a very specific diagnosis. And learning this skill or asking good questions to elicit a good history, is not difficult and it also is a transferable skill in other areas of our lives.
Now in terms of Kelly’s situation, I needed to get a clearer sense of what was happening in her world and who were the key players . That’s why asking good questions were important in terms of providing clarity of her situation and understanding her needs. In her specific situation, she and her husband were arguing for several months, (note: this was new). She had told me that they generally had a good marriage and he wasn’t cheating on her or anything like that. Tensions between them had been slowly escalating but they still talked, but now, for the last three days, he hadn’t come home even to see the kids, who he was very close with. He had now even stopped texting and calling her. So, in this situation, or any similar situation, it was important to ask some good questions...more open-ended questions Such as :
“How would you describe your relationship?”
“What change happened?”
“When did you notice a change? What do you think caused the change?”
“Who else was involved? “
“What do you think might have caused this?”
To get insight into her and her husband’s psychology, or in other words, their life story, it was helpful for me to ask questions such as:
“What was your childhood like? “
“What was your husband’s childhood like? What was your father and mother like?”
“What were his parents like?”
These types of questions helped create a clearer picture to see who were/are the key people involved and/or influencing the person’s behaviors and decisions. This type of expansion helps create understanding from many relevant perspectives which increases the options and areas of influence. Together, we were able to understand her role, and his role, in the conflict and come up with some empowering solutions.
As an aside, I learned that most doctors will interrupt the patient within seven seconds. It’s no wonder the number one complaint patients have about their doctor is that they don’t feel that their doctor listens to them.
Have you ever had a doctor ask you little or not enough questions—before giving you a treatment plan? It’s not a very reassuring experience.
As patients, we feel we’ve been listened to when the doctor has taken the time to ask questions to learn more about our particular symptom or situation. When the doctor doesn’t ask questions, we, as patients, feel unsatisfied, as though the interaction is incomplete.
Patients have complained to me that they saw another doctor who briefly examined their rash, for example, and then instantaneously wrote out a medication without asking any questions about that rash. In such cases, the diagnosis may be correct, but the interaction felt empty for those patients. It was mechanical, robotic and the whole experience/ treatment felt incomplete for the patient.
Have you ever had a doctor ask you little or not enough questions—before giving you a treatment plan? It’s not a very reassuring experience.
All great clinicians know that asking questions not only helps establish a clear history, but it also helps create a greater sense of empathy or connection with the patient. I became a better clinician once I understood the art of asking better questions, especially when to ask open- ended versus closed-ended questions. Questions are not only a vehicle to get useful clinical information, but they are also helpful in reshaping and redefining a situation so that we can come up with more empowering answers.
Questions as it Relates in the Clinical Setting
Patients will come in with statements such as:
“Doctor, I have a pain in my chest“
“My eye is red”
“I feel weak“
“I feel dizzy“
“I’m having difficulty in my life. I feel stressed and anxious” etc.
All clinicians hear these common statements on a daily basis. What inevitably follows is a question from the physician, either open-ended (those whose answers require more thought and elaboration by the patient) or closed-ended (those requiring yes or no responses). I often get asked from medical learners, “When I should use open ended questions vs. closed ended questions?” Here are some examples of open ended questions.
‘Open-ended questions’ are a great way to start into the middle of the conversation or medical issue at hand. As a rule, they generally start with “What” or “How” statements.
‘Open-ended questions’ are a great way to start into the middle of the conversation or medical issue at hand. As a rule, they generally start with “What” or “How” statements. Those questions look like:
“What brings you in today?”
“What do you mean when you say you feel anxious or frustrated?”
“What do you understand about the illness?”
“What treatment modalities have you tried?”
“What did you hope to accomplish with this clinical visit? “
“What is your biggest concern?”
“What is taking most of your attention?”
“How do you feel?”
“How would you describe your pain?”
“How were you expecting me to help you today? “
“What can you tell me more about the situation? “
“Does the pain radiate anywhere? “
“Did your symptoms give you any preconceived ideas of what illness you may have?”
“What are you hoping to achieve today? “
‘Closed-ended questions’ are short, generally have one-word answers and are useful when we need to find specific information.
‘Closed-ended questions’ are short, generally have one-word answers and are useful when we need to find specific information. When we, in our own mind, are trying to rule in or rule out a possible diagnosis, for example, if we are trying to determine if a patient’s chest pain is cardiac in nature or not:
“Do you have chest pain? Does it radiate to your jaw, arm, back?”
“Is it severe? Is it dull? Is it a sharp pain? Is it constant? Does exercise or climbing stairs make it worse? Do you wake up with pain?”
Other examples of closed-ended questions can be:
“Do you have a headache? “
“Do you take your medication daily?”
“Do you ever miss more than one dose? “
“Are you having trouble seeing things up close versus far away? “
“Do you have any support, like friends or family that can help you?”
“Did I answer all your questions?”
“Did I understand you correctly when you said...? “
“Did we deal with all the core issues today?”
‘Closed-ended questions’ help create a greater sense of focus and help you support what you may be thinking in terms of ruling in or ruling out a diagnosis.
So the general rule is, that I’ll start off the clinical visit or issue with an open-ended question and then use closed-ended questions to zero in on specifics.
Questions can re-frame, re-evaluate and re-elevate tragic situations.
Questions for Re-framing, Re-evaluating and Re-elevating:
Tanya’s 34 year- old son, Brian, was severely injured in a car accident and was admitted to the Intensive Care Unit (ICU). Understandably, she was worried and she was consumed with questions like,
“Will he recover completely? Is the brain injury permanent?”
“Will he be able to work again? Will he be able to pay for the treatments?”
“Is his wife going to leave him?”
She couldn’t stop asking these types of questions. Questions that had no immediate answers. She approached the doctor and healthcare staff looking for definitive answers, but given the severity of her son’s injuries, they couldn’t provide any concrete answers.
Understandably she was stressed.
One of the most challenging parts in a situation like hers is waiting for the result of a test, or waiting for the treatment to kick in. Have you ever had to wait to find the result of a test to see if was cancerous or not, or to wait to get surgery? I can tell you personally, time can move along incredibly slowly.
So Tanya booked an appointment with me because she was anxious, sleepless and distraught. She told me what had happened to Brian and how she was not coping well. She told me Brian was able to talk to her. He was slowly eating but he was nowhere close to being back to his normal self. I asked Tanya one simple question: “If you looked hard enough, what possible good can you see that could/has come from this situation for you and him?” (Alternatively, I could have asked her, “How would you advise someone else if they were in a similar situation?” Removing a person from a scenario allows a person to look at things from a distance, which then allows them to re-frame and come up with better questions and better answers).
With great courage, Tanya said, “Well, I have had more quality time with him than I’ve ever had. I’ve come to understand the value of life. He’s also looking at his own life differently and realizing how short life is. He also realized that he was not spending as much time with his wife and kids, which probably contributed to their failing marriage.”
This was an incredibly thoughtful response which showed great insight. It didn’t change what was happening in her world, but it did change how she viewed what was happening in her world.
Just by asking this question, she was able to see a different and more empowering perspective which gave her greater control over the circumstances. She subsequently used the same question to help her son re-frame the challenging situation he was in. Essentially, one better question created a shift in her perspective.
I also ended up discussing with her about the six human needs and created greater self-awareness about the questions she was asking. She was able to see her situation in an entirely hopeful way. She knew she needed a high level of certainty and control in her life and she valued the love and connection she had with her son.
By challenging her, she was able to ask herself a different question:
“How can I bring the most love and joy into today, to create the best day possible, because in reality I only have this day?”
She allowed herself to move from feeling helpless to feeling helpful. She went from feeling powerless to being in greater control of her responses and outlook.
From asking disempowering and unanswerable questions such as, “Why did this happen?” to asking more solution-focused questions such as, “What/how can I learn from this situation and how can I help him recover?”
Tanya was able to increase her degree of certainty.
Moving away from "why" or "if" questions are generally critical, judgmental and rarely reveal any answers.
Moving away from “why” or “if” questions, which generally are critical, judgmental and rarely reveal any answers, and moving towards a “what” or “how” type of questions, allows a person to come up with greater possibilities. “If you ask better questions, you will find better answers.”
Happier and successful people ask more of these empowering types of questions.
Well that’s really the core of what I wanted to share with you in this episode; ‘Questions’ and establishing the dialogue with the patient. The next podcast, of this little miniseries, deals with how we effectively close or wrap up the interaction in a clinical visit.
Here is a summary of the key points:
1. Questions are a key component of every clinical interaction. Asking great questions helps demonstrate to the patient that we care enough to ask and that we want to know the situation as correctly and as complete as possible.
2. Start the interview with open-ended questions which generally start with ‘What’ and ‘How’. Be patient and listen to the patient, it’s hard when there’s a time crunch...remember “Fast is slow and Slow is Fast.”
3. Use closed-ended questions to narrow in on specific information. For sensitive questions, such as taking a sexual history or street drug information or code status, use the phrase “The next question or questions are standard questions I ask everyone.” It helps minimize the feeling that you are judging them and that they understand that these questions are routine in your day to day conversations.
4. Be cautious using ‘Why’ or ‘If’ questions, as they can leave you and the patient stuck. If you are trying to find some reason, they might be doing something, ask them “Do you have any thoughts as to the choice you made?”
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(A special thanks to the talented William Brown who edited the above transcript)