In a recent comment in the BMJ Sosena Kebede writes: Ask patients “What matters to you?”. Continuing a pattern of my objections to easy solutions for clinical communication, I am writing this with a plea to the contrary. Please don’t!
The sentiment behind Kebede’s appeal is, of course, admirable. Indeed, I agree with her. She makes a well-rehearsed argument about patient-centred care which focuses around what I, the patient, need and value. The question she advocates is aimed at teasing out those needs and values. And I, of course, should have a say in where we go with my ‘condition’. Moreover, I accept that the question, potentially, opens up the space for a patient’s story. Still, I think, it is counteruseful, as are its equivalents like “What is important to you?”.
In the article we read:
The question “What matters to you?” allows patients to disclose their interests, values, and preferences, and it gives the clinical team a chance to appreciate patients as full humans and not just as recipients of care.
Time and again, clinical communication is constructed in terms of easy and simple (OK – simplistic, really) triggers which, when uttered by the doctor, will result in me just oozing information about my “interests, values, and preferences”. It’s as if revealing my soul and life to you were so simple and easy, just because you ask me this incredible and fantastic question of what matters to me. Can we get real?!
It’s noteworthy that the question is to get me to ‘disclose’ things. And so, I shall be saying things which are potentially secret, private. Something I might prefer to keep to myself. But then the doctor waves the magic wand and hey, presto, off I go disclosing. The other interesting word is ‘allow’. Your question allows me to disclose, as if I wanted nothing else. I also thank you very much for the offer to appreciate me as a ‘full human’. Not certain what it is, but I am touched.
So, as a patient and a linguist, I would l like to point out that questions don’t work like that. Believe it or not, even doctors’ questions have contexts and there are doctors to whom I would not reveal last year’s double parking for a minute! In other words, it takes considerably more than one question to tell you anything beyond the current problem I see you with. I need to trust you, probably, like you. I need to think that ‘disclosing’ makes sense, that you do not simply pay lip service to the current set of communication procedures. And probably a few other things. And that’s precisely the context in which you ask me your question. Incidentally, I always find it bewildering to see clinicians’ surprise when I tell them that I actually can find them nice, obnoxious, attractive, interesting, dull, stupid, bright and so and, and the like. I can (dis-)like their spectacles, shoes, sweaters, shirts or bracelets.
Let me put it differently, asking the question “What matters to you?” doesn’t even begin to get me to tell you what matters to me. And I really wish you, my doctor, stopped thinking of me as a book which simply opens at your say-so.
Now, the question “What matters to you?” is very general. Yes, you could argue that the context of an interaction with my doctor makes the answer easier, yet, the article actually does confirm that it is meant to be just about as general as it sounds. So, what might matter to me is to have more money, more hair on my head, speak Mandarin, and run marathon below 3 minutes per kilometre and the black belt I am now unlikely to achieve (in either of the martial arts I have practiced). This is what matters to me, but do you really want to know it?
Incidentally, what really (like – really) matters to me, I am not prepared to share publicly. In fact, I am not prepared to share most of what really matters to me with my GP, whom I like and respect. It’s none of his business. I would actually find the question quite intrusive, to be honest.
Moreover, if these responses are not responses you want, then what exactly are you asking me? And this is the other side of the medical view of clinical communication I often find and dislike. As you ask me your question, I am supposed to know what you mean. I am supposed to understand what exactly I should say. The problem has been addressed by Justyna Ziółkowska on the basis of data from psychiatric interviews (here you’ll find the link to her article).
Analysing the form of doctors’ questions, she shows that they do not only construct patients’ problems differently, but also ask questions which are unlikely to be understood by their patients. I would argue that questions such as ‘What matters to you?” are precisely questions which are mostly confusing. This is also why they should be avoided.
I’ll end with a story. Some time ago I wrote about a man in his pyjamas whom I interviewed. He was hospitalised after a suicide attempt. It was the second time he tried to kill himself, after his child had been killed by a car. The interview was surprising. First, he talked about his daughter – there was a smooth narrative that he offered me about how much he cared and still loved her. Then the interview changed – he spoke of his inability to find a job, to care for his family.
Let’s speculate what he would have said if asked what mattered to him? I would guess the answer would have been something like: my daughter and my job. And so, what would you, doctor, offer him? His daughter’s life or a job? Or perhaps a spiel about unrealistic expectations in the 10 minutes you will have for him?
Clinical communication does not and cannot depend on asking ‘the question’. Yes, there are good questions, there are bad questions, but none ever can guarantee an answer. Patients are not people who simply are triggered to say how it is, and say it all. It’s worth remembering that. How about just having a conversation with me?