What should be the first question you ask me as I sit down in your surgery? This is an issue raised by the oncologist, Martin Stockler in a comment under the previous post. Apart from the usual ‘It depends.’, I would like to try and offer linguist’s more detailed view on this.
Before I do, I would like to begin again with a little ground-clearing. Here is the first point. Some time ago, I wrote about the distinction between open and closed questions. I suggested that the distinction is largely unhelpful and that the so-called closed questions can and do serve useful communication functions. Put differently, the question:
Are you OK?
can be the most useful means of telling me you’re concerned. Empathy and with a closed question!
The second and related point I want to make is that what I say below is not meant to be directive. In other words, I don’t mean at all to say: ‘You should/must do this.’. Or ‘If you do this, you will be communicating well.’. No, there cannot be such rules, whether regarding open/closed questions or anything else. What I write is meant to be ‘food for thought’, so when you ask your question, doctor, you know what kind of question you ask and why.
Finally, a brief comment about questions. A questioner through her/his question seeks some information. The information sought, the proposition (a sentence, really) which answers the question is the question’s focus. Thus, if somebody asks, ‘Why did you leave so early?’, the focus of the question consists of a proposition stating the reasons for the addressee’s leaving (so) early. The addressee, in turn, can be thought of in terms of the focal argument of the proposition, i.e. what or who is referred to in the answering proposition as its theme (the grammatical subject, really). And it is this part of the question’s focus that I will be talking about below. I am interested in the ‘who’ in the question’s focus.
So, after this, let me consider the opening questions. In contrast to what Ziółkowska did (I discuss her research in the previous post), I would like to offer a different take on questions. And so, the way I see it, there can be three kinds of questions you, the doctor, can ask me:
- one which focuses on me (the patient);
- one which focuses on you (the doctor);
- one which focuses on something else.
And even though it’s very different from what communication skill textbooks in clinical communication suggest, I still think in the context it is actually useful. Below, I am discussing them in turn, using the examples from the previous post (and the comments) and some others from medical literature.
1. So, let’s start with the questions focusing on me. These are questions in which you ask me, straight off, about me. Here are the examples of the questions:
- What would you like to discuss?
- What question do you have?
- What kind of problems would you like to share with me?
I’m sure that medics will recognise the iconic Calgary-Cambridge questions in the first two. I want to focus on what they mean.
First, I’ll tell you why I like them. I like them because they not only focus on me, but also on talking. You ask me to tell you something and this very firmly places me in charge of the agenda of the consultation. I can tell you something and your question does not restrict me (well, almost – see below). Also, by focusing on me, you (possibly) tell me who is important here. We focus on me, not you.
But the questions have disadvantages. The focus of talking is a double-edged sword. Have I really come to discuss anything with you? Hardly – I came for help, advice, maybe for other things. Can I only have questions? I hope not, I hope I also can tell you something and you will listen. You are not a deity which has answers and I also hope we can talk, not just ask questions and answer them. Do I want to share anything with you? No, not really.
So, what about questions such as:
- What kind of problems have you been having recently?
We lose the focus on me talking, but introduce me having problems. What if I come for advice?
So, are we left with: ‘How are you?’ Possibly, but given that the question is used very conventionally, it has obvious drawbacks.
2. Let’s explore the questions focusing on you. These are questions such as:
- How can I help you today?
This is the question I have been asked most often. It makes the issues I raised earlier disappear, which is its main advantage. You also offer help (sort of).
Unfortunately, it raises other issues. First and foremost, it focuses on you, but isn’t this consultation about me not you? Also, it assumes that I know what you can help me with. For the most part I probably do, but what I am not certain?
There are two more things I don’t like about such questions, perhaps they are minor, perhaps not. First, and more important, it constructs our relationship in terms of help, and not, for example, advice. Does it matter? I don’t know, but we do know that men tend not to go to see their doctors. Is it because they don’t want ‘help’? Would they would accept advice? I have no answers, still helping someone is very powerful. Second, less important, it reminds me of questions I am asked by shop assistants.
3. And here we come to the largest group of questions. Those that focus on ‘something else’. They would be questions such as:
- What problems brought you to the hospital (or office) today?
- What are the three things that trouble you the most?
- What are your symptoms?
And the question I really, really dislike:
Again, the first of the questions is taken from Calgary-Cambridge advice, the second is one I used in the previous post. Although they are different, they all focus ‘external’ to me or you. Are there advantages? Yes, paradoxically, there are. As you focus on the issue, you (potentially) focus my story, you set up our relationship as one which focuses on the ‘problem’ or on the ‘symptoms’. Yes, you could argue that the question is unnecessarily medical (and I don’t have any bloody symptoms), but still I will cope, won’t I?
Alas, that’s not the end. These questions also pretend that our relationship doesn’t matter. That I cannot simply tell you something, my story and you are not here to ‘help me’. Moreover, such questions suggest that there is one (two or three) easily identifiable problems which I had already identified and can now simply report them, ideally in an objective manner. But what if I hadn’t? What if my problem must be negotiated with you, as you talk to me and I talk to you? I might be the only person like that, but I often don’t know what’s wrong with me, apart from knowing that there is ‘something wrong’, possibly.
Well, I hope I muddled the waters and made things awkward and unclear (though I do hope it will not put you off reading!). But I also hope that I showed you the complication every question carries, the assumptions it makes, the issues it raises. Which to choose? I have no idea, it depends on you, the time you have, your patient. My personal non-academic preference? I like being asked to talk. I like the idea of having the agenda, I also like talking. But only with a doctor who wants to listen. Such a question irritates me no end when I can see that the medic doesn’t give two hoots about what I am saying. Then, let’s not pretend.
But I suppose there is a confession to be made here. I should also declare my hand and tell you how I have answered question of the opening question in various sessions and lectures. Well, my response is:
What have you come to see me with?
In Polish it also sounds somewhat awkward, but ‘What’s the purpose of your visit’ sounds off. I’ll explain why. First, because it does focus on me, so to say. On the patient. Second, because you don’t have to make any assumptions about discussing, problems, helping etc. In other words, you are only about what you know. You do know that I have come to see you – after all I am sitting in front of you. You also know that I don’t come to see you just for a chat, so there is a purpose to my visit and you are asking me about it.
I want to stress, however, I have no idea whether this is the best question, I don’t even know whether it is a good question. But I can explain why I use it for student-clinicians.
But then there is a story I want to share at the end. A few years ago, I had a communication skills workshop with future clinicians. We explored communicative strategies and we had interviewing exercises in which I was the patient. And so, I was interviewed by a student whose voice was just mesmerising. Some of his questions were quite terrible – pathologising, patronising, leading. But both other students and I agreed the interview was the best of the lot and it was because of his voice. It was calm, warm, inducing trust. As I said – mesmerising (it turned out later that the student was about to finish his training in psychodynamic therapy, which explained at least some of it). Am I then just wasting my time, as it is all about whispering?
No idea. But perhaps it is about yet another thing. In a recent consultation, the doctor touched my hand. It was a brief, fleeting touch, meant as a reassurance, concern. He showed he cared. And it worked (apart from the academic me noticing it and making a mental note), as it was very human. I stopped listening to his questions. We just talked.
I hate ending by undermining what I have just said.