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Linus Geisler: Doctor and patient - a partnership through dialogue   © Pharma Verlag Frankfurt
The art of questioning
The right question
Unproductive questions
Forbidden questions
Questions by the patient
The art of questioning 
The right question
Posing the right question counts as one of the elementary techniques of every interview. Poor questioning technique inevitably leads to an unsatisfactory discussion. Many doctor-patient discussions fail because the doctor poses inappropriate questions. These questions can be unsuitable either because questioning technique or the intention of the question are incorrect. An example would be a discussion which is only aimed to fulfill the objectives of the doctor, rather than those of the patient. A question is the request, put into words, for certain information. Only good questions are able to lead to the desired answer. A good question is one which is:
formulated clearly and is unlikely to be misunderstood,
posed at the right time,
encourages an answer,
serves the objectives of the discussion,
increases the depth of the dialogue,
brings the discussion further forward,
encourages communication and
is empathetic.

This means: woolly, imprecise questions, as well as those with double meanings will not lead to illuminating answers. Posing questions at an inappropriate time is one of the classic mistakes. All judgmental, aggressive, wounding or interrogatory questions give rise to resistance. It is unlikely that the information obtained in an unwillingly answer will be worth much. The content of the question has to be put together, and the question posed in such manner that the patient answers willingly. A good question encourages communication between the doctor and the patient, because it demonstrates that the doctor is interested in the situation of the patient, shows that he understands, and makes an answer possible without raising anger, shame or anxiety.

The good question leads the conversation on by encouraging the flow of the discussion. This is particularly important at the start of a conversation. Goethe wrote in his "Maxims and Reflections": "He who misses the first button hole, does not complete the buttoning". Ideally questions and answers should follow the zipper principle: interlocking and encouraging willingness to talk and trust one another, and avoiding digressions from the theme or breakdown, either in information flow or in the level of contact.

In discussions between doctor and patients, the good question is an instrument with a variety of uses. Questions are used not only to obtain information (as does the questionnaire), but can also act as an important element in guiding and establishing a dependable doctor-patient relationship. The good question is already part of therapy.

Two forms of questions can be distinguished as regards questioning techniques:
1. Closed questions (decision or structured questions)
2. Open questions (unstructured questions)

Closed questions

Closed questions can only be answered with yes or no, or perhaps a brief statement. Examples are: "Do you often have headaches?" "Yes", or: "When were you operated on for your stomach ulcer?" "1981". Closed questions are used primarily to obtain specific precise information. They can be introduced to keep the patient to the subject of the conversation, and to prevent long excursions in which the significant information content is low.

Because of their concise form, and because they are limited to a narrow range of the total problem, closed questions are less useful for deepening a discussion. They should only be used as and when really necessary, and should be avoided at the onset of the discussion. A discussion which is carried out basically as a series of closed questions takes on a programmed nature, the dry style and the limited flexibility typical of a questionnaire.

The technique of questioning with closed questions involves a series of disadvantages and dangers:
As closed questions usually aim only to deal with part of the complete problem, they can lead to limitation of the subject matter rather than to deepening it. There is the danger that the conversation will only deal with facts of superficial importance, and the underlying problems will not be discussed. The "ping-pong" technique of leading the conversation with closed questions is not suitable for encouraging contact between those taking part in a dialogue.
The patient is unable to answer most closed questions as precisely as he is expected to. How many patients do know with absolute certainty when their appendix was removed, how high their blood pressure is, and whether 0.1 mg or 0.2 mg tablets have been prescribed? The closed question however tends to evoke a quick answer and may in fact lead the patient to respond without really thinking about the accuracy of the answer.
The rapid to-and-fro of question and answer appears to lead to acceleration in the pace of the conversation. However the advantage in gaining time is at the cost of the interviewer, who is constantly under pressure to produce more questions. This leads to the phenomenon of asking for the sake of asking, rather than really thinking through the problem, for which time would be available had less superficial questions been asked. This can also have a marked influence on active listening.
Of course in acute and emergency situations, it is not possible to proceed without using the technique of closed questions, in order to obtain as much information as possible in the shortest possible time. Closed questions are of most use in the rapid collection of facts, quick orientation or the point-by-point dissection of a problem. They are of less use for initiating a discussion, unraveling the various dimensions of a subject or building up and consolidating relationships.

Open questions

Open questions allow the patient to describe in his own words what is troubling him or making life difficult. The opportunity for contact and self-exposure is clearly much wider. Open questions also encourage the patient, warming him to the subject, and allowing him to explain his problems openly and freely. Open questions are also appropriate to initiate a process of self-awareness. The study of the psychology of learning has shown that the most effective learning takes place when one describes things in one's own words. Talking freely about one's own problems, and attempting to make the conversation partner understand, also leads to an increased confrontation with matter for conflict and makes for better management of such problems. Open questions are better for allowing the doctor to convey interest and attention to the patient.

The superiority of the open questioning technique as opposed to the closed can be illustrated as follows:

The open question, "The atmosphere at work has a marked effect on some people: what is your opinion?" is more likely to encourage a patient to discuss problems at work than the closed question: "Does your boss think highly of you?".

The closed question: "Are you upset that the treatment has not worked?" is certainly less suitable for an open discussion with the patient over the extent of his disappointment, than the question "I am very interested to know how you see the effect of your treatment so far?".

The closed question, "Haven't you got any more desire to live?" probably has a blocking effect. It is better to approach the subject by asking the open question, "The last few months were certainly difficult for you. How much did this affect you?".

The technique of open questioning has two important disadvantages; firstly it makes it easier for the patient to avoid unpleasant subjects, and secondly it makes it easier to digress.

A typical example in practice:

Question: "What do you mean when you say you can't manage the tablets?" with the answer, "I seem to feel very funny after I take them. Yesterday I took the last one before the 9 o'clock news, and found that I really could not concentrate during the weather report. It has been more and more difficult to concentrate recently. It's really difficult to remember names. I met my old school teacher, a few days ago. I think it was near the market, and I just couldn't remember his name. He was so nice, and always gave me good marks, even though I wasn't very bright. He didn't get on so well with my brother and always gave him poorer grades ..." etc. etc. It is of course quite in order to break this cascade of words by asking: "Did you feel sick after taking the tablet that you took before the news?"

"Serving men" questions

These include when?, what?, who?, where?, as well as how?, and are also referred to as supplementary or semi-structured questions, as they are halfway between closed and open questions. Questions of this type are equally good for leading onto a subject as for going deeper into particular points.

Sounding questions

Sounding questions are posed to obtain specific information from the patient. They allow the patient to express himself freely, but at the same time prevent a drift away from the subject.

For example: A 52-year old office worker complained of "pressure in the chest", but was unable to state clearly what brought it on. He could not give a satisfactory answer to the question: "Does this come on at rest or under stress?" - "It happens more often at work I think." What does that mean; is the patient under more emotional stress at work than at home? Is he anxious when dealing with the public, or has he got problems with his colleagues? Does his work actually involve heavy physical activity and stress?

More clarity can be attained by the use of sounding questions such as:

"Tell me about the work that you actually do ...", "Does this pressure occur when you play tennis?", "Have you been woken by it at night?", etc.

Catalogue questioning

If open questions do not satisfactorily lead to enough clear information, catalogue questions can be used. They give the patient the choice of a number of alternative key words or descriptions.

For example where a patient is not able to clearly describe his abdominal pain, catalogue questions such as, "Is the discomfort that of pressure, burning, cramping or drilling?" or "Does this discomfort come before, during or after eating or only between meals?" can usually lead to more objective information.

The disadvantage of catalogue questioning is that it still only offers the patient a limited number of options, none of which may be appropriate to him.

Confrontation questions

Such questions confront the patient with his behaviour, his feelings or an earlier statement. They are suitable to direct his thinking onto himself, to make him aware of contradictions or to explain them.

Examples: "You mentioned that you take your blood pressure tablets regularly, but that you feel best when you don't take them?" "Do you believe that it's mainly the doctors' fault if a patient changes his doctor frequently?"

Reflection or echoing questions

The reflection question repeats a part of what the patient has said. It is an "echo" of what he has expressed, and is intended to encourage the patient to consider that part of the particular subject, and go into it more deeply.

Examples: "You are drinking more since your divorce ...?." "You lie awake the whole night ...?"

Interpretation questions

Interpretation questions contain implications that can be concluded from statements that the patient makes or from his behaviour.

Example: "Do you mean to imply that at the present time your success in business is more important to you than a stable blood sugar?"

These questions should only be used sparingly as they mostly are judgmental in character.
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Unproductive questions
Certain questioning techniques are often used, even though they are less productive. Most arise from impatience on the part of the questioner. Information obtained by these methods have questionable value; examples include suggestive, double and multiple questions as well as "hold-up" questions.

Leading questions

"Have you noticed nausea after you take these new tablets?". Such leading questions will certainly raise the prevalence of patients with nausea. A more valid answer would be follow a neutrally-formulated question: "How did these new tablets affect you?".

Prejudice on the part of the questioner is often present in the background ("nausea is often caused by drug X") or wishful thinking ("aren't the new sleeping tablets really much more effective?").

Leading questions also serve to avoid the discussion of unpleasant subjects. The question: "Aren't you really feeling much better today?" exerts subconscious pressure on the patient who actually feels worse, and leads to the answer: "Perhaps a little", which frees the doctor to get on with other tasks. The conversation appears smooth and polished, and nothing unpleasant is discussed, but the actual effect is limitation of the discussion and a dissatisfied patient.

Leading questions are of little use for the recognition of problems and are not suitable for problem solving. They can be used in exceptional circumstances, for example to encourage a patient who is finding it difficult to achieve an objective improvement.

Example: "Haven't you noticed that you can walk much better since the day before yesterday?"

Double and multiple questions

These usually arise out of impatience or inexperience of the questioner. The doctor does not take enough time to break two different discussion points into two separate questions. It is difficult for many patients to respond to a question such as "Do you still have abdominal pain, and is your motion still black?", because they are not used to giving one answer to two questions, and find it difficult to formulate "I still have slight abdominal pain, but the motion is no longer black".

The patient probably remains with the first part of the question, so that the doctor has to repeat the second half of the question. Even experienced speakers usually only get round to answering the first two questions when three are posed consecutively. Questions should not be strung together in twos (or even more), but the posed singly. The answers are more precise, and the conversation time will not be increased.

Hold-up questions

"Ambush" questioning is usually unfavourable in discussions between doctor and patient. There are a few exceptions, in which consciously producing a surprise attack makes it easier to get at the truth. Ambush questions signal impatience, impoliteness or lack of awareness, and lead to defensiveness and aggressively, or produce answers that should be regarded with suspicion.

No bank manager would immediately confront a customer who does not appear to be very credit-worthy with the question: "Do you really think that you will be able to repay this money?"

The question "Do you sometimes hit your daughter?" is certainly not a clever way of introducing the subject. It is easier to reply to difficult or painful questions if the response can be constructed on a previously suggested sentence.

Example: "Children can often provoke even the most patient parents to smack them. Have you found that this has happened at all with your daughter?".
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Forbidden questions
There is a series of questioning techniques that not only do not encourage conversation but usually inhibit it: questions that do not take account of the patient's autonomy, show no empathy, sound presumptuous and usually only enhance the questioner's display behaviour. These questions are included in the category of "forbidden questions" and include trap questions, questions motivated by curiosity, socratic questions, judgmental questions, aggressive questions and the superficial rhetorical questions.

Trap questions

These questions aim to over-ride or trip up. A classic example is that of the judge dealing with divorce proceedings who asks: "Did you or did you not drink alcohol after you had beaten your wife?". If the accused had never beaten his wife, it would not matter if he said either yes or no, but in either case the answer implies that he did. A typical medical question would be, "Do you have more or less thirst on the days when you do not take your diabetes tablets?".

Curious questions

Questions arising from pure curiosity, which although they satisfy the questioner, do not deepen the relationship, and either lead to a feeling of shame in the person who is questioned or evoke the climate of an interrogation by the police.
Example:
Doctor: "Have you had difficulties with potency for some time?"
Patient: "Yes."
Doctor: "Does it worry you?"
Patient: "Of course."
Doctor: "How does your wife react?"
Patient: "I would rather no talk about it."
Doctor: "Have you already given her suggestions of how to manage?".

Socratic questions:

So-called socratic questions usually only lead to an increase in the self-assurance of the questioner, and result in a marked asymmetry in the discussion. These are questions that the questioner knows the other cannot answer. Socrates wanted to make it clear to his fellow-citizens, that they really did not know what they believed they knew.

Judgmental questions

Judgmental questions are inappropriate, as they produce a defensive response. These are very often "why" questions.

Example:
"Why are you so irrational and drink so much fluid, even though I forbade it?" (instead of: "What was the reason that you found it difficult to limit the amount you drank to that which I had suggested?") or "Why have you got such a bleak outlook about your illness?" (instead of: "You seem to be finding it difficult to believe that your chances of recovery are in fact very good: are there reasons why you find it hard?").

The suggestion of judgement puts the patient on the defensive. Because he is forced to defend himself powerfully, there is a danger of raising issues which are not the true ones.

Aggressive questions

Aggressive questions are often posed with the objective of creating a particular behaviour or action on the part of the patient. They usually achieve the opposite of that which they intend, which is to motivate the patient.

A question such as: "Can you not, or don't you want to, understand how important this operation is for you?" will hardly be effective for convincing a patient about the importance of a necessary surgical intervention.

Rhetorical questions

Rhetorical questions are perceived as hollow and insincere. They do not convey the impression that the doctor is genuinely interested in the patient's problems. Superficially phrased, they can only actually be answered superficially. Although they maintain the flow of conversation, they are nevertheless disruptive as they block every attempt to go deeper. Such questions include those such as: "Can you just about manage?", "How are we getting on then?", "What's going on here?", "Is there anything in particular?" etc.

Of course it is not possible to weigh every question in a discussion between doctor and patient. This would spoil the spontaneity in the unfolding of the discussion. What is decisive is however what the various questioning techniques can support and what not, which particular technique will be best in certain situations, and those which must be avoided at all costs. It involves the process of consciously relearning how to lead such a discussion.

In order to assess how you question, start off initially by analyzing which questioning technique you prefer and which you usually avoid.
Questioning techniques
Questioning technique Characteristic Meaning
A. Appropriate questions
Closes (structured questions, decision) Can only be answered by yes/no Advantage: Obtains rapid pertinent information without getting away from the train of discussion
Disadvantage: Not suitable for opening discussion and deepening; danger of pseudo-precise answers
Open (unstructured) questions Possible to freely formulate an answer Advantage: Suitable for initiating a discussion or deepening it; unlock, encourage, and bring into contact
Disadvantage: deviation from subject and long-windedness
"Serving men" questions 
Who? How? When?
Semi structured pointed question Suitable for clearing up certain points
Sounding questions Question posed to narrow description Free expression about the matter in hand within bounds
Confrontation questions Holding up previous answer for reexamination To point out and resolve contradictions
Reflection questions "Echo" questions Deepening of a subject which was touched upon
Interpretation question Questions which include a summary or consequence Definition of a problem; should only be used infrequently as they are judgmental
Questioning technique Characteristic Meaning
B. Inappropriate questions
1. Unproductive questions
Leading Anticipation of the answer Hardly appropriate for problem solving use in exceptional cases for encouragement (rooted in prejudice or wishful thinking)
Double or multiple questions Expectation of several concurrent answers Overwhelms the other (rooted in impatience or time pressure)
Hold-up questions Shock technique Danger of aggressive or irrelevant answer
2. Forbidden questions
Trap questions Intention: trip up the other partner >
Curious questions Curiosity as the only driver of the conversation >
Socratic questions With a view to unanswerability  >
Ignoring empathy and personal worth
Asymmetry
Inhibition of conversation
Value questions Intention of value judgement >
Aggressive questions Questions contain (personal) attack >
Flowery rhetorical Superficial, cliched >
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Questions by the patient
Discussions during which the patient does not pose any questions are rarely good discussions. Of course the patient is entitled to ask the doctor whatever he likes. He also has the right to ask everything, as even "superfluous" questions are often found on active listening not to be superfluous at all. Just the opposite; they key to what particularly concerns the patient is often encapsulated in questions.

The doctor must always attempt to elucidate why a patient asks a particular question, why he poses this question now, and why he does not ask.

There are many reasons why the patient asks questions. The question can simply arise from his need for information. Rather than needing an answer, the patient may simply ask a question to be noticed. A question simply can be a cry for help. A question can be a sign of anxiety, doubt or hopelessness. The question can also be a transport mechanism for letting the other know something that could otherwise not be verbalized.

The patient who poses a question is not begging. It would go against all principles of personal worth and a balanced doctor-patient relationship to answer a patient's questions either incompletely, evasively or to just not reply. This obvious postulate however is not always observed in clinical daily practice.

D.L. Rosenhan, professor of psychology at the University of Stanford analyzed the response of doctors and nursing staff to patient's questions in a much-quoted study. Eight completely sound individuals presented themselves at 12 various psychiatric hospitals in America, and were admitted after they had complained of hearing voices. During their stay in hospital they acted completely unremarkably. In four of the hospitals, they approached doctors and nursing staff with questions about the daily routine (i.e. "May I walk in the gardens this afternoon?"). Even though the findings are not perhaps generally applicable as they came from a psychiatric hospital, the results are nevertheless depressing: 71% of the doctors passed the questioner with his head turned in the other direction, 23% made eye contact, 2% paused briefly and chatted, whilst only 4% stopped and started a discussion. Even worse responses were obtained from nurses and other personnel.

Active listening is the best method to determine the real question behind the question that is posed. The patient who asks: "Will I have another infusion tomorrow as well?", probably does not really want this question answered with a brief yes or no. In fact, the questions that he really wants answered might be: "How much longer will the treatment take?", "How effective has it been so far?". "Dare I believe that there will be an improvement?"

Many questions are basically deputizing questions. One question is put instead of another, perhaps because the patient is too shy to introduce the problem directly. The asthmatic patient who enquires if he must take cortisone for the rest of his life is probably really asking: "Is my asthma curable?". If it is thought that the question is actually deputizing for another, the probable background question should be openly mentioned in the form of metacommunication ("I have the impression that you are asking this question for a particular reason. Could that be?").

Repetition of a question can lead to the doctor feeling mild despair. In such cases, it is decisive to determine what reasons might underlie the repetition of such a question. Is he trying to obtain another answer to that which he has been given, because he cannot come to terms with or accept the original answer? Is anxiety the underlying motivation for repeating the question? Is he constantly wanting to be reassured that things are not as bad, dangerous or as hopeless as he believes? Does the patient continue to question because, although the answer is correct from the doctor's perspective, it does not correspond with reality as perceived by the patient?

Patients who appear for an appointment with a more or less extensive handwritten list of questions usually produce internal blockages in the doctor. Listing symptoms and complaints are usually regarded as one sign of psychopathic behaviour. French clinicians have even given this the name of "la malady du petit paper".

Why is it that doctors tend to react negatively to handwritten lists? The patient is only doing what is obvious; he has a list of unclear points which seem to him to be important, and is taking them to his doctor. He is using this in order not to forget anything. Ultimately, the list of questions shows that the patient would like to present his problems and symptoms with a certain amount of order.

The phenomenon of the patient who comes to an appointment bringing such a list of questions with him has been systematically investigated in America. J.S. Burnum (1985) looked at the meaning of a written list of questions in a prospective study in 900 patients in an internal medical practice. 72 patients (8%) attended with a list of questions. The list contained on average 5-6 points. The longest (with 20 points) came from a completely psychologically stable top manager. The questions pertained to subjects which would normally arise in the course of discussions between doctors and patients. Although these questions were more complex, the fact that they were put in a systematic order made it possible to give carefully thought-through answers. Viewed without prejudice, the lists proved to be a definite help in the diagnosis.

Only one of the 72 patients continued to bring the doctor new lists of questions, which made the doctor impatient. For this particular phenomenon, the author introduced the particularly apt expression of "Polonius syndrome", basing this on the character of Polonius in Hamlet. Burnum concluded that those who write lists of questions are not suffering as such from a disease, and that they are usually not psychologically disturbed. Burnum: "Taking account of the contents of a list of questions is nothing more than a part of listening, the key to our handiwork. Whatever helps the patient to express himself, and whatever helps the doctor to understand him, is acceptable."

Going patiently through the list of questions once usually unburdens the patient, and indirectly saves time, as it is the inconsequential unsystematic discussion of problems which usually steals time and is unproductive. Tangential questions are damped down by offering the patient clearly defined questions; he can, for example, be asked: "What are the two most important points that you would like to discuss with me?".

On the other hand, the patient who poses no questions should alert the doctor. Usually what the patient hears is neither so clear from the content nor from the manner of speech that no counter-question appears. There are various reasons which might account for the fact that the patient does not put any questions. Is the doctor speaking about problems which do not really concern the patient at all? Perhaps he is expressing himself so incomprehensibly that the patient does not dare to show, by asking a question, how little he has understood, or understands? Perhaps the patient is so distressed by what he has heard that he is not able, at that particular moment, to formulate a question.

There are therefore good grounds for encouraging the patient to ask questions. This encouragement has a feed-back function: has the patient understood what it is all about? Are there inhibitory or blocking influences which prevent the patient asking questions? Have misunderstandings arisen in the course of the explanation or discussion? Are the doctor and patient actually discussing the same thing?

Check list: questioning behaviour of the patient
1. Why is the patient really asking (need for information, desire for contact, criticism, call for help)?
2. Why is he asking this question at this time?
3. Is this a case of a question covering or overlying the real question?
4. Why does the patient continue to repeat a question?
5. Why does the patient not ask questions? (anxiety, time pressure, speech barriers, different realities)
6. Was the patient sufficiently stimulated to put his own question?
 
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Linus Geisler: Doctor and patient - a partnership through dialogue
© Pharma Verlag Frankfurt/Germany, 1991
URL of this page: http://www.linus-geisler.de/dp/dp08_questioning.html
 
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