Asking the right question for the patient in front of you

Earlier this year I was in hospital for urgent surgery after it was found I had an ectopic pregnancy. While waiting in the anaesthetic bay at around 10 pm, the anaesthetist came in to ask me what I assume are all the usual preoperative questions. The nurse had already asked a few and now the doctor was asking those again as well as more. The anaesthetist asked me “do you have any heart problems?” to which I answered “no”.

The anaesthetist was later surprised, and concerned, when during the operation the cardiac monitor showed frequent ventricular ectopic beats.

On my way back to the ward after midnight, a nurse mentioned to me, in my post-anaesthetic haze, that I would need to see a cardiologist. The next day the anaesthetist called me to tell me his concern at what the electrocardiogram had shown, given I had no heart problems. To which I sheepishly replied that I do in fact have a heart problem if one considers benign ectopic beats a problem.

I’d know about this for 4 years at least. So why didn’t I mention it? It would be easy to dismiss it. Perhaps I was emotional and distracted given the reason for the surgery. Maybe it was because of the late hour of the surgery and I was too tired to remember. But when I look back on it, I can see an interactional reason.

To understand medical questioning, we must look at the multiple factors that influence how those questions are designed. As a clinician, you probably don’t even realise you’re making this multitude of small decisions all throughout the consultation. Not just what information you need, but the decisions you make in terms of how you will ask it.

Questions have preferences – both grammatical and social. I’ve previously mentioned the influence grammatical preference can have on patient response. You can see that the question I was asked, “do you have any heart problems,” is more likely to receive a “no” response because of the word “any”. Beyond this grammatical preference, Heritage and Clayman describe both congruent and cross-cutting social preferences that influence question design in medicine.

Question design in medical consultations — that is, how you ask a question — is guided by three key principles: optimisation, problem attentiveness, and recipient design.

Optimisation refers to how questions can be designed to assume a favourable health or social response from a patient. In “do you have any heart problems,” no is the preferred answer because the favourable health response is that I do not ,and there was no reason to necessarily believe that there was a “problem”.

Problem attentiveness refers to the moments when optimisation is not appropriate, usually in regard to the presenting concerns or knowledge of another existing health concern. If I’d been seeing a cardiologist for palpitations, on the other hand, and they’d asked “do you have any heart problems?” I might think it odd because that would be why I am there.

Recipient design refers to asking a question with the addressee or recipient’s circumstances in mind. This is a more general principle that guides conversation. Perhaps if I had been older or male, the recipient design principle would have prompted the anaesthetist to ask it in a different way based on the assumptions related to that demographic information.

These principles might seem unnecessarily technical, but they provide insight into why you design questions in particular ways, why a patient might answer with a “no” to you but with information about a problem to another clinician, and why sometimes it can seem tricky to ask a question when these principles are cross-cutting.

“Do you have any heart problems” is not inherently wrong, it just didn’t work for me. With the “any” as well as the use of the word “problem” when the ectopic beats had previously been considered not a problem, I was not prompted to disclose relevant information – it didn’t even cross my mind. What could have the anaesthetist asked me? If the question had been “have you seen your GP or a cardiologist about your heart?”, I would have been more likely to say “yes”.

Originally published on MJA Insight+ https://insightplus.mja.com.au/2021/40/asking-the-right-question-for-the-patient-in-front-of-you/ 25 October 2021