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Ask more questions

Bartol, Tom APRN

doi: 10.1097/01.NPR.0000444230.53368.f7
Department: NP Insights

Tom Bartol is an Advanced Practice Registered Nurse at Richmond Area Health Center, HealthReach Community Health Centers, Richmond, Me.

The author has disclosed that he has no financial relationships related to this article.

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As nurse practitioners (NPs), we ask a lot of questions. There are questions about onset, location, duration, and severity of symptoms to establish a history of the present illness (HPI). Then we have screening questions: “Do you feel safe at home?” and “Have there been any recent falls?” Our list continues with smoking status, employment status, marital status, and on and on. Yet, are these questions really helping patients tell their story? It is easy to come up with a list of symptoms and an HPI, but underlying everyone's present illness is a lifetime of experiences and emotions. There is often much beyond the physical symptoms we inquire about that affects these symptoms and how people respond to them. When we ask patients questions to become aware of their situation, their circumstances, their perspective, and their story, we can find out what is really important to them and what they may need from us at that moment.

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Understanding perspectives

Asking more questions (questions beyond inquiring) can be a way to understand and even facilitate change. This is true beyond patient care situations, such as in our home and personal lives. For example, say I want to see a change at work. I feel passionate about it, and I push for the change, trying to convince others of the need while pursuing my agenda. In the end, it may result in more casualties, hurt feelings, and defenses than beneficial change. The intent is admirable, but the process is not always successful. A more useful approach is to ask questions–not to inquire or to accuse–but to understand. Asking questions and listening in order to understand the perspective of others can bring us to a shared understanding and maybe even a shared vision. Inquiring before we share our opinion, to clarify and understand, is more effective and less threatening than pointing out the problems or asking challenging or threatening questions.

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Deeper issues

What questions might we ask? Consider the patient coming in for a follow-up visit for diabetes: We know we want to check their weight, BP, and hemoglobin A1c. We ask about home blood glucose levels, medication use, exercise, and diet. Our focus is on the diabetes, on achieving care goals, and on helping our patient. The patient, though, may have something more significant than diabetes. A great question to ask is, “What's the hardest thing for you right now in dealing with your diabetes?” Now, the patient can tell their story. The hardest thing may have nothing to do with medications or blood glucose. The most important issue at that moment may be the stress of a strained relationship, a challenging job, or some type of loss or grief. If there are emotionally charged issues occurring, blood glucose levels, medications, and exercise may not be a priority for this patient. Finding out and dealing with what the patient needs at that particular time can then guide the encounter.

Another useful question I often ask patients is, “If you could change one thing in your life, what would you change?” This question can open up what is really significant in the patient's life. I have had patients respond with statements about stressful things in their past or present life that I had no idea about, often challenging, troubling issues. This question helps patients tell their story and helps me focus my care toward the patients' needs beyond my own agenda.

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How was your childhood?

Because our past often affects our current health and behaviors, I find it helpful to inquire about it. A simple screen for abuse or depression often yields a negative result. A direct question about traumatic events in the past also often yields a cursory, negative response. A very high-yield question I often use to learn about a patient's past is, “How was your childhood?” It is a useful question especially when I just cannot seem to figure things out or a patient is not responding to treatment in the ways I might expect. This question is nonthreatening and broad. I have found the responses can be both revealing and therapeutic; they help put perspective on a patient's life. Many people respond with one-word answers, such as “terrible.” Asking patients to tell you more allows them to tell a story, and I have found many of these stories, though painful and challenging, have been waiting to be told. I often hear about childhood abuse, neglect, and trauma that have never or rarely been shared. The reason for a patient's anxiety, depression, even obesity, or hypertension often becomes clearer. It is an opening, a beginning, a building of a deeper relationship between patient and clinician–a relationship of hope. Sometimes, a response to the question of how was childhood will be “fine” or “ok.” I usually inquire a bit more to these responses by asking if both parents were present or how relationships with siblings were. I may even ask, “Who loved you as a child?” or “Were there challenges in your childhood?” Childhood experiences can often explain clinical symptoms in adults that are difficult to understand.1,2 I hear stories of trauma, abuse, and challenges more than I ever expected, but as I listen, and as the stories are told, healing begins. After sharing their story and working on healing, patients often begin to lose weight and blood pressure improves along with depression and anxiety, as a relationship is developed through sharing. This type of questioning often leads to longer visits, but it also leads to less testing and medications, and the results are both rewarding and valuable.

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What do you want to work on?

Questions can often help us to identify goals, strategies, and outcomes for our patients. We may know the solution to our patient's problem: He is overweight, not eating well, and underactive. Telling him this, telling him to eat differently or to exercise more often does not necessarily lead to change. The patient has not owned it, bought into it, and may even feel hurt or hopeless. Instead, asking the person, “Would you like to work on your weight (exercise, diet, etc.)?” offers an opportunity and support. An affirmative response can be followed by a question regarding possible areas of focus. Through these questions, the process changes from a paternalistic, directive, or even defense provoking to one of caring and understanding.

A friend and former NP classmate taught me an effective question to use when starting an antidepressant or antianxiety medication: Ask the patient to identify what success will look like in 3 months if this medication is working. “What behaviors will you see in 3 months that will help you to know that this medication is effective and working?” She would write down what the patient says and refer to it at the follow-up visit to help evaluate effectiveness. If the identified goal is not achieved by the medication, a different strategy can be developed. Rather than giving medications and asking if the patients are depressed or anxious, the question leads to patient-identified evaluation criteria–a useful tool to evaluate effectiveness.

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Questions for building relationships

We can use questions to help build relationships with our children, coworkers, and even with our adversaries. If children are not behaving in ways that seem appropriate, rather than telling them what they should or should not be doing, a simple question such as, “Was your behavior just now respectful?” or “Is this how you would like someone to treat you?” becomes less threatening, less directive, and allows the child to actively process the situation, working with you rather than obeying out of fear. Asking questions to understand the perspective of colleagues and coworkers leads to less defending, rationalizing, and justifying; it can also bring growth. With adversaries, questioning to understand rather than arguing or criticizing can be a way to acknowledge and open up dialogue rather than create conflict. When inclined to criticize or blame, try asking a question instead.

Asking more questions is the heart of what a healthy relationship is all about. It shows an eagerness to learn about the other and to have them tell their story. Our questions can let our patients know that we care; we care not just about symptoms and diseases but also who they are and what they need. It is easy to get wrapped up in our own agenda, our own story. Instead, ask questions to understand and listen. This will lead us to the heart of what really matters, beyond judgment and toward growth. I believe everyone is seeking meaning in life, a purpose, a reason to live, but unfortunately, many people struggle with this. Through asking questions, we convey interest and importance to others. It can be life giving for both patient and clinician. This is what our patients need, and this is a part of what NPs do so well.

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1. Katon W, Sullivan M, Walker E. Medical symptoms without identified pathology: relationship to psychiatric disorders, childhood and adult trauma. Ann Intern Med. 2001;134(9 Pt 2):917–925.
2. Felitti VJ. Adverse childhood experiences and adult health. Acad Pediatr. 2009;9(3):131–132.
© 2014 Lippincott Williams & Wilkins