by Carolyn Thomas ♥ @HeartSisters
“When I was in medical school, I was always told to question what was taught – even by the teachers who taught it to me. That was amazing!”
Amazing, indeed! Questioning everything your teachers tell you may seem risky, but that observation from veteran cardiologist Dr. Milton Packer about his own med school experience feels oddly encouraging even to non-students like me. I’m naturally curious, skeptical, eager to learn, and sometimes a pain in the neck to physicians who may not be as open to questioning as Dr. Packer is! .
Dan Rothstein would echo Dr. Packer’s perspective. He is the Co-Director of The Right Question Institute (RQI), and co-author of the book Make Just One Change: Teach Students to Ask Their Own Questions (Harvard Education Press, 2011). In his essay called Lessons from a Harvard Medical School Conference on Medical Education, he writes:
“Medical students need more than information. They need to learn to think well. Information will, of course, still be important, but any knowledge – informed even by a vast amount of information – must be used to shape good thinking. And good thinking is a complex task.”
The Right Question Institute (RQI) is an American non-profit society that began decades ago as a school dropout prevention program. The students’ parents were often hesitant to participate in their kids’ education because they “didn’t even know what to ask.” Being confident about asking questions, according to RQI, can enable people not only to become more effective advocates for themselves and their families, but ‘to become active citizens participating in all levels of society.”
The keynote speaker at that Harvard medical education conference was Dr. Ronald Epstein of the University of Rochester School of Medicine, who had this take on education:
“So much of education in general, not only medical education, has been based on a model in which the ‘wiser’ and more ‘knowledgeable’ person asks questions of the ‘less wise’.”
Flipping that model to encourage med students to question their wise teachers may impact not only their medical education, but their future patients after they graduate. Asking good questions of medical school professors may subsequently lead to asking good questions of their patients one day.
RQI even suggests that you’re never too young to learn the value of asking good questions in life, no matter who you are. When RQI staff asked a group of Detroit first graders,“Why do you think we ask questions?”, for example, one child named Akaya shared: “So we can be curious about what we are learning and want to know more.”
What an answer! Akaya has the same attitude about asking questions that I do!
Wouldn’t you love a physician who was curious about learning and wanted to know more about you? And wouldn’t a physician with those skills welcome a curious patient’s questions?
Dr. Epstein gives specific examples of the kind of self-reflective questioning he wants his med students to consider, such as:
“What are you assuming about this patient that might not be true?”
He admits that this is a question that can sometimes stop both students and their teachers in their tracks. A person with what he calls a “rigid personality” neither wants to ask reflective questions – nor to be asked such questions by others.
Speaking of “rigid personalities” who do NOT like being questioned. . . The Emergeny physician who misdiagnosed my textbook heart attack symptoms (central chest pain, nausea, sweating and pain down my left arm) had sent me home with a dismissive“You are in the right demographic for acid reflux!”) He did not make eye contact. He did not introduce himself to me. This doc didn’t see any need to ask me questions, because he’d already made up his mind, and because I was clearly wasting valuable space in his Emergency Department, and because he’d already told me that all I needed was to get a prescription from my family doctor for antacid drugs.
And even worse, a few minutes after he’d left my curtained-off cubicle in Emergency, one of the Emerg nurses walked over to my bedside and scolded me quite sternly:
“You’ll have to stop asking questions of the doctor. He is a very good doctor, and he does NOT like to be questioned!”
I felt stunned and humiliated by this scolding. I couldn’t get out of there fast enough. And when my cardiac symptoms returned (which, of course, they did!) there was no way I was going to return for more humiliation to that Emergency Department – until those symptoms became unbearable.
By the way, the only question I’d had the gall to ask that doctor was this: “But what about this pain down my arm?” (I’m not a doctor, but even I knew at that moment that arm pain is NOT a sign of indigestion).
Dr. Epstein believes that such “maladaptive personality traits are reinforced in the first two years of medical school because there are right answers to every question most med school professors ask. But when people who do really well in the classroom hit the hospital wards, we sometimes get messages that they are clearly not well suited to providing medical care.”
When interviewed by McMaster University cardiologist Dr. Harriet Van Spall in a 7-part series of short videos called A Masterclass on Building a Legacy , Dr. Milton Packer was asked about lessons he’s learned over his long career in cardiology. For example:
“All through my medical training, my tendency was to think of things differently. I always teach young cardiologists that if you want to succeed, you must challenge the status quo, not reinforce it. Never assume that what you are taught is correct. The goal is to think of things differently.”
“Never assume that the status quo represents the whole truth. It does represent some truth, some fiction, some story-telling, but the worst thing a person can do is to spend time reinforcing the status quo. There are already enough people who do that!”
Reading Dr. Packer’s words on being willing to challenge the status quo reminded me of some of the uncomfortable questions I’ve been asking physicians for years.
There are at least two favourite questions which I feel compelled to keep asking. Each requires “thinking things differently”, as Dr. Packer teaches. They are:
Question #1: When will doctors decide to change the hurtful name of heart FAILURE? Once a patient hears a physician say out loud those cruel words “Your heart is FAILING”, they cannot be unheard, no matter how doctors try to re-embroider that hurtful name by explaining they don’t really mean “FAILING”. But if you don’t mean it, then why keep saying it? (And remember what Dr. Packer said about people who want to maintain the status quo!?) Words do matter. In recent years, more cardiologists, thank goodness, are now asking that same question, too. See also: Is it Finally Time to Change the Name ‘Heart FAILURE’?
Question #2: When will medicine require mandatory reporting of diagnostic errors? Nobody knows how many women like me have been misdiagnosed in mid-heart attack and sent home – because doctors are NOT required to report diagnostic errors. A societal shift toward mandatory reporting of diagnostic errors is a public safety issue. If implemented, it would happen just as workplace safety, highway safety, aviation safety or any other public safety protocols that already require mandatory reporting of adverse events must do in order to protect future victims. But we cannot improve what is not even measured. See also: Mandatory Reporting of Diagnostic Errors: “Not the Right Time?”
Sometimes asking these questions (here in my Heart Sisters blog articles, on social media, onstage at medical conferences, or in real life conversations with doctors) can feel uncomfortable for me, a lowly heart patient. But I’m reminded of Audre Lorde’s words – in which she wrote: “My silences had not protected me. Your silence will not protect you.” And in another poem I love, she wrote these words:
“If we speak we are afraid
that our words will be used
And if we do not speak
we are still afraid
So, it is better to speak. . .”
Image: Pete Linforth, Pixabay
Q: Have you ever felt reluctant to ask certain questions you now wish you’d asked?
NOTE FROM CAROLYN: I wrote much more about doctor-patient communication in my book “A Woman’s Guide to Living with Heart Disease (Johns Hopkins University Press). You can ask for this book at your local library, your favourite bookshop (please support your independent booksellers) or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from Johns Hopkins University Press (and if you use their code HTWN, you can save 30% off the list price when you order).
6 thoughts on “Will asking good questions in med school help doctors ask good questions of patients?”
After 74 years of living and dealing with every kind of professional from Insurance agents to Cardiac Surgeons… I am finally learning to recognize the professional with a “rigid personality”.
I used to question myself, what’s wrong with me? Why do I feel intimidated, or that I am not welcome to ask questions? Now I realize I am NOT the problem. I generally read about my problems, learn as much as I can if I am able, and then I ask fairly intelligent questions.
The problem is not my question – it’s the doctor or the insurance agent that doesn’t care to listen.
The emergency room is a very difficult place to do this “intelligent questioning” when you are in a vulnerable position and the choice to leave is not an option. That’s why, when feeling vulnerable and not at your best, it is a blessing to take a strong advocate with you to MD appointments and to the ER. But of course that is not always possible.
When I am in an “able” position rather than a “vulnerable” position, I can make a choice not to work with the rigid personality, like my most recent choice to get a different cardiologist.
If I get a rigid customer service rep on the phone, I often hang up and call back hoping to get someone more interested in helping me.
Doctors are taught they are experts and that they need to come across as confident. True confidence is not rigid, it welcomes questioning.
When doctors start thinking “What does this patient need to know to decrease their anxiety and suffering?” rather than thinking only, what do I need to tell them as the expert in the room? – conversations can be more valuable. If you relieve a patient’s anxiety before you give them huge amounts of technical information, they will ask more questions and learn more from the MD.
We also need to be confident enough to look a doctor in the eye and say “I am afraid, I am worried and nothing you are saying makes sense. Let me ask you a few questions before we continue.” We can own our vulnerability as well as our strength. Calling on the rigid expert in the room to soften up and listen.
Happy Mothers Day 🌷
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Happy Mothers Day 🌷 to you too, Jill.
You make so many sound points. I especially loved your statement “True confidence is not rigid, it welcomes questioning.” I’m going to go embroider that on a pillow. . .
The current hierarchy in medicine (generally: doctor/expert way up there, us way down here) is structured to make us feel intimidated or even inappropriate if we don’t show the proper level of deference. Lots of research out there on the perils of being viewed as the ‘difficult’ patient. But you’re so right: we do own our vulnerability because we ARE vulnerable when we decide we need to see a doctor.
Reminding our docs that “I need your help here…” can sometimes interrupt that flow of reflex tech info. I remember my late mother returning from her many doctor visits with absolutely no clue at all when we asked her “What did the Doctor say?”
But I know that she had smiled and nodded throughout each visit as if she understood because she did NOT want to be “difficult” or (worse!) “waste the doctor’s time!”
I now place my trust in med students who will one day be practicing medicine.
Take care, Jill . . . ♥
I have heart issues in my mom’s side of the family. Heart disease and I don’t have the usual symptoms of heart problems.
I usually get jaw, back pain and feeling sick to my stomach. My vitals are all good and EKG as well. The last time I had a stent put in 2017; those were the symptoms I had.
For women, we don’t have symptoms like men do. Some do and some don’t.
Good article about how Doctors should speak to their patients, and what kind of questions to ask.
Hello Judith – your case is a puzzle for your doctors: e.g. “normal” test results plus symptoms that COULD be blamed on many other non-cardiac causes – unless the doctor is well-informed about women’s heart disease.
I suspect that many women presenting with your symptoms and those test results would have trouble getting a correct diagnosis.
You lucked out!
Take care. . . ♥
Carolyn, another thought-provoking article. I was reminded that in some hospitals, staff are required to report “near-misses” and not just errors (i.e. while transferring a patient from bed to chair, they almost fell….).
Perhaps doctors when submitting their billing info could be required to answer a question like Should I have done things differently?
Hi Louise! The Institute of Medicine report specifically argues for what you suggest too: reporting of three kinds of close call errors (e.g. all harmful errors that were intercepted BEFORE harm was done, errors that did NOT cause harm, and NEAR-MISS errors that are considered “as important as reporting the ones that do harm patients.” If this were the airline industry, every close call would be thoroughly discussed and investigated to help prevent future close calls – and to protect public safety. That’s the only way to improve the way things are done – to catch problems (like your excellent example of ‘almost falling’) to figure out ways to make patient lifts and transfers safer.
My question is still: Whose responsibility is it to report these close calls when the reality is that reporting them is not even a requirement?
I’m 100% sure that the Emergency doctor who sent me home in mid-heart attack didn’t give that misdiagnosis a second thought after I left the building, nor was he (or his boss) notified of that misdiagnosis by the other Emerg doc who learned of my that misdiagnosis two weeks later when I was finally admitted. I wonder how many physicians would voluntarily answer a question like “Should I have done things differently?”
Thanks for sharing your thoughts here!
Take care. . . ♥
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