Will asking good questions in med school help doctors ask good questions of patients?

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
against us
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).