Objection, Your Honor!

A few years ago I was training a new hire.  We were sent to a chest pain call where we found the fire department caring for a middle-aged man.  The trainee walked up to him and asked his first question: “Sir, do you have chest pain?”

“Objection!” I said quickly.

“Sustained!” said two firefighters simultaneously.  That’s awesome.  I love good comedy.

They're never unanimous… (Public domain photo)

What was the issue?

The issue, at least the one I want to write about now, is a common error that I see.  Actually, I hear the error.  It is asking leading questions. 

Leading questions, for our purposes, are questions that can be answered either yes or no.  "Do you have chest pain" is answered 'yes' or 'no' (or 'I don’t know', but if they don’t know that is a whole different rant).  There are two problems with leading questions.  First, a leading question doesn’t facilitate a conversation as well as an open-ended question.  Conversation is good for us – it allows us to get more detail, bond with our patients, and allow the chance for information that we didn’t ask for to be volunteered.  Second, like an unwary Jedi, you can unintentionally lead a patient to answer questions the way they think you want them to be answered.  You are leading them to the answer.  It can be due to people attempting to make sure you pay them attention, or people trying to give you the answer they want you to hear.  Whether it is for good or bad reasons, you are essentially leading them to the answer.  Picture where you would end up if each of these questions were answered in the affirmative:

Do you have chest pain?

Does it radiate to your left arm?

Is it causing you shortness of breath?

Are you nauseated?

Does the pain feel like an elephant sitting on your chest?

The way to avoid leading questions is simple.  All you have to do is start each question with one of the six “journalism questions”: Who, What, Where, When, Why, How.

“How does your chest feel?” can’t be answered with a yes or no.  Neither can “How is your breathing? Why did you call 911 today? How is your stomach doing?  What does your chest discomfort feel like?  Where is the discomfort located?  What would you have to do to me to get me to feel the same way?”

If you start each question with who, what, where, when, why, or how you will be ahead of the game.  How many times have you asked a patient, “Do you know your social security number?” and gotten “Yes” as an answer?  Frustrating, isn’t it?  Replace the ‘do’ with a ‘what’: “What is your social security number?”

Good supervisors will use this on you (at least I did).  “The patient said you were a jerk.  Is that true?” is a dumb question – it is begging for a ‘no’ accompanied by a facial expression that appears to be holding up a halo.  “What happened on that call after you arrived on scene?” is a better way for the supe to phrase it because it is open-ended and without prior assumptions.  By the way, avoiding leading questions also works well when dating.  Remember, the journalism questions are conversation starters:

Me: “Do you work near here?”

Hottie: “No.”

[cricket  cricket  cricket  then I run]

There are three main caveats to the No Leading Questions rule.  First, people in extremis who are 1-2 word dyspneic (or aphasic for whatever reason) are not known to be good conversationalists.  You have a limited amount of time to ask 3-5 questions before they get things placed in their mouth (or between their vocal cords).  Don’t be afraid to ask direct leading questions then.  “Are you asthmatic?  Are you getting tired of breathing?  Do you want me to take over that work for you?”

The second caveat comes up when the open-ended question isn’t working.  For example, I have had this conversation seemingly a thousand times:

Me: “What does your chest discomfort feel like?”

Patient: “I don’t know, it just hurts.”

Me: “I understand, but what would you have to do to make me feel the same way?”

Patient: “Are you an idiot?  I told you, it hurts.”

What we have here is failure to communicate.  In this case, I feed the patient the answers that I am looking for, but it is important that I shotgun a lot of choices at them.

Me: “What I mean is, is it sharp, stabbing, aching, cramping, crushing, burning, dull…”

Even if they start to answer, I try to get through all of my choices.  That way I am not leading them to agree with the first option.  A lot of times, a light bulb comes on over their head and they give me an answer.
Patient: “Oh, I see.  Kind of a dull ache.”

The third caveat is when I am trying to specifically rule something important out.  I had a patient a few weeks ago with ST elevation on his ECG, along with bigeminal multiform PVCs.  His ECG from two weeks before had neither of those concerning findings.  After getting “Fine” in response to several variations to the “how is your chest” question, I really wanted to make sure that we were speaking the same language.  I wanted to know if his chest hurt at all.  At that point, since I gave it a couple of open-ended tries, I asked flat out if his chest felt completely normal.  But I phrased it as: “Let me make sure I understand, because I can be dumb from time to time.  Correct me if I have it wrong.  What you’re saying is that your chest area feels completely normal.  Nothing weird at all, right?”  He said it did.  Weird.  But it can be important to know that his definition of Fine is the same as my definition of Fine.

The three caveats are rare, so if you keep to the journalism questions for the most part you will be doing fine.  Practice asking your questions that begin with did, is, are, and does by using who, what, where, when, why, or how.  

Who, what, where, when, why, and how are your friends.