A physician once saved my life with a question, or more precisely, with two questions.
I had been short of breath for several months. Because I had had some cardiac problems in the past, I called my cardiologist. He thought it sounded like a slight worsening of my mild asthma, and reassured me. As the weeks passed, I had good days and bad, and sometimes I worried more and sometimes less. At some point I organised a chest X-ray and an electro-cardiogram for myself, and I also saw my GP. The tests were normal, there were no physical signs of anything, and the message was one of unconcerned uncertainty. Then one day I could not walk to the shops at the end of the road without stopping. My wife thought that my lips were now slightly blue. She insisted that my GP should send me to hospital.
In the back of my mind I had a nagging fear that I was having pulmonary emboli – clots on my lungs. In any logical sense, this seemed absurd. I had none of the classic symptoms of this, such as pain in my chest or legs, or coughing up blood. I was generally fit, and had not gone on any long flights that year that might have caused such clots. But my mother had died of a pulmonary embolus during a hospital admission. Also, for the first time in my life, I was unaccountably having dreams about her brother, who was murdered by the Nazis as a teenager – almost certainly by cyanide asphyxiation in Auschwitz. I had not known him, and she had virtually never talked about him.
I saw a chest physician who could not have been more thorough, but it was clear from her questions that pulmonary emboli did not figure remotely in her thinking. All the same, when she had finished examining me, she asked, ‘Have you come up with any diagnosis yourself ?’ Sheepishly, and with the slight fear of ridicule that comes with not being a specialist, I told her of my specific anxiety. She then asked one further question, ‘Does that mean you’d like a lung scan to reassure you?’ I said yes. Three days later it was done, and showed I had already lost twenty-five per cent of my lungs to clots. ‘You’re a very good diagnostician,’ she said, graciously. I never told her about the bad dreams.
At medical school, we are taught meticulously about the importance of asking the right questions. Yet in our subsequent careers we often forget two of the most crucial ones: ‘What do you think you’ve got?’ and ‘What would you like me to do?’ As my physician demonstrated, the art of questioning clearly needs to go beyond the dry litany of formal history-taking and should embrace the patient’s view as well. When we remember this, we nearly always save our patients many sleepless nights, and sometimes we save their lives too.
The art of questioning may go further still. One of the most challenging researchers ever to have looked at questions in consultations is the Canadian psychiatrist Karl Tomm. He talks of conversations between professionals and patients as being treatments in themselves. He doesn’t mean this in the relatively banal sense of offering reassurance or empathy. Instead he talks about ‘questions as interventions’. He suggests that the chief purpose of clinical questioning is not primarily to pin problems down, but to try and redefine and resolve them through the conversational process itself. As a result of his researches, Tomm has proposed ways of using questions in order to call forth new and unexpected expressions, memories and ideas from the patient, including ones that they might otherwise not have expressed, or even thought. Although Tomm is writing principally about consultations in mental health clinics, his approach to questioning may have equal application to medical contexts. One way of describing the kind of clinical interview that he recommends is as ‘conversations inviting change’ – a term I have adopted to describe the approach to consultation skills I mainly teach.
Tomm’s original paper on questions has a stupefyingly off-putting title and it appears in a journal that few doctors will have heard of. Nevertheless, I would say that it has influenced my professional behaviour more than anything I have ever read – and almost as much as the two questions my chest physician asked that saved my life.