Friday, February 3, 2012

Assumptions vs. Directed Questions

It was the first day in PM&R and my partner and I were assigned to interview and examine a 30 yo male. Let's call him Leroy. Right away upon entering the room, we started trying to piece together what was going on, because it seemed odd to us that somebody only 30 should have had a stroke. The interview went rather well, and we both felt that we had obtained a complete history Leroy.

The interview was however, remarkable for how many times my partner and I were surprised by our patients answers to our questions. In fact, the answers surprised us so much in some cases that there were seconds of awkward silence because the question had been framed in a manner that anticipated an answer other than what we got. This was embarrassing at times, but more importantly, it could have easily led to misunderstandings or complete omissions because a patient might feel it's easier to just give an answer that is more expected by the way that a question was asked.

The first one came when we asked about where Leroy had gone to school. I think our question was "when did you finish school?". Now I know it seems obvious that the question is loaded with assumptions, but we slipped over this first hurdle easily. "2003". Quick math. Wow, seems that it took Leroy a while to finish school. "Where did you go?". Leroy- "Arkansas State". Oops, apparently Leroy finished college, and played DI football while majoring in business. Why did that surprise us so much? Perhaps it was the fact that Leroy is unemployed, obese, and African American. How much did we stereotype and then ask questions that fit the stereotype but not reality?

Our next line of questioning was about Leroy's family. "Do you live with anyone?" Leroy - "my cousin and his friend". Do you have a partner, male or female? Leroy - "yes, my girlfriend lives across town with three children". Now for some reason, we both assumed that perhaps they were not his children, but kids from an earlier partner. Then we asked some more about how he got along with his girlfriend's kids. Leroy -"They're my kids". We both paused. Why was this so surprising? How had we made so many assumptions?

We both felt confused after the encounter. We are supposed to use everything in the room to give us hints about who our patient is and what ails him. Yet here every clue we had lead us astray. Perhaps we simply forgot about pre-test odds, and they idea that a hint does not guarantee a corresponding etiology. The solution is obvious: assume nothing. Yet is this possible? Is there enough time to ask about everything without using your other senses to make assumptions and apply reasonable judgements?

The answers to these questions may become clear with more clinical experience. For now, we have decided to apply the lessons of cultural sensitivity more carefully. Mindful listening only works well with mindful questioning.