Better Clinicians Asking Better Questions
Notes from a Family Meeting, Vol. 3, No. 3
George Frame, though burdened with a crumbling spine and crooked knuckles, was himself a fixer.1 He began working as a laborer framing houses about fifty years ago under a Michigan sun more forgiving than his foreman. Since then, he had built his career, slowly earning experience and a good reputation, so that now he was a general contractor managing a well-known residential construction company. He had eased out of building houses in his older age, but still would do big remodeling projects. Although he rarely spoke of his heart, something in him warmed to see that he and his team had taken a ramshackle space and made it beautiful and functional again.
Laura, his wife of equal passion and, he believed, greater strength, had been with him through thick and thin. They had faced near-bankruptcy once, and after that she had helped him figure out how to run a business. She was his right hand in the office. They had been married about as long as he’d been in construction. No kids, but they had borne a thousand projects.
Now, with lonesome rain falling on a lonesome window, George faced a problem he couldn’t fix. He looked up at the gaggle of white coats that towered over him and his wife. The gentle hiss of her ventilator nudged into one of the doctors’ monologues about failing kidneys. There was also something wrong with her toes and a few of her fingers; they were turning black. George struggled to understand. Not that he didn’t understand each of the words the doctor was saying, but that the whole place was bearing down on him, making it hard to focus. He looked at Laura, who seemed to be sleeping though he knew she would rouse neither at his voice nor his touch. What would she say about this? George was the fixer, but she was the miracle worker.
“Wait. What did you say?” George looked up at the doctor. He hadn’t really been listening. He didn’t care about the details, but wanted to re-engage the conversation.
“I said we’ll be able to switch her antibiotics since her cultures came back. We don’t have to use all of these now.” The doctor spoke louder, as they sometimes do when confronted with older folks. George could hear fine, but listening to this was a burden he was struggling to bear.
George nodded. For the past week, Laura’s medical team had been adding and removing medicines with no appreciable benefit that he could see. They said her vitals looked good and George had to agree. The team was adept at pushing numbers up and down in the directions they should go. But if that were the case, why wasn’t Laura awake? Why wasn’t she able to get off the ventilator?
George held her hand, careful not to squeeze the darkened fingers, and let the hum of the ICU overtake the doctor’s voice again. What happens now? What was going to happen to Laura?
In The Phantom Tollbooth, Norman Juster tells a story about a boy, Milo, who adventured through a land divided over words and numbers. Two kings, one in Dictionopolis and the other in Digitopolis, had set themselves against each other after they had banished the Princesses of Rhyme and Reason. On his journey to rescue the princesses and restore wisdom, Milo and his companions encounter a strange, twelve-faced person called the Dodecahedron. After having a conversation in which the Dodecahedron proposes a series of absurd hypothetical situations where mathematics features prominently and indispensably, Milo observes that all of it was, indeed, nonsense.
The Dodecahedron balks: “If the answer is right, who cares if the question is wrong?”
Returning to the real, although often no less absurd, world, this seems to be a guiding principle of so much medical education. As a result, it’s the guiding principle of so much medicine. We’re replete with right answers, and deficient in right questions. Indeed, in medicine, we’re afraid of wrong answers. For good reason, too: wrong answers can be deadly. We fail to appreciate, though, how harmful wrong questions can be.
I enjoyed caring for patients like Laura and family members like George when I was a resident in the ICU. Well, to put it more accurately, I enjoyed intervening on (caring for?) the pathophysiology carried by patients like Laura as family members like George watched on. There was such a depth and breadth of disease. It felt like all the detailed physiology I had learned in medical school really counted for something in the ICU. We had some medication, procedure, or bit of technology that could monitor or modify almost all of it. But it was the panoply of ill-fitting right answers that nudged me toward palliative care, a discipline that usually asks different kinds of questions altogether.
Nowadays I sit with questions as often as I do answers.
What Questions?
Neil Postman observed that, “Questions […] are like computers or television or stethoscopes or lie detectors, in that they are mechanisms that give direction to our thoughts, generate new ideas, venerate old ones, expose facts, or hide them.” Questions can be more powerful than answers, for they set the frame in which certain answers are possible or impossible, reasonable or unreasonable, helpful or harmful. Answers can be disputed, but questions set invisible boundaries in our minds. Finding answers is hard; finding questions, especially good questions, is harder. This isn’t necessarily because they’re hidden, but because they must first find us. The really important questions reach out for us as we stumble in the dark, pulling us back from a ledge or pushing us forward into the light.
Matthew Crawford picks up on this elusiveness when he describes the ambiguity of real world problems:
“When you do the math problems at the back of a chapter in an algebra textbook, you are problem solving. […] In such a constrained situation, the pertinent context in which to view the problem has already been determined, so there is no effort of interpretation required. But in the real world, problems don’t present themselves in this predigested way; usually there is too much information, and it is difficult to know what is pertinent and what isn’t. Knowing what kind of problem you have on hand means knowing what features of the situation can be ignored. Even the boundaries of what counts as ‘the situation’ can be ambiguous; making discriminations of pertinence cannot be achieved by the application of rules, and requires the kind of judgment that comes with experience.”
Questions serve as a filter to help us determine what warrants attention. Because questions are formed at such a basic level, we often don’t know what we’re missing when we don’t ask certain questions. So, for example, American clinicians often don’t ask about the financial impact of their recommended therapies - this is improving, but it’s still much the case. But these clinicians haven’t chosen not to ask these questions; rather, they ask many other questions that they deem important and, outside of that, otherwise don’t know what they don’t know. The clinical encounter is constructed in a way that these clinicians just don’t see money factoring into their biologically-oriented clinical decision-making. Light can help us see and can blind us; the same is true for questions.
This starts with learning how to ask questions and what questions to ask, earlier than medical school but certainly continuing there. Postman remarked that in modern education “students are restricted to […] the process of memorizing (partially and temporarily) somebody else’s answers to somebody else’s questions.” This is how we learn to be citizens of any country or culture, not just medicine. We follow in the footsteps of those who came before us, receiving as established fact those things that were hard-wrought discoveries for others. This is a problem, according to Postman, because learners don’t actually learn how to learn; they just learn to consume information.
This is the way a lot of education must be, though. Before coming to medical school, I knew very little about how sodium was managed in the body. Once there, I was taught about hypo- and hypernatremia, how to diagnose these conditions, why they’re harmful, and how to treat them. These weren’t my questions; they were questions I was told I should care about, if I was going to be a good doctor. And I came to really care about them.
Questions for Me, Questions for You
A problem arises when we stop there, though. A foundational question that guides the formation of new questions is, “Why do we care?” New questions in medical training are primarily formed in response to problems with the human body or, more cynically, by figuring out what’s going to be on the test. I came to care about sodium disorders because they could be debilitating or life-threatening (and they were on the test). I taught my patients to care about sodium too. It wasn’t the number itself that mattered (it was, after all, only a number), but what that number represented. But should clinicians care only about pathophysiology? If not, should their concern intrude into every corner of someone’s life? Health is, after all, the means through which we experience anything else. Every human experience relates in some form to health. Where do we draw the line?
To figure that out, let’s go a bit deeper. Alasdair MacIntyre reminds us that there are more foundational questions still: “I can only answer the question ‘What am I to do?’ if I can answer the prior question ‘Of what story or stories do I find myself a part?’” Questions are often the beginning of a story, or, more often, someone’s induction into a story that has existed long before they got there. The thousands of questions I’ve inherited, asked, and answered on tests, with other clinicians, in classrooms, in workrooms, in call rooms, on rounds, and with patients have shaped me to see the role of medicine, and my role in it, in a particular way.
MacIntyre continues:
“We enter human society […] with one or more imputed characters - roles into which we have been drafted - and we have to learn what they are in order to be able to understand how others respond to us and how our responses to them are apt to be construed. It is through hearing stories about wicked step-mothers, lost children, good but misguided kings, wolves that suckle twin boys, youngest sons who receive no inheritance but must make their own way in the world and eldest sons who waste their inheritance on riotous living and go into exile to live with the swine, that children learn or mis-learn both what a child and what a parent is, what the cast of characters may be in the drama into which they have been born and what the ways of the world are. Deprive children of stories and you leave them unscripted, anxious stutterers in their actions as in their words. Hence there is no way to give us an understanding of any society, including our own, except through the stock of stories which constitute its initial dramatic resources.”
Stories work with questions to help set boundaries for our roles and identities so we know what we should do and become. They’re mutually reinforcing: stories make sense of and give us questions, and questions help to tell the stories. A powerful story can also bury previously compelling questions. Likewise, powerful questions can shift or even rewrite previously compelling stories. For George, part of the burden he felt in the ICU was the weight of the clinicians’ biologically reductionistic questions bearing down on the greater concerns of his “merely human love,” to borrow a description from Wendell Berry. That tension sometimes resolves itself in the rewriting of a story: families become more biologically focused than even the clinicians as they cope with their dilemma using medical information.
Without a clear story, we become overwhelmed. We can be swept away into the all-encompassing tale of bureaucracy. Bureaucracy, helpfully described by Postman, is a “coordinated series of techniques for reducing the amount of information that requires processing.” The need to manage information is so great, in modern life and certainly in modern medicine, that bureaucratic, technical management has become the default strategy. Question-management (who can ask, who to ask, what can be asked) becomes a major instrument of the bureaucracy.
Not only does bureaucracy help to filter information but it also helps to form one’s identity. We’ve known for decades that the formal curriculum of medical education, including inspirational graduation speeches, “how to be a doctor” courses, and humanistic perspective pieces in academic journals, is in tension with the “hidden curriculum” of cultural formation that occurs on rounds and in the workroom. This creates distress. That distress can be resolved in reforming the clinician’s identity into a technician. The technical identity is very helpful because it sets narrow boundaries for what’s within the clinician’s purview. But the identity has at least two trade-offs: you risk becoming a robot, and you may ask a bunch of wrong questions (even if technical prowess leads you to a bunch of right answers).
If bureaucracy and the technical identity are insufficient for helping people pursue health, what’s the more compelling story that helps us ask more compelling questions?
Curious Clinicians
How can clinicians walk the line between being overly reductionistic (“I’ll only care about sodium disorders and never a social determinant of health or an existential crisis”) without being overly intrusive (“Everything submits to measurement and management because everything is mediated through health”)? If we were able to uncover a list of better questions, maybe that would help. However, I worry that asking the wrong questions is a symptom of a deeper issue, which I’ve alluded to in this circuitous discussion about identity and stories.
Instead of supplying a list of questions, let me describe how we might set ourselves up to frame those better questions ourselves. I’m not trying to be evasive by avoiding such a list. I worry that the desire for one (and I want one too) arises from the same technical impulse that pulls clinicians into the aforementioned bureaucracy and about which I’ve written before. If we had a list, then we could standardize this whole process, but standardization would undermine the whole project. So, here’s where I’m going instead.
Warren Kinghorn, relying on Aristotle, identifies two ways of thinking about moral formation in medical education: techne and phronesis. Techne is the capacity of knowing how to do something, like baking bread or managing hyponatremia. Phronesis is “practical wisdom.” Kinghorn explains that, “if techne is practical reason leading to production […], phronesis is practical reason leading towards action […] Unlike techne, therefore, the function of phronesis is not to make or produce anything, but rather to guide human action in a particular way…” That particular way is toward human flourishing or, as Aristotle called it, eudaimonia, of which health is a part.
Phronesis is one virtue among many, with all the virtues (like compassion, courage, honesty, loyalty, patience, and so on) reinforcing one another to guide action. Some people are put off by the moralistic undertones of the lingo here, but virtues are simply those qualities of character that one requires to pursue the good of a practice. So a clinician needs practical wisdom (among other things) to pursue their patients’ health. Practical wisdom isn’t necessary, though, if the purpose of medicine is technical manipulation of the human body for the sake of efficiency and wish fulfillment. In such a world, techne is all that’s required and all that’s taught.
We use phronesis to identify those questions worth asking. Some of those questions will require techne; there will never be a shortage of sodium disorders that need careful management. But the ever-present temptation is to reduce medical practice to mere technique so we can avoid bigger questions that require phronesis (or any virtue at all, really). This way we can produce medical trainees like we would hope to manage pathology: algorithmically, in standardized fashion, efficiently. We avoid stickier questions about intangible things like goodness and focus on far more concrete aspects of reality like creatinine and cerebrospinal fluid.
So, sometimes we’ll find ourselves huddled outside the room of a person dying in an ICU, someone like Laura, discussing what we should do about her insulin and whether we should tinker with her ventilator settings. In one context, those may be the most important questions we could be asking. In another context (probably the one in which we’re huddling), those questions become distractions from the larger questions of what it means to actually pursue health even as someone is dying.
I don’t think our work, then, is to cobble together a list of better questions, published and taught to medical students. I think our work is to help clinicians become the types of people who can pursue good and, in the case of medicine, their patients’ health. Questions will be both formative and expressive of that growth. Inevitably, this will involve awkwardness and error, but it’s worth it. Later on in Juster’s The Phantom Tollbooth, one of the famed princesses tells Milo that we “often learn more by being wrong for the right reasons than [we] do by being right for the wrong reasons,” which is a clever response to the Dodecahedron’s earlier rhetorical question. Can we risk being wrong for the right reasons?
Trajectories
Following a meandering reading-path, sharing some brief commentary along the way.
“The Doctor’s Art: Ethical Dilemmas in the Hospital”
Tyler Johnson and Henry Bair host a podcast where they discuss meaning in medicine with their various guests. On this episode, they start out discussing medical ethics with David Magnus. He highlights the importance of language in ethics, as well as how specialization has contributed to clinicians’ loss of connection with their patients. Rather than caring for people, sub-specialized clinicians come to care for organs or diseases. Medicine’s greatest strengths become its greatest weaknesses as it’s transformed into what Neil Postman would call a “technopoly.” Faced with information glut, technopolies allow us, in this case, to break very complex people down into their more digestible parts and diseases. Medicine thus shrinks back from its greater moral aspirations and instead focuses upon technical intervention upon anatomy and physiology. Even language becomes co-opted in this technical endeavor.
Mark Twain reportedly said, “It ain’t what you don’t know that gets you into trouble, it’s what you know that just ain’t so.” So it is when we think we know what we mean when we speak. These authors discovered that patients and physicians come to different conclusions about the word “treatable” means: either it means “good news” or it simply implies action is possible, respectively. Here they develop more of the linguistic theory behind what’s going on: “Physicians assume that treatability statements are made to communicate that something can be done, and to clarify what that is. […] In contrast, patients assume that treatability statements are made to provide news about a patient’s future; treatment is conceived of as inherently beneficial, making a substantial difference for a patient’s life or experience in terms that matter to the patient. […] For the physicians, treatability statements emphasize what the physician can do; for patients, they emphasize how the patient will do.”
A speech given by Kristin Collier, a primary care doc at University of Michigan, at their medical school’s White Coat Ceremony. As inspirational as these keynotes are, I inevitably forget them: I don’t remember those given at any of my graduations or other ceremonies. I guess it’s something about the excitement of the moment. Nevertheless, these words are like a nourishing meal. Sure, I might not remember what I ate for dinner years ago, even if it was outstanding, but what I ate kept me nourished. It’s value isn’t necessarily in how easily we remember the details, but how well we integrate its substance into our being. So it is with these keynote speeches. And all the better that Dr. Collier’s words are written down so we can more slowly reflect upon and digest them.
“A father’s wish, a bioethicist’s dilemma”
A beautiful, messy portrait of a family at the bedside in an ICU, struggling to make the best decisions they can for their father. It reminds me of another piece written by Gilbert Meilaender, reflecting on how people often just want their loved ones to make the best decision they know how. They love you, and just want you to do your best. Not all people are blessed to have such people in their lives, which is tragic, but many are.
“Climbing melatonin use for insomnia raises safety concerns”
Lots of people take melatonin for insomnia but it’s just not good for that indication. It also distracts people from what may be other, better interventions (e.g., psychotherapy). I take a very careful sleep history with my patients, as many things can impact sleep, and when sleep is disrupted it can impact many other things. In particular, untreated sleep apnea causes all sorts of problems. Melatonin (or any medication) won’t help that.
“Rituals, death and the moral practice of medical futility”
Providing what clinicians believe to be is futile care can be morally distressing and corrodes rapport with families. The culmination of futile care is futile CPR (though, let’s not forget, CPR is frequently ineffective in restoring people to health beyond mere ROSC). However, these authors argue that CPR and other life-sustaining interventions may provide rituals for families and clinicians to make sense of death. If they’re seeing this rightly, then, part of the way many now construct the dying role is through the medium of advanced technology.
A very helpful GeriPal podcast on a very tough topic. I don’t usually ask about driving as part of my assessment of function, but I’ll start to do so now.
Closing Thoughts
My grandpa had a sayin’ that I got from him, no doubt One day he had me loading hay ‘till I was plumb wore out I said, “If I load any more, this mule will be zigzaggin’!” He said, “Don’t worry ‘bout the mule, now you just load the wagon.”
Junior Sisk, Just Load the Wagon
A fictional case, but woven with the color of experience.