On Call Magazine, November/December 2006

By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting

“Do you have any questions?” the provider asks. The patient shakes her head, indicating “no.” While the provider might assume this response means he did a good job communicating, the patient may think this is a polite way of not saying how confused she really is. “Asking questions is one of the most difficult tasks patients face,” says Lisa Bernstein, executive director of the What to Expect Foundation, based in New York City. She explains that asking questions is a learned skill, not an innate ability. For patients to ask, Bernstein says, they must be fluent in medical vocabulary, understand basic biology, and have enough confidence to speak up to respected health professionals.

According to Laurie Scudder, a member of the board of directors of the Partnership for Clear Health Communication and Ask Me 3 initiatives based in Washington D.C., patients need to ask about what they need to know. Asking questions, Scudder says, empowers patients. “Medical information is hard for everyone to understand, regardless of their education or literacy level. Patients can’t be expected to understand information critical to their health unless they are able to ask questions and have these questions answered.”

Anne Sage, RN, agrees. As a staff nurse in radiology at the MetroWest Medical Center in Natick, Massachusetts, she works with patients having angioplasties or other radiological procedures. As a member of the treatment team, Sage must confirm that patients understand the procedures they are about to undergo. One way Sage does this is by asking and answering questions. But sometimes patients are reluctant or unwilling to speak up. Sage attributes this reluctance, in part, to generational differences. “Many older patients were brought up to believe that the doctor is always right.”

Bernstein, Scudder, and Sage know how beneficial asking questions can be, and they have a lot of advice to offer regarding strategies providers can use to make this task easier for the patient.

Offer reassurance. While providers may feel quite comfortable in healthcare settings, these environments can be very frightening and overwhelming to patients. Sage helps patients feel more at ease by letting them know that they can ask any question they want. When patients sheepishly admit they have some “stupid questions,” Sage reassures them that there are no “bad” (she prefers this word to “stupid”) questions. Indeed, in her more than 40 years of practice, Sage really has heard all the questions before.

Ask as well as answer. When patients have no questions, Sage asks some of her own. For instance, when a patient comes in for an angioplasty, she might ask “Do you know why you are here?” If he answers (as many patients in this situation do) “Because of a bad leg,” Sage then follows up with more specific questions. These may focus on recent symptoms or the patient’s understanding of angioplasty. Sage finds that this question-and-answer format invariably leads to a fuller discussion about the upcoming procedure.

Encourage patients to use the Ask Me 3 technique. Ask Me 3 is a quick and effective tool to help patients improve communication with their healthcare provider. It gives them three simple questions to ask and encourages their use in every interaction between patient and provider, according to Scudder. The questions are:

• What is my main problem?
• What do I need to do about it?
• Why is it important for me to do this?

Ask Me 3 questions, Scudder says, are well received and useful to both patients and providers. Recent studies show that Ask Me 3

• adds structure to provider-patient communication
• increases patient satisfaction with each visit
• decreases the number of missed visits
• reduces the number of call-backs (patient calls for clarification or more information)
• does not add significant time to the length of patient visits

Prepare commonly asked questions. Bernstein works with providers at prenatal clinics who often see women with limited education or literacy and language skills. Frequently, these women are reluctant to ask questions. One communication strategy that Bernstein recommends is for providers to prepare questions that women commonly ask in routine prenatal visits. Then, when a woman says she has no questions, the provider can readily say “A lot of women in their (x) month of pregnancy ask about ___. Is that a question you want me to answer?” Bernstein finds that doing so starts a dialogue about important health information and also models good question-asking behavior. “Good questioners come up with new questions after they get some answers,” she says.

Similarly, FAQs (Frequently Asked Questions) can be helpful in print materials. But Bernstein cautions that written questions alone are not sufficient. “Just handing someone a brochure with FAQs without going over them together is useless because brochures are frequently thrown away. It is important to review the material together rather than speaking at a person and then, when finished, handing her a brochure.”

Help patients come up with their own questions. It is not just health professionals who can help patients ask questions. Friends, family, and volunteers can also assist. For example, when Bernstein’s friend was scheduled for surgery, she helped her come up with questions to ask. One way was by asking what her friend was most afraid of. When the friend said anesthesia, they together came up with questions such as “Will I have general or local anesthesia?” and “How long will I be under?”

Having seen how well this friendly assistance works, Bernstein now places volunteers in clinic waiting rooms. The volunteers are trained to help elicit, not answer, patients’ questions. They introduce themselves to patients by saying, “This appointment is for you. It is a time to get all your questions answered.” Then, as Bernstein did with her friend, the volunteers help women formulate their questions. After appointments, the volunteers meet again with the women to make sure all their questions were answered.

Encourage patients to write down their questions. It is hard for almost all patients, no matter how well educated and articulate they are, to think of questions to ask. Sage talks of her own experience leaving a doctor’s office and then thinking, “I should have asked about ___.” Providers can help by encouraging patients to write their questions ahead of time. This can be done by putting pens and paper in the waiting room, having space for questions on instruction sheets, and posting sample questions on Web sites, and, consistent with good patient practices, providing lists of credible resources so that patients can continue to learn and ask more.

Ways to learn more:

• Lisa Bernstein is the executive director of the What to Expect Foundation. You can reach her at lisab@whattoexpect.org
• Anne Sage, RN, is a staff nurse in radiology at the MetroWest Medical Center in Natick, Massachusetts.
• Laurie Scudder is a member of the board of directors of the Partnership for Clear Health Communication and Ask Me 3. You can learn more by emailing her at askme3@fleishman.com

Ask Me 3. Providers can obtain free Ask Me 3 kits with posters and brochures in English or Spanish. Since the initiative began three years ago, more than 1 million educational brochures have been requested by health systems, hospitals, outpatient clinics, schools, libraries, senior centers, insurance companies, and industries across the U.S. and Canada. To learn more, go to the Ask Me 3 Web site at http://www.askme3.org