A paper that changed my practice: The question cube

Abstract

When was the last time you came to the end of a consultation feeling unsatisfied (maybe even a little grumpy), unable to address a patient's problems neatly and unsure what to do next? Our response to patients with persistent symptoms that are proving difficult to treat may be to reconsider our original diagnosis, order more tests or search for a new drug that we have not tried before. Making a referral to a subspecialist or allied health colleague might buy us some time. Or perhaps we should consider an alternative therapist. Having often been in this situation, it was a joy to come across the Question Cube, a paper that changed my practice by offering a more satisfying way of approaching this type of encounter.1 The paper, given to me as part of the introductory reading for a family therapy course, offers practical advice on how to use questions to open up stuck consultations and steer them into previously unexplored areas. The technique is rewarding for the doctor and, if nothing else, may make a pleasant change for the patient. The key message of the paper is that questions, in addition to being used to elicit factual information, can be used strategically in a number of other ways. Most clinicians are familiar with open questions –‘How are you? How have the headaches been recently?’ These allow patients to expand on their symptoms but often along familiar lines and with no guarantee of a tidy conclusion. In these situations, closed questions (‘Have you taken any paracetamol today?’) can contain patients who have little problem talking but with minimal progression in the information presented. Closed questions ('Did the pain wake you during the night?') can also be used to obtain information from patients (e.g. many adolescents) whose typical response is either silence or a shrug. A follow-up is the forced choice question –‘Did you go to school yesterday or stay at home?’ Although the answers to questions such as these are inevitably brief, they do provide specific information. When working with patients who say very little, this is a valuable technique for allowing a conversation to develop. Forced choice questions also enable the clinician to suggest options or alternatives that the patient may not have considered and to test out hypotheses or hunches. ‘Do you think your symptoms been worse recently because you have had a lot on at school or because of problems at home?’ Ranking questions introduce ideas as to how others may be feeling. ‘Who would you say is most worried by your headaches? And who is the next most worried?’ while rating questions provide information regarding the importance or impact of a particular symptom. ‘On a scale of 1 to 10, how much of a problem are the headaches at the moment?’‘If not the headaches, what is the biggest problem for you at the moment?’ The value of these questions is that the answers can highlight issues, such as school non-attendance or the worries of a parent, which may be easier to address than the presenting problem. If you have your fair share of challenging patients but are too busy to enrol in another professional development course, this paper may be just what you are looking for.