The Way You Ask Questions Matters, Doesn't It?

I've been a nurse practitioner since 2011, and in that short time, my practice has shown me over and over that how I ask my patients questions matters. A lot.

I've had patients who have had the grace and understanding to tell me when I've asked questions in a way that lands as insensitive or culturally unsafe. And I know that for each patient who has told me when I've been unintentionally insensitive, I've most certainly had patients who haven't said a darn thing. Maybe they left my office swearing they'd never come back. Or worse, maybe they felt bad about themselves.  Note that as a provider, it's NOT the patient's job to point out your ignorance or lack of knowledge, but sometimes you can learn a lot about providing better care when they do.

The most humbling example I've had thus far of asking a patient a culturally unsafe and ignorant question was when I was seeing a young woman for her annual exam.

She had been raped in the past and had also had some consensual sex partners. I'd never worked with a patient who had been raped before and didn't know exactly how to ask her questions about her sexual history. Previously, I always related to sexual histories by asking about "sexual partners." I wanted to assess her STI (Sexually Transmitted Infection) risk, discuss safe sex practices, etc. I started taking her sexual history like I normally would.

I asked her, "So, you've had a total of _____ sexual partners, then?" And, in my number, I ignorantly included the man who had raped her. She immediately responded, "Well, I wouldn't call him a PARTNER."

Oh. My. God. Of course not. I immediately apologized and clarified that what I meant was the number of people she had had sexual relations with, consensual or not. She was very gracious. And following that patient visit, it gave me a lot to think about.

When I got out of school, I was not fully prepared for what was coming. No provider can ever be fully prepared to encounter a first-time situation. It's amazing how much grace patients have extended to me as I continually learn.

Amidst all the uncertainty, there are some things we do know. Educating yourself about diverse, minority and under-served populations and their cultures is a good way to start.

The most helpful universal thing I've learned is to never make assumptions.

We learn about different cultures because we know when people share some common traits, or behaviors, or beliefs, sometimes they also share similar health issues, ways of interacting, or share similar cultural "norms."

But use caution; while it's good to learn about other cultures, it's never safe to assume that someone who "belongs" to a specific culture shares the stereotypical traits, behaviors or belief systems. For example, just because I'm a self-identified lesbian doesn't mean I've got short hair, am a little overweight, own a bulldog (or two) and like to wear a black leather jacket. Or maybe it does. Maybe it also means I'm religious, conservative, exercise like crazy, am shy, and like to have sex with men on the weekends. Or maybe it doesn't.

You never know. So don't assume.

One of the biggest lessons I learned from an instructor of mine in grad school is the importance of not asking leading questions, or questions that have a "right" answer.

When you do this as a provider, you're more likely to get an inauthentic answer, because often our patients want to have the "right" answer, to be "good" patients, and to make the visit easier or feel less vulnerable than they have to. When you stop assuming and don't ask leading questions, you might be surprised at the answers you get from people.

The example my instructor used when describing the importance of not asking leading questions was when assessing suicidal ideation. She taught us that you don't ask someone if they are contemplating suicide by asking, "You're not suicidal, are you?" This implies, in more ways than one, that the correct answer here is, "No."  This very well may not give you an accurate or truthful answer from the patient. A better way of asking about suicidal ideation is to say something like "Have you had any thoughts of hurting yourself?" or "Do you ever feel like hurting yourself?"

This illustrates an important principle that can (and should) be used for effective patient interviewing. And it ties into the language aspect of the culturally safety framework I've introduced. For the WSW population, asking questions without assumptions is part of providing a safe and caring health care context.

Instead of asking, "How many men have you had sex with?" you can ask, "Do you, or have you had, sex with men, women, both or none?"

Instead of assuming that a lesbian woman will never want to have children, or doesn't need contraception, and treating her as such, you can ask, "What are your plans and needs around family planning?" Instead of assuming she is straight, you can ask a woman, "Do you self-identify as straight, gay, lesbian, bisexual, transgender, questioning, or other?"

There are many assumptions made about the WSW population (and most individuals for that matter) that can simply be re-thought and dissipated if we're willing to ask open-ended questions and ask them without expectation of a specific response.

I've continued to learn this lesson over and over again. Not only as a health care provider, but as a friend, patient, daughter, and lover. It's important to know you will make mistakes. Learning from them and doing it better next time is what matters. Luckily, I've had good teachers along the way.

What have been some loaded questions you have been asked as a patient or have learned not to ask as a provider? How has that impacted what you're willing to share and/or the answers you've received?