The art of questioning
The right question
Posing the right question counts
as one of the elementary techniques of every interview. Poor questioning
technique inevitably leads to an unsatisfactory discussion. Many doctor-patient
discussions fail because the doctor poses inappropriate questions. These
questions can be unsuitable either because questioning technique
or the intention of the question are incorrect. An example would
be a discussion which is only aimed to fulfill the objectives of the doctor,
rather than those of the patient. A question is the request, put into words,
for certain information. Only good questions are able to lead to
the desired answer. A good question is one which is:
and is unlikely to be misunderstood,
||posed at the
||serves the objectives
of the discussion,
||increases the depth
of the dialogue,
||brings the discussion
This means: woolly, imprecise
questions, as well as those with double meanings will not lead to illuminating
answers. Posing questions at an inappropriate time is one of the classic
mistakes. All judgmental, aggressive, wounding or interrogatory questions
give rise to resistance. It is unlikely that the information obtained in
an unwillingly answer will be worth much. The content of the question has
to be put together, and the question posed in such manner that the patient
answers willingly. A good question encourages communication between
the doctor and the patient, because it demonstrates that the doctor is
interested in the situation of the patient, shows that he understands,
and makes an answer possible without raising anger, shame or anxiety.
The good question leads the
conversation on by encouraging the flow of the discussion. This is particularly
important at the start of a conversation. Goethe wrote in his "Maxims and
Reflections": "He who misses the first button hole, does not complete the
buttoning". Ideally questions and answers should follow the zipper principle:
interlocking and encouraging willingness to talk and trust one another,
and avoiding digressions from the theme or breakdown, either in information
flow or in the level of contact.
In discussions between doctor
and patients, the good question is an instrument with a variety of uses.
Questions are used not only to obtain information (as does the questionnaire),
but can also act as an important element in guiding and establishing a
dependable doctor-patient relationship. The good question is already
Two forms of questions can
be distinguished as regards questioning techniques:
questions (decision or structured questions)
Closed questions can only
be answered with yes or no, or perhaps a brief statement. Examples are:
"Do you often have headaches?" "Yes", or: "When were you operated on for
your stomach ulcer?" "1981". Closed questions are used primarily to obtain
specific precise information. They can be introduced to keep the patient
to the subject of the conversation, and to prevent long excursions in which
the significant information content is low.
Because of their concise
form, and because they are limited to a narrow range of the total problem,
closed questions are less useful for deepening a discussion. They should
only be used as and when really necessary, and should be avoided at the
onset of the discussion. A discussion which is carried out basically as
a series of closed questions takes on a programmed nature, the dry style
and the limited flexibility typical of a questionnaire.
The technique of questioning
with closed questions involves a series of disadvantages and dangers:
closed questions usually aim only to deal with part of the complete problem,
they can lead to limitation of the subject matter rather than to deepening
it. There is the danger that the conversation will only deal with facts
of superficial importance, and the underlying problems will not be discussed.
The "ping-pong" technique of leading the conversation with closed questions
is not suitable for encouraging contact between those taking part in a
patient is unable to answer most closed questions as precisely as he is
expected to. How many patients do know with absolute certainty when their
appendix was removed, how high their blood pressure is, and whether 0.1
mg or 0.2 mg tablets have been prescribed? The closed question however
tends to evoke a quick answer and may in fact lead the patient to respond
without really thinking about the accuracy of the answer.
rapid to-and-fro of question and answer appears to lead to acceleration
in the pace of the conversation. However the advantage in gaining time
is at the cost of the interviewer, who is constantly under pressure to
produce more questions. This leads to the phenomenon of asking for the
sake of asking, rather than really thinking through the problem, for which
time would be available had less superficial questions been asked. This
can also have a marked influence on active listening.
course in acute and emergency situations, it is not possible to proceed
without using the technique of closed questions, in order to obtain as
much information as possible in the shortest possible time. Closed questions
are of most use in the rapid collection of facts, quick orientation or
the point-by-point dissection of a problem. They are of less use for initiating
a discussion, unraveling the various dimensions of a subject or building
up and consolidating relationships.
questions allow the patient to describe in his own words what is
troubling him or making life difficult. The opportunity for contact and
self-exposure is clearly much wider. Open questions also encourage the
patient, warming him to the subject, and allowing him to explain his problems
openly and freely. Open questions are also appropriate to initiate a process
of self-awareness. The study of the psychology of learning has shown that
the most effective learning takes place when one describes things in one's
own words. Talking freely about one's own problems, and attempting to make
the conversation partner understand, also leads to an increased confrontation
with matter for conflict and makes for better management of such problems.
Open questions are better for allowing the doctor to convey interest and
attention to the patient.
superiority of the open questioning technique as opposed to the closed
can be illustrated as follows:
The open question, "The atmosphere
at work has a marked effect on some people: what is your opinion?" is more
likely to encourage a patient to discuss problems at work than the closed
question: "Does your boss think highly of you?".
The closed question: "Are
you upset that the treatment has not worked?" is certainly less suitable
for an open discussion with the patient over the extent of his disappointment,
than the question "I am very interested to know how you see the
effect of your treatment so far?".
The closed question, "Haven't
you got any more desire to live?" probably has a blocking effect. It is
better to approach the subject by asking the open question, "The last few
months were certainly difficult for you. How much did this affect you?".
The technique of open questioning
has two important disadvantages; firstly it makes it easier for
the patient to avoid unpleasant subjects, and secondly it makes it easier
A typical example in practice:
Question: "What do you mean
when you say you can't manage the tablets?" with the answer, "I seem to
feel very funny after I take them. Yesterday I took the last one before
the 9 o'clock news, and found that I really could not concentrate during
the weather report. It has been more and more difficult to concentrate
recently. It's really difficult to remember names. I met my old school
teacher, a few days ago. I think it was near the market, and I just couldn't
remember his name. He was so nice, and always gave me good marks, even
though I wasn't very bright. He didn't get on so well with my brother and
always gave him poorer grades ..." etc. etc. It is of course quite in order
to break this cascade of words by asking: "Did you feel sick after taking
the tablet that you took before the news?"
"Serving men" questions
These include when?, what?,
who?, where?, as well as how?, and are also referred to as supplementary
or semi-structured questions, as they are halfway between closed
and open questions. Questions of this type are equally good for leading
onto a subject as for going deeper into particular points.
Sounding questions are posed
to obtain specific information from the patient. They allow the
patient to express himself freely, but at the same time prevent a drift
away from the subject.
For example: A 52-year old
office worker complained of "pressure in the chest", but was unable to
state clearly what brought it on. He could not give a satisfactory answer
to the question: "Does this come on at rest or under stress?" - "It happens
more often at work I think." What does that mean; is the patient under
more emotional stress at work than at home? Is he anxious when dealing
with the public, or has he got problems with his colleagues? Does his work
actually involve heavy physical activity and stress?
More clarity can be attained
by the use of sounding questions such as:
"Tell me about the work that
you actually do ...", "Does this pressure occur when you play tennis?",
"Have you been woken by it at night?", etc.
If open questions do not
satisfactorily lead to enough clear information, catalogue questions can
be used. They give the patient the choice of a number of alternative key
words or descriptions.
For example where a patient
is not able to clearly describe his abdominal pain, catalogue questions
such as, "Is the discomfort that of pressure, burning, cramping or drilling?"
or "Does this discomfort come before, during or after eating or only between
meals?" can usually lead to more objective information.
The disadvantage of catalogue
questioning is that it still only offers the patient a limited number of
options, none of which may be appropriate to him.
Such questions confront the
patient with his behaviour, his feelings or an earlier statement. They
are suitable to direct his thinking onto himself, to make him aware of
contradictions or to explain them.
Examples: "You mentioned
that you take your blood pressure tablets regularly, but that you feel
best when you don't take them?" "Do you believe that it's mainly the doctors'
fault if a patient changes his doctor frequently?"
Reflection or echoing
The reflection question repeats
a part of what the patient has said. It is an "echo" of what he has expressed,
and is intended to encourage the patient to consider that part of the particular
subject, and go into it more deeply.
Examples: "You are drinking
more since your divorce ...?." "You lie awake the whole night ...?"
contain implications that can be concluded from statements that the patient
makes or from his behaviour.
Example: "Do you mean to
imply that at the present time your success in business is more important
to you than a stable blood sugar?"
These questions should only
be used sparingly as they mostly are judgmental in character.
Certain questioning techniques
are often used, even though they are less productive. Most arise from impatience
on the part of the questioner. Information obtained by these methods have
questionable value; examples include suggestive, double and multiple questions
as well as "hold-up" questions.
"Have you noticed nausea
after you take these new tablets?". Such leading questions will certainly
raise the prevalence of patients with nausea. A more valid answer would
be follow a neutrally-formulated question: "How did these new tablets affect
Prejudice on the part of
the questioner is often present in the background ("nausea is often caused
by drug X") or wishful thinking ("aren't the new sleeping tablets really
much more effective?").
Leading questions also serve
to avoid the discussion of unpleasant subjects. The question: "Aren't you
really feeling much better today?" exerts subconscious pressure on the
patient who actually feels worse, and leads to the answer: "Perhaps a little",
which frees the doctor to get on with other tasks. The conversation appears
smooth and polished, and nothing unpleasant is discussed, but the actual
effect is limitation of the discussion and a dissatisfied patient.
Leading questions are of
little use for the recognition of problems and are not suitable for problem
solving. They can be used in exceptional circumstances, for example to
encourage a patient who is finding it difficult to achieve an objective
Example: "Haven't you noticed
that you can walk much better since the day before yesterday?"
Double and multiple
These usually arise out of
impatience or inexperience of the questioner. The doctor does not take
enough time to break two different discussion points into two separate
questions. It is difficult for many patients to respond to a question such
as "Do you still have abdominal pain, and is your motion still black?",
because they are not used to giving one answer to two questions, and find
it difficult to formulate "I still have slight abdominal pain, but the
motion is no longer black".
The patient probably remains
with the first part of the question, so that the doctor has to repeat the
second half of the question. Even experienced speakers usually only get
round to answering the first two questions when three are posed consecutively.
Questions should not be strung together in twos (or even more), but the
posed singly. The answers are more precise, and the conversation time will
not be increased.
"Ambush" questioning is usually
unfavourable in discussions between doctor and patient. There are a few
exceptions, in which consciously producing a surprise attack makes it easier
to get at the truth. Ambush questions signal impatience, impoliteness or
lack of awareness, and lead to defensiveness and aggressively, or produce
answers that should be regarded with suspicion.
No bank manager would immediately
confront a customer who does not appear to be very credit-worthy with the
question: "Do you really think that you will be able to repay this money?"
The question "Do you sometimes
hit your daughter?" is certainly not a clever way of introducing the subject.
It is easier to reply to difficult or painful questions if the response
can be constructed on a previously suggested sentence.
Example: "Children can often
provoke even the most patient parents to smack them. Have you found that
this has happened at all with your daughter?".
There is a series of questioning
techniques that not only do not encourage conversation but usually inhibit
it: questions that do not take account of the patient's autonomy, show
no empathy, sound presumptuous and usually only enhance the questioner's
display behaviour. These questions are included in the category of "forbidden
questions" and include trap questions, questions motivated by curiosity,
socratic questions, judgmental questions, aggressive questions and the
superficial rhetorical questions.
These questions aim to over-ride
or trip up. A classic example is that of the judge dealing with divorce
proceedings who asks: "Did you or did you not drink alcohol after you had
beaten your wife?". If the accused had never beaten his wife, it would
not matter if he said either yes or no, but in either case the answer implies
that he did. A typical medical question would be, "Do you have more or
less thirst on the days when you do not take your diabetes tablets?".
Questions arising from pure
curiosity, which although they satisfy the questioner, do not deepen the
relationship, and either lead to a feeling of shame in the person who is
questioned or evoke the climate of an interrogation by the police.
||"Have you had
difficulties with potency for some time?"
||"Does it worry
||"How does your wife react?"
||"I would rather no talk
||"Have you already given
her suggestions of how to manage?".
So-called socratic questions
usually only lead to an increase in the self-assurance of the questioner,
and result in a marked asymmetry in the discussion. These are questions
that the questioner knows the other cannot answer. Socrates wanted
to make it clear to his fellow-citizens, that they really did not know
what they believed they knew.
Judgmental questions are
inappropriate, as they produce a defensive response. These are very
often "why" questions.
"Why are you so irrational
and drink so much fluid, even though I forbade it?" (instead of: "What
was the reason that you found it difficult to limit the amount you drank
to that which I had suggested?") or "Why have you got such a bleak outlook
about your illness?" (instead of: "You seem to be finding it difficult
to believe that your chances of recovery are in fact very good: are there
reasons why you find it hard?").
The suggestion of judgement
puts the patient on the defensive. Because he is forced to defend himself
powerfully, there is a danger of raising issues which are not the true
Aggressive questions are
often posed with the objective of creating a particular behaviour or action
on the part of the patient. They usually achieve the opposite of that which
they intend, which is to motivate the patient.
A question such as: "Can
you not, or don't you want to, understand how important this operation
is for you?" will hardly be effective for convincing a patient about the
importance of a necessary surgical intervention.
Rhetorical questions are
perceived as hollow and insincere. They do not convey the impression that
the doctor is genuinely interested in the patient's problems. Superficially
phrased, they can only actually be answered superficially. Although they
maintain the flow of conversation, they are nevertheless disruptive as
they block every attempt to go deeper. Such questions include those such
as: "Can you just about manage?", "How are we getting on then?", "What's
going on here?", "Is there anything in particular?" etc.
Of course it is not possible
to weigh every question in a discussion between doctor and patient. This
would spoil the spontaneity in the unfolding of the discussion. What is
decisive is however what the various questioning techniques can support
and what not, which particular technique will be best in certain situations,
and those which must be avoided at all costs. It involves the process of
consciously relearning how to lead such a discussion.
In order to assess how you
question, start off initially by analyzing which questioning technique
you prefer and which you usually avoid.
||Can only be answered
rapid pertinent information without getting away from the train of discussion
Disadvantage: Not suitable for
opening discussion and deepening; danger of pseudo-precise answers
||Possible to freely
formulate an answer
for initiating a discussion or deepening it; unlock, encourage, and bring
Disadvantage: deviation from
subject and long-windedness
Who? How? When?
clearing up certain points
to narrow description
about the matter in hand within bounds
||Holding up previous
answer for reexamination
||To point out
and resolve contradictions
a subject which was touched upon
include a summary or consequence
a problem; should only be used infrequently as they are judgmental
of the answer
for problem solving use in exceptional cases for encouragement (rooted
in prejudice or wishful thinking)
|Double or multiple
several concurrent answers
other (rooted in impatience or time pressure)
||Danger of aggressive
or irrelevant answer
up the other partner —>
the only driver of the conversation —>
||With a view to
|Ignoring empathy and personal
|Inhibition of conversation
value judgement —>
(personal) attack —>
Questions by the patient
Discussions during which the
patient does not pose any questions are rarely good discussions. Of course
the patient is entitled to ask the doctor whatever he likes. He also has
the right to ask everything, as even "superfluous" questions are often
found on active listening not to be superfluous at all. Just the opposite;
they key to what particularly concerns the patient is often encapsulated
The doctor must always attempt
to elucidate why a patient asks a particular question, why he poses
question now, and why he does not ask.
There are many reasons
why the patient asks questions. The question can simply arise from his
for information. Rather than needing an answer, the patient may simply
ask a question to be noticed. A question simply can be a cry
for help. A question can be a sign of anxiety, doubt or hopelessness.
The question can also be a transport mechanism for letting the other
know something that could otherwise not be verbalized.
The patient who poses a question
is not begging. It would go against all principles of personal worth and
a balanced doctor-patient relationship to answer a patient's questions
either incompletely, evasively or to just not reply. This obvious postulate
however is not always observed in clinical daily practice.
D.L. Rosenhan, professor
of psychology at the University of Stanford analyzed the response of doctors
and nursing staff to patient's questions in a much-quoted study. Eight
completely sound individuals presented themselves at 12 various psychiatric
hospitals in America, and were admitted after they had complained of hearing
voices. During their stay in hospital they acted completely unremarkably.
In four of the hospitals, they approached doctors and nursing staff with
questions about the daily routine (i.e. "May I walk in the gardens this
afternoon?"). Even though the findings are not perhaps generally applicable
as they came from a psychiatric hospital, the results are nevertheless
depressing: 71% of the doctors passed the questioner with his head turned
in the other direction, 23% made eye contact, 2% paused briefly and chatted,
whilst only 4% stopped and started a discussion. Even worse responses were
obtained from nurses and other personnel.
Active listening is the best
method to determine the real question behind the question that is
posed. The patient who asks: "Will I have another infusion tomorrow as
well?", probably does not really want this question answered with a brief
yes or no. In fact, the questions that he really wants answered might be:
"How much longer will the treatment take?", "How effective has it been
so far?". "Dare I believe that there will be an improvement?"
Many questions are basically
questions. One question is put instead of another, perhaps because
the patient is too shy to introduce the problem directly. The asthmatic
patient who enquires if he must take cortisone for the rest of his life
is probably really asking: "Is my asthma curable?". If it is thought that
the question is actually deputizing for another, the probable background
question should be openly mentioned in the form of metacommunication ("I
have the impression that you are asking this question for a particular
reason. Could that be?").
Repetition of a question
can lead to the doctor feeling mild despair. In such cases, it is decisive
to determine what reasons might underlie the repetition of such a question.
Is he trying to obtain another answer to that which he has been given,
because he cannot come to terms with or accept the original answer? Is
anxiety the underlying motivation for repeating the question? Is he constantly
wanting to be reassured that things are not as bad, dangerous or as hopeless
as he believes? Does the patient continue to question because, although
the answer is correct from the doctor's perspective, it does not correspond
with reality as perceived by the patient?
Patients who appear for an
appointment with a more or less extensive handwritten list of questions
usually produce internal blockages in the doctor. Listing symptoms and
complaints are usually regarded as one sign of psychopathic behaviour.
French clinicians have even given this the name of "la malady du petit
Why is it that doctors tend
to react negatively to handwritten lists? The patient is only doing what
is obvious; he has a list of unclear points which seem to him to be important,
and is taking them to his doctor. He is using this in order not to forget
anything. Ultimately, the list of questions shows that the patient would
like to present his problems and symptoms with a certain amount of order.
The phenomenon of the patient
who comes to an appointment bringing such a list of questions with him
has been systematically investigated in America. J.S. Burnum (1985) looked
at the meaning of a written list of questions in a prospective study in
900 patients in an internal medical practice. 72 patients (8%) attended
with a list of questions. The list contained on average 5-6 points. The
longest (with 20 points) came from a completely psychologically stable
top manager. The questions pertained to subjects which would normally arise
in the course of discussions between doctors and patients. Although these
questions were more complex, the fact that they were put in a systematic
order made it possible to give carefully thought-through answers. Viewed
without prejudice, the lists proved to be a definite help in the diagnosis.
Only one of the 72 patients
continued to bring the doctor new lists of questions, which made the doctor
impatient. For this particular phenomenon, the author introduced the particularly
apt expression of "Polonius syndrome", basing this on the character of
Polonius in Hamlet. Burnum concluded that those who write lists
of questions are not suffering as such from a disease, and that they are
usually not psychologically disturbed. Burnum: "Taking account of the contents
of a list of questions is nothing more than a part of listening, the key
to our handiwork. Whatever helps the patient to express himself, and whatever
helps the doctor to understand him, is acceptable."
Going patiently through the
list of questions once usually unburdens the patient, and indirectly saves
time, as it is the inconsequential unsystematic discussion of problems
which usually steals time and is unproductive. Tangential questions
are damped down by offering the patient clearly defined questions; he can,
for example, be asked: "What are the two most important points that you
would like to discuss with me?".
On the other hand, the patient
who poses no questions should alert the doctor. Usually what the
patient hears is neither so clear from the content nor from the manner
of speech that no counter-question appears. There are various reasons which
might account for the fact that the patient does not put any questions.
Is the doctor speaking about problems which do not really concern the patient
at all? Perhaps he is expressing himself so incomprehensibly that the patient
does not dare to show, by asking a question, how little he has understood,
or understands? Perhaps the patient is so distressed by what he has heard
that he is not able, at that particular moment, to formulate a question.
There are therefore good
grounds for encouraging the patient to ask questions. This encouragement
has a feed-back function: has the patient understood what it is all about?
Are there inhibitory or blocking influences which prevent the patient asking
questions? Have misunderstandings arisen in the course of the explanation
or discussion? Are the doctor and patient actually discussing the same
|Check list: questioning
behaviour of the patient
is the patient really asking (need for information, desire for contact,
criticism, call for help)?
||Why is he asking
this question at this time?
||Is this a case
of a question covering or overlying the real question?
||Why does the
patient continue to repeat a question?
||Why does the
patient not ask questions? (anxiety, time pressure, speech barriers,
||Was the patient
sufficiently stimulated to put his own question?
Geisler: Doctor and patient - a partnership through dialogue
Pharma Verlag Frankfurt/Germany, 1991
of this page: http://www.linus-geisler.de/dp/dp08_questioning.html