This question was raised by Winston Wong, Director of Disparities Improvement and Quality Initiatives at Kaiser Permanente, during the Institute of Medicine's recent workshop, Health Literacy: Past, Present and Future.
The workshop marked 10 years since IOM released the landmark report Health Literacy: A Prescription to End
Confusion. A summary of the workshop proceedings was released this month. Download a summary of the
workshop free from National Academy of Sciences. Definitely worth the read.
Here's the part that made me stop and applaud
In a discussion about health literacy and its role in achieving equity, Wong recounted a conversation among
health plan leaders on patients' non-medical needs (social determinants of health), that led to the question:
What should be the core conversation between a doctor and an individual s/he sees for 15 minutes per year?
“One interesting proposition is that we should start the discussion with every person we come in contact with
by asking 'what does a good day mean to you,’" Wong said, "because that’s really a much more important
question than ‘what hurts’ or ‘have you been taking your medicine today.’”
Why is this question more important than typical problem-focused inquiries?
Wong said it reflects the fact that medicine can help with some problems, but what ultimately makes for a
good day for someone is determined by a constellation of actors that foster good health. The question
recognizes that on average Americans spend about one hour per year in a clinical setting; the healthcare
professional is just one actors; s/he marshals resources that account for about 10% of health. The other
actors are the people the individual is with the other 8764.81 hours per year. The power to create health,
and to live well with disease, is with the patient.
What is a good day like for you? addresses the person and his/her "real life", instead of focusing narrowly
on the patients' disease and treatment. It suggests the patient's selfcare is achieving some good days, rather
than reducing the person to a medical problem and assuming that s/he has failed to comply with the medication
What is a good day like for you? is a good reflective question.
> It cannot be answered yes or no. It requires the respondent to think critically about what matters to them,
to reflect on what they want from medical care and how they will know they got it. It leads to conversation
about what the person is able and willing to do now to achieve more good days.
> The response serves the patient, rather than simply informing the clinician.
> The response enables the clinician to hear and adopt the patient's words, so the patient is not expected
to learn medical terminology, and the clinician is not expected to check a glossary of simplified terms.
> The question allows the patient to figure out and articulate what they want and need, making it easier
for the provider to achieve patient satisfaction.
> It shifts thinking and conversation from what patient and clinician do not want — disease and suffering—
and how to get rid of it, to what they do want —good days— and how to get more of them.
The hard part is waiting for the response
Patients are not accustomed to being asked reflective questions, especially by clinicians. Many, especially
those who live in poverty and face daily discrimination, are rarely asked questions and may be trained not
to think. The reflexive first response is likely to be "I don't know". They need a way to think about it. Try
again; Can you remember a good day or a good moment? Then the hard part: wait. Let them be the one to
fill the silence. Ask follow up questions to help the patient clarify what s/he wants, and what will tell her
that she got it; what has worked before and what is needed to achieve more good days. An effective
conversation will end with the patient articulating the action s/he will take and the clinician offering
supportive information and services.
More on reflective questioning
Reference & further reading:
J. Michael McGinnis, Pamela Williams-Russo and James R. Knickman The Case For More Active Policy Attention
To Health Promotion Health Affairs, 21, no.2 (2002):78-93 doi: 10.1377/hlthaff.21.2.78 Full text online at http://content.healthaffairs.org/content/21/2/78.full.pdf