The Yale Journal for Humanities in Medicine

Questions That Hurt

Jeremy Daniels
jdaniels2@cw.bc.ca

History-taking is an essential technique of modern medicine. To help, it is reasoned, one must first understand; and to understand one must ask questions. The steps are straightforward: elicit the chief complaints, then primary, secondary, and tertiary histories, and end with past medical history. The steps are unassuming, and form a cornerstone of modern medical science.

Influential 20th century scientific philosopher Karl Popper outlined an approach for scientific investigation and induction called falsifiability (1). Under this scheme, theories are tested by attempting to refute them. The end point is an irrefutable theory constituting a universally true proposition. It is difficult to underestimate the impact of this theory on contemporary scientific practice. For doctors acting as scientists then, uncovering a counter-instance to a disease theory is a powerful finding. But where does this leave the patient?

I remember an experience I had as a pediatric cardiology patient, being examined by a keen Resident. I had Kawasaki’s disease as a baby, and grew up with atherosclerotic after-effects. After my standard checkup (ECG, Echocardiogram, Stress Test, Conversation-with-Doctor), the floor was given to the resident. Asked if I minded his examining me, I replied I did not. What did I have to lose?

What followed was the routine physical exam, and standard questions I had answered so many times before: did I get tired playing sports? (sometimes), how did I keep up with the other kids? (I did not try to), what type of thing was I usually doing when chest pain came on? (lots of different stuff), did the chest pain go away if I slowed down? (sometimes). I remember him turning to my cardiologist, Dr A, to discuss his reasoning. The word Kawasaki came up. And then came the question no one was prepared for.

It was not directed to me, but to my mother, who sat, waited, and watched while the Resident examined me. Even today the question rings in my ears and influences my behaviour when working with sick people.

The resident asked: “Was he exposed to carpet cleaners when he was a baby?”

I can remember a gush of silence filling the room, and the feeling of grief that came over me as the meaning of this question clicked into place. Even to my 10 year old mind, the meaning was obvious: my disease was possibly caused by carpet cleaner. The simple implication was unavoidable: my parents may have caused my disease.

Such is the reality of questions that hurt.

But in asking a hurtful question, the Resident was merely trying to do what Karl Popper explained good scientists do: weed out the bad theories from the good ones by falsification. For this he can hardly be blamed. However, the results of his question went beyond their intended result.

For one, he gave a 10 year old boy reason to believe his parents were to blame for his disease. Secondly, he gave a concerned parent reason to believe she caused her son’s illness. These unintended consequences were chocked with emotional impact.

But what was the Resident to do? How should he have proceeded in gaining information about an emotionally charged disease theory? What exactly were the costs and benefits of his course of inquiry? And did he consider them?

To specify the costs associated with answering his question, he would have had to imagine himself as me, the patient, and consider my likely emotional and intellectual reaction. I believe that if the Resident had engaged in this reflective practice (empathy), the result would have been different.

Very likely, he would have realized the inappropriateness of the question, and quelled his Popperian scientific urge. Yale gastroentologist Howard Spiro has argued cogently for such practice in medicine (2), and today few would dispute empathy as a key medical skill.

But in a case where scientific and empathetic goals are at odds, how should doctors proceed? I do not know whether the Resident who examined me used empathy to guide his actions, but if he did, he chose the Popperian path.

And I think he chose wrong.

He may disagree, and claim that the added knowledge from his question being asked enhanced his understanding of disease theory, which has helped many others. This is a legitimate and defensible response. However, if this were the case, I only wish I had known his preference up front. I would have asked for someone else to examine me instead.

References:

1. Stanford Encyclopedia of Philosophy, "Karl Popper," Stanford University. http://plato.stanford.edu/entries/popper/ (Accessed 15 November 2006)
2. Empathy and the Practice of Medicine. Eds. Howard M. Spiro, Mary G. McCrea Curnen, Enid Peschel, and Deborah St. James. New Haven, Conn.: Yale University Press, 1993.

Jeremy Daniels studies at the University of British Columbia, conducts patient safety research within the Anesthesiology department, and stresses out over applying to medical school in Canada and the United States.

Published: January 18, 2007