Asking the Right Questions

This post was written by Michael W. Hess, MPH, RRT, RPFT.

Early on in my primary care days, I had a patient come in for a one-month follow-up visit after starting a new medication. I asked them, "Are you taking your inhaler 2 puffs every day?" They nodded quickly and replied, "Oh, yes. Every day." I then handed them a demo version of the device and asked them to show me their technique. They turned the inhaler around in their hands once, twice, three times. They were unable to perform the task.

I am sure many of you have been in that position, where someone tells you something about their regimen that may not be accurate. Many of our discussions about assessment and adherence include discussing the use of objective measures or testing to overcome barriers. However, a better question might be, "Why does this happen?" Understanding the reasons for inaccuracy can help clinicians create environments where people feel empowered to overcome barriers to adherence, whether they are related to a lack of confidence, a lack of understanding, or another combination of factors.

Building Trust

Many of our modern chronic conditions can be closely tied to lifestyle-related factors like diet, exercise level, and, of course, tobacco exposure. That means many of the people living with these conditions have repeatedly heard things like, "Why don't you just quit smoking?" "Why don't you just eat less?" One I have heard myself is, "Can't you just go for a walk?" Of course, it is not that easy to "just" start doing those things regularly, so people are often made to feel guilty at every appointment for their lack of success. In these situations, to avoid that cycle of guilt, some people decide to just say, "yes, I'm doing that," and get that box checked off.

This is extremely prevalent in the setting of tobacco treatment, where people are often asked (if not outright commanded) to quit immediately. The Transtheoretical Model (TTM) can offer a solution here. Often described as the "Stages of Change," the TTM suggests that people go from not even thinking about behavior change, to the contemplation of it, to planning, to implementing, to sustaining it.¹ The key here is realizing that it is a process, not a binary decision. People weigh the relative pros and cons of change, and clinicians must understand the values in play. For example, I was often told that people feared losing their friend group if they quit smoking. That changed the focus of counseling from basic internal motivation to overcoming those fears of isolation. In other words, I had to ask the right questions.

Growing Symptom Awareness

We also must remember that not every omission is intentional. A 2016 study found that people often underestimate the impact of symptoms on their quality of life, with over a third of respondents mentioning their symptoms were mild or moderate, while simultaneously reporting they were too short of breath to be active.² Other studies have suggested that people with COPD may not fully understand their health status³ or how to recognize when an exacerbation is imminent.⁴ Just like someone who has never been taught to use an inhaler and is therefore unintentionally nonadherent, these people may not report increases in symptoms simply because they have adapted to the rough seas of COPD.

It is therefore vitally important to avoid asking vague, broad questions like, "Have your symptoms gotten worse since we last spoke?" The gradual nature of COPD makes it very difficult for many to answer that question accurately, even with a solid understanding of their individual symptom burden. Tools like the COPD Assessment Test (CAT) can be invaluable to establish a clear symptom baseline and potentially detect changes in symptom burden between visits. Variations in the individual CAT domains can then lead you to ask questions like, "You seem to be coughing more over the last month, does that sound right?" With a direct prompt, many people may respond with, "Now that you mention it, it does seem a bit worse." This admission can then lead to other discussions, such as a deeper dive into potential triggers, which may unveil a need for advancing therapy or otherwise optimizing their care.

Putting It Together

There are many reasons why someone might not be giving you the answers you look for in clinical interviews. Sometimes, it's a matter of trust. Sometimes, it's a matter of misunderstanding previous coaching. Very often, it's a matter of not asking the right questions. As you get to know your COPD population, consider individualizing your "stock" questions and tying them into the goals and values that you know are important to each person. When you get to that point, you will get the straight talk you have been seeking.