ALiEM Bookclub: Humble Inquiry

3148In this month’s ALiEM Book Club selection, Humble Inquiry: The Gentle Art of Asking Instead of Telling, author Edgar Schein describes a model of communication termed “humble inquiry” which he defines as “the fine art of drawing someone out, of asking questions to which you do not already know the answer, of building a relationship based on curiosity and interest in the other person”. Although a very quick read (100 short pages!), it is packed with profound insights about the way we communicate and a vision for what might be! Communication is so pertinent to our work in the medical field from encounters with our colleagues, our learners, and our patients. Striving to improve communication is a goal that every provider should have and this powerful book can help!

A free excerpt of the book can be accessed here.

Schein first clarifies the concept of “here-and-now” humility, which is necessary precursor for true humble inquiry. Here and now humility is the recognition of one’s own dependence on another, especially with regards to information. Recognition of dependency is not just for subordinates but it is even more essential for those working in teams or in positions of power.

Consider for example anytime either you have taken a clinical case presentation from a junior learner or had to provide a presentation. Traditionally, this experience was fraught with anxiety or fear, especially if working with a supervising doctor who readily employed communication styles that were considered in the realm of “pimping” – a method whereby evaluative and trivial questions are asked in ascending hierarchical order, using power status to embarrass and humiliate learners in a group environment. For example, when a medical student is presenting a patient with sepsis the supervising physician might interrupt and ask “who coined the term sepsis?” When the student inevitably doesn’t know he shakes his head and turns to the resident. The student feels inadequate when they finally return to discussing the case. Instead consider how differently such an encounter would go if your supervising doctor employed strategies of humble inquiry, which would acknowledge that the learner has just spent a significant amount of time with the patient and holds a wealth of information.

With use of humble inquiry, the information can be gleaned from the learner and together the learner and the attending can come up with a treatment plan with educational pearls taught in a comfortable learning environment. But how to go about doing this and employing the strategy of Humble Inquiry?

“Humble inquiry is the fine art of drawing someone out, of asking questions to which you do not already know the answer, of building a relationship based on curiosity and interest in the other person.”

How to practice humble inquiry? Schein suggests:

Do less talking.
Do more asking.
Get better at listening to and acknowledging others.

Consider your own prior positive educational experiences. Likely the educator minimized interruptions. Questions may have been raised that were not answerable, but helped to foster thoughtful discussion. Most of all, you probably felt listened to and satisfied that the management plan was mutually generated.

Sounds easy, right? Wrong.

Schein explores many impediments to humble inquiry.  In our organizations, norms about the expectations of superiors (attendings) and the preferred deference of subordinates (residents and medical students) make it unnatural for those in a position of power to ask for help. For example, in the current traditional model, the attending physician should not rely on the medical student. Furthermore, the task oriented, rather than personal nature, of many of our jobs makes fostering relationships difficult. Working through lunch and breaks instead of holding short teaching sessions or simply bonding over a meal happens far too frequently because there are so many clinical tasks to accomplish. Unfortunately, there are also forces within ourselves that prevent humble inquiry from being the norm. Occasionally the primitive instinct to be right, to one up another person, takes over. And sadly, sometimes the attending (or the resident, or the medical student) likes to be right, just because.

Applications for patient care

There are obvious advantages to humble inquiry that Schein outlines. Most examples were related to patient-safety issues but it seems that the advantages for patient-care might extend beyond allowing subordinates to speak up when they feel something is going wrong. There must be implications for patient care when junior learners, allied health care professionals, families and patients don’t just feel listened to, but are listened to.

Applications for medical education

Learners are asked many questions but often these questions are not coming from a place of humble inquiry. What muscle is this? What dermatome does it supply? What is the appropriate treatment plan? Schein discusses other forms of questioning, described here, including diagnostic inquiry, confrontational inquiry and process-oriented inquiry that are much more common in medical education but don’t necessarily promote relationships or cooperation towards a common goal. There seems to be a role for humble inquiry in the teaching role.
We look forward to hearing your thoughts about the book and about humble inquiry in our discussions in the comments section and on twitter.
* Thanks to Dr. Goldstein at Queen’s University for directing me to this book. He recommends it to all medical students rotating through the anesthesia department!

Questions for Discussion

  1. How might you apply the concept of humble inquiry to patient care? To medical education?
  2. Think about a situation in which you were the subordinate or had a lower status than another other person yet felt respected and acknowledged. Can you identify what the other person did to make you feel that way?
  3. What are impediments in our culture and within ourselves to practicing humble inquiry? And is humble inquiry appropriate in all circumstances?

ALiEM Bookclub Google Hangout

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Watch this for more background on Humble Inquiry:

 

Disclaimer: We have no affiliations financial or otherwise with the authors, the books, or Amazon.

Edited by:
Nikita Joshi MD

Author information

Eve Purdy, BHSc

Eve Purdy, BHSc

Medical student

Queen's University in Kingston, Ontario, Canada

Student editor at BoringEM.org

Founder of manuetcorde.org

The post ALiEM Bookclub: Humble Inquiry appeared first on ALiEM.

Jornadas Osatzen Donostia 2014

La semana pasada celebramos las Jornadas de Osatzen de este año. Para los que estábamos metidos en este lío fueron la culminación de varios meses de trabajo y los damos por bien empleados. A falta de una última reunión para evaluar las jornadas, que la haremos, nos sentimos satisfechos...
La asistencia fue importante; fueron muchos los residentes, ¡qué bien!, que acudieron a la cita. Ellos inauguraron las Jornadas con una mesa que a mí me pareció muy bonita y, además, con contenido: Visiones, percepciones y proyecciones de la AP era su título y a través de su video y de sus palabras hice mi propio viaje interior y, de alguna manera, me sirvieron para reconciliarme con lo que es nuestra especialidad: hermosa mezcla la que vivimos de emoción y razón en las voces de estos jóvenes compañeros.
Posteriormente tanto las mesa inaugural como la de clausura, los encuentros en Para saber más y los distintos talleres que se desarrollaron creo que fueron de interés y de calidad. También fueron numerosas las comunicaciones que tuvimos la ocasión de disfrutar de un nivel alto.
En mente está la idea de que podamos disponer de las presentaciones de los distintos eventos, os invito a consultar la página de las Jornadas en días sucesivos.
Y todo ello sin la participación de la industria farmacéutica, lo que equivale a decir que organizadas y realizadas en libertad, gracias a la generosidad de todos/as los compañeros/as que  nos brindaron su tiempo, su trabajo y su presencia de  forma desinteresada durante estos dos días: ¡muchas, muchas gracias! Eskerrik asko!
Y gracias también a todos/as los que asististeis a los diferentes actos, perdonad los errores, que los hubo...
Creemos que no hay marcha atrás y que mantener nuestra independencia es fundamental, en eso estamos. Nos veremos en otras, espero...

JC: PARAMEDIC trial m-CPR at St.Emlyn’s

St Emlyns - Meducation in Virchester #FOAMed

  In some ways you might be forgiven for thinking that 2014 was a bit disappointing in terms of EBM. A number of clinical trials that I’ve been looking forward to for some time have in effect produced negative results. Early goal directed therapy, target blood pressures for sepsis, hypothermia for post cardiac arrest patients […]

The post JC: PARAMEDIC trial m-CPR at St.Emlyn’s appeared first on St Emlyns.

Pediyatrik EKG

Özet Doğumda, sağ ventrikül sol ventrikülden daha geniş ve kalın olup, sağ ventrikül üzerinde in utero daha büyük fizyolojik stres varlığını göstermektedir (ör. göreceli olarak daha yüksek basınçlı olan pulmoner dolaşıma kan pompalar). Bu durum yetişkindeki sağ ventrikül hipertrofisi görüntüsünü andıran bir EKG görüntüsü meydana getirir: belirgin sağ aks, V1’de dominant R dalgası ve V1-3’te ...

SEMS 2014: Prof Karim Brohi – Major Haemorrhage and Trauma Induced Coagulopathy

We have come to the end our run of selected videos from the SEMS Annual Scientific Meeting 2014 and it has been our pleasure to bring you this series. Hopefully this ushers in a new era of FOAM video and audiocasts of South East Asian Conferences.

We leave you with a detailed analysis on bleeding and coagulopathy in major trauma from the trauma guru himself. Prof Karim Brohi gave a series of talks in Singapore (not just the conference) and this one is essential for any level of medical personnel who deals with major trauma.



Slides are here:

If patients do not ask questions, don´t they really want to know the answer?

Hola a tod@s, my dear Friends.

Someone very special visits today this blog. A new friend, or maybe not so new, who lives at the end of the world in the Scottish land although she is from Cataluña. Elena Lorente is a nurse and has a beautiful and full of sensitivity blog: De Tots El Colors, a blog about the care of the Invisible, Intangible, the essential.

Maybe the scientific method is just the opposite. Perhaps not all may need explanation. We should look and listen more with our heart. Things are as we are.

Welcome to IC-HU Project, I believe that we can learn a lot from you. For the time being, keeps alive the flame that lit Yasmina on Tuesday...

This is her post. Enjoy it!





It never seems the right time to address the issue of death with patients either in primary health care either in hospital care. 
Dying well is a right and just as we talk about quality of life and organize care around this premise, quality of death should also take their place in care plans.

In the community health approach, if we sit down to talk about death with chronic patients calmly, if we listen what it means for each one to die well, we'll help to improve their quality of life. 

Regarding hospital care, it is often assumed that if the patient does not ask is because they don’t want to know. But the reality is that maybe never have found the right time to do it because we have never given, or do not know how to ask the question, or they feel fear about the response, which does not necessarily mean that they do not want to know.

We also assume that patients already sense or know when death is near. Why then mulling the issue? With that excuse we lighten our load, we silence our conscience and we turn our back to the patient. We forget that this "no action" contributes to building an invisible bubble of isolation and loneliness in which, perhaps, is the most important act of life; to die. 

Is it ethical to silence the reality of approaching death, denying that information to the patient by our inability to address the issue? Is it ethical to provide it only to the family? Do we belong that information? Who are we protecting?. 

On the other hand, if it is a mistake to assume that patients do not want to know, it's also a mistake to think otherwise. How do we do then? Starting to combine other verbs besides "to do". Beginning with "to be, to listen, to observe, accompanying". 

We have to learn how to interact therapeutically, creating adequate space, finding the right time to see what the patient wants to know, how far wants to know, and with who wants to share that information. We also need to learn to respect their decisions, and not judge. 

In addition to being good at all levels to patients, and professionals, we would be acting from the ethics of care, avoiding unnecessary interventions, and probably reducing health care costs. 

Good death can never be the result of improvisation.  Stopping to think and listen before acting is often the greatest challenge in the emergency department, acute and critical; but it may be what makes the difference.

Elena Lorente.