Getting the right information from patients can be one of the biggest challenges of many EMS responses. We might ask a patient an open-ended introductory question, such as, "Did you call 9-1-1 for help today?" or, "Can you tell us what’s bothering you?" However, these questions are often met with confusing and frustrating responses rather than precise and clear answers that point us in the right direction. Also, some patients will go on endlessly about irrelevant problems while others barely reveal anything at all, and certainly not what’s really bothering them that day.
The skilled responder becomes adept at listening and interpreting what the patient is saying by their pauses and facial expressions, and by what they aren't saying, too. Still, we tend to formulate fairly quickly in our minds what problem we think the patient is most likely experiencing and begin to narrow our focus on those problems. It’s at this point that we are at risk of starting to ask "leading questions" and query patients in a way that suggests how they should answer.(1)
For example, if you’re attempting to urge a seriously ill or injured patient to go to an emergency department (ED), you might say, "You want to go to the hospital, don’t you?" You’re intentionally putting psychological pressure on the patient to go, which might be good to do—and legally and ethically necessary. After all, if you ask, "Are you interested in going to the hospital or remaining here at home?" you make it seem quite acceptable with you that the patient stays at home.
Asking leading questions becomes a problem, however, when the EMS provider guides the assessment in the wrong direction, either intentionally or unintentionally. We know our patients can be anxious and embarrassed by having an ambulance filled with strangers rushing up to their house with lights and sirens. We approach them quickly and act with a degree of urgency. We do things at a fast pace, touching them and probing and taking measurements. Then, we ask a series of rapid-fire questions. That's a lot of pressure, especially when patients are confused or disoriented and unsure of what to do.
Nervous patients who really need EMS often believe that they must say the right things to get the best care and be seen quickly at the ED. They may correctly presume every question is important and is being asked for a very good reason. The patient may answer honestly, "Yes, I’m feeling a little anxious," or, "Yes, I have been a little dizzy." Then, we ask, "Have you had any difficulty breathing?" There’s another leading question!
The neutral question is: "Is there anything else bothering you?" You could then place a stethoscope on the chest and ask the patient to take a deep breath and ask, "How does that feel when you breathe in and out?" It may seem like semantics, but this approach distinguishes a rapid and shallow assessment from a masterful and unbiased assessment, and it’s imperative for educators and training coordinators to understand and teach this subtle difference.
It's important to understand the psychology behind the problem with leading questions. Elizabeth F. Loftus, an American psychologist and expert on human memory, was a pioneer psychologist who researched leading questions in her studies on the effect of misinformation and false memories.
In 1975, Loftus published a report of a series of four experiments in which 490 college students were shown films of complex, fast-moving events, such as automobile collisions and classroom disruptions.(2) She was able to show how the wording of questions asked immediately after an event influenced the responses. When the questions contained true statements about what happened, the students remembered seeing the events as they happened; but when the questions contained false statements about what happened, the students incorrectly remembered the event to match the questions. Her studies showed that when leading questions were asked, they actually created new false memories of events.
One clarification is important: Some "leading" questions aren’t really leading questions at all. For example, "Are you still stealing money from your employer?" isn’t really a leading question. This type of question fits the general description of a leading question, except that no one actually expects an answer. Rather than a valid leading question, it might be thought of more as a "loaded question."
Problems with leading questions:
- They presume knowledge about something that isn't known.
- They guide the interview or conversation in the direction intended by the person asking the question. In the case of an EMS emergency, it means the assessment is being directed to what the EMT or paramedic thinks is the problem, which may not be correct.
- They are often unilaterally directional in that, even if they don’t indicate the expected or preferred answer, they tend to prevent the conversation from going in an unwanted direction.
- Accompanying facial expressions, body language and tone of voice can also strongly influence the answers.
These pitfalls aren't addressed in depth in most current EMS textbooks. A scan of several paramedic and nursing textbooks revealed, to my surprise, that in general only a few lines are devoted to the principles of how to ask good questions when obtaining the patient history.(3, 4) Most recommend asking open-ended questions to start, allowing patients to reveal the chief complaint and the most relevant concerns about why they called for help. Several also give the sage advice to avoid asking "why" questions because they create tension for patients, as they usually don’t know "why" something happened, or "why" they got their disease, or "why" they did something so foolish. An alternative to "why" questions are "what" questions, such as "What else can you tell me about the accident?"(5, 6)
Eventually, however, the interview reaches a point where the follow-up questions need to be direct and leading. For instance, "Have you ever had an allergic reaction?" is a straightforward "yes" or "no" directing question. If you ask, "What are you allergic to?" then you are mildly leading the patient and risking blocking the flow of information and trust. On a recent EMS response, a paramedic asked our patient, "You aren’t allergic to anything, are you?" The mental health patient was emotionally labile and had been non-compliant with her medication. The negative form of the question was problematic, as the patient was being directed away from revealing any allergies she might have had.
hese nuances can be taught and practiced. Try these scenarios with your students and crews, and observe and record the interviews.
Practice Scenario 1: Chronic Smoker/Drinker
The patient is a chronic smoker (two packs a day) who also routinely consumes a bottle of wine daily. The EMT student asks questions about the history of tobacco and alcohol use. The patient is evasive and understates the extent of their smoking and drinking. The scenario can be enhanced by placing full ashtrays at the scene and empty bottles of wine, beer or liquor around the mock patient. Burn a little tobacco (or a small square of paper and oregano to simulate marijuana) and spill a small amount of alcohol on the patient’s shirt, just to increase the "evidence."
How does the student respond to obviously dishonest answers? As the student pursues the interview and the patient gives evasive answers, the questions will need to become more directing (i.e., leading).
After the interview, analyze the "leading" questions with the class. If the leading questions seemed hostile, explore how they might have served only to block further communication. If they were asked in a neutral and concerned manner, discuss how this different approach helped keep the information flowing, with the result being a better interview with more honest information.
Practice Scenario 2: Flu Symptoms
Your student responds to a patient who has flu symptoms. The patient is HIV-positive and has a history of hepatitis B. The patient lives in a boarding house with other residents who don’t know about the patient’s medical history.
Does the student ask appropriate introductory questions? (The chief complaint of flu-like symptoms should come forth immediately.) Does the student adequately explore the patient’s history of infectious diseases? When the patient is hesitant and evasive, does the student respond appropriately by deferring further probes until they’re in a private setting? Does the student pick up on the clues of subtle and uncomfortable denial and carefully and compassionately attempt to elicit the history, giving appropriate clinical reasons for asking? Does the student avoid leading questions that can be perceived as accusatory or judgmental and that, ultimately, block further communication and acceptance of care?
Practice Scenario 3: MVC
The student arrives at the scene of an MVC with no obvious driver in sight. In the group of about five onlookers, one person appears anxious. Have the student interview the group and attempt to discern whether the onlooker was actually the driver or not. Randomly change the scenario for different students. In one instance, have the onlooker be the driver (who had been drinking), and in the alternate scenario make the onlooker be just a nervous person who’s upset by seeing the damage and is concerned for the missing driver who might be injured.
In both instances, no information will be forthcoming. In the first instance, it might be possible to elicit the information from the suspected driver, but that would have to be accomplished through very skilled and subtle questioning. In the second instance, the onlooker should appear guilty while still truthfully denying any involvement.
Does the student appear hostile when asking questions of the suspected driver? What kinds of leading questions does the student ask? Are they accusatory or presuming involvement, or are they neutral and showing only concern?
Practice Scenario 4: Abdominal Pain
You have a 30-year-old female patient who is married. She presents with a chief complaint of acute abdominal pain. Your student needs to differentiate between possible ectopic pregnancy, an ulcer with anxiety, appendicitis and pelvic inflammatory disease (PID). When she was 16, the patient had a prior birth that was given up for adoption. She hasn’t told her husband. She also has a history of an STD when she was 20. She has been in good health and in a stable relationship for the past 10 years. Your student knows only about the complaint of acute abdominal pain. The patient wants to keep her past medical history a secret from her husband, who is present at her side.
What questions does the student ask about her pain? Do they directly ask about possible pregnancy and sexual activity?
The patient gives a history that includes a menses that’s six weeks late. The student should be most concerned with a possible pregnancy at this point. What questions do they ask?
Coach the female patient to be evasive, not wanting to openly lie but not wanting to reveal her history of a prior birth and PID. The EMS provider will be frustrated in attempting to obtain the history and will have to ask pointed and direct yes/no and leading questions. The key is whether the questions are appropriate or inappropriate, and leading or non-leading, and whether the EMT is sensitive or insensitive to the patient’s psychological state.
Ideally, these sessions would be recorded and the class could review the interviews and see how the questions could be asked with more sensitivity or neutrality and help keep the lines of communication open. These scenarios present just a few examples of how to help develop the interviewing skills of every level of EMS provider. By understanding and applying these approaches, the highly skilled EMT or paramedic is able to explore a patient’s present and past medical histories without overly controlling the interview and misdirecting it.JEMS
Bill Raynovich,NREMT-P, EdD, is an associate professor of EMS for Creighton University, Omaha, Neb. Contact him at BillRaynovich@creighton.edu.
1. U.S. DOT NHTSA: "Patient Assessment: History-taking." National Standard Curriculum. III.D.2
2. Loftus EF. Leading questions and the eyewitness report. Cognitive Psychology. 1975;7:560-572.
3. Bledsoe BE, Porter RS, Cherry RA: Essentials of Paramedic Care, 2nd ed. Brady: Upper Saddle River, N.J., 2007.
4. Aehlert B: Paramedic Practice Today: Above and Beyond. Elsevier: St. Louis, 2010. p. 562, 567.
5. Platt FW, Gordon GH: "Chapter 2." Field Guide to the Difficult Patient Interview. Lippincott, Williams & Wilkins: Philadelphia, 1999. p. 14.
6. Davis CM: Patient Practitioner Interaction: An experimental manual for developing the art of health care, 2nd ed. SLACK Inc.: Thorofare, N.J., 1994. 147.