Can you hear me?!
The man lay unconscious on the floor.
His wife stood nearby, nervously shifting from foot to foot.
What was going on? Why was he unconscious? As a paramedic, it was my job to find out. The best way to do this was by asking diagnostic questions.
Anybody can use diagnostic questioning to get to the root cause of a problem.
In asking diagnostic questions, listen closely to words used to describe the problem and its symptoms, when the problem occurs, and actions that connect to it or seem to cause it.
The devil is in the details.
In the case above, I followed an algorithm to guide my inquiry. In the emergency medical services professional, everything starts with the ABCs — airway, breathing, and circulation.
- Was his airway open?
- Was he breathing?
- Was his heart beating?
A “no” answer to any of these required immediate interventions, i.e. clear the airway, breathe for the patient, or start performing cardiopulmonary resuscitation (CPR) to act as the patient’s heart.
Notice the direct connection between the question that identified the problem, and the intervention that addressed the problem. Was the airway open? If not, open it. Was the patient breathing? If not, breathe for them. Does the patient have a pulse? If not, perform chest compressions. Diagnostic questioning can be broken down into four steps.
Step 1. Before you can fix a problem, you need to know what it is.
For example, if the airway is blocked, and I don’t diagnose it appropriately, you can’t get oxygen to your patient and they die. In short, failure to identify the problem equates to certain death.
Get it right, and you’re on your way. Get it wrong and you face the consequences, and they can be costly.
Diagnostic questions help identify a problem with precision, separating the symptoms from the disease.
You should think of diagnostic questioning like a funnel, or casting a wide net. Start broad and then zero in.
Then, get more specific with your questions. Look for ways to describe what is happening, make comparisons with things you have observed before, and quantify what you are observing.
Think like a detective. You are looking for details and patterns.
Always begin with the question:
“What’s going on here?”
A corollary to this is, “what’s the matter?”
Notice the broad open-ended question? This is purposeful. You want the person you are asking to respond in their own words. You do not want to put words in their mouth.
Your follow-up questions should ask for a description of the problem in the present tense.
Examine the problem from the perspective of the five senses, i.e. sight, sound, smell, taste, and touch. For example, what does the problem looks like? What does it sound like? What does it smell like? What does it taste like? What does it feel like?
Remember, these are present-tense questions designed to get a full and accurate description of the problem from all angles.
Once you have a surface level understanding, ask some deeper questions about how it manifests. Does anything make it worse? Better?
Step 2. Explore the history of the problem.
After you understand the present, it is time to explore the history of the problem.
This can reveal some pivotal or crucial clues.
Questions can include, when did this problem begin? How has it changed?
If we have learned nothing as human beings, we have learned that history repeats itself.
Use this to your advantage and learn from it.
Look for comparisons, parallels, patterns.
Ask about previous experience with the problem — when it was first detected, how it’s changed over time, what’s been done to address it in the past. Ask whether the problem has gotten worse and in what ways.
Ask if anything has been tried in the past to mitigate the issue and with what effect. In short, leverage the past to inform the present.
Now that you know the present and the past, you should be asking yourself a very important question:
Step 3. What are you missing?
In medicine, there is a saying:
When you hear hoofbeats, think horses, not zebras.
This means, when you start an investigation, you should think of the most likely and common things first. However, as you rule them out, you need to consider the differentials. Differentials are the things that share some of the same characteristics but are different.
Ask yourself, what else could be at work here to cause the problem? Is there something nefarious at play? Is somebody hiding something, i.e. is there a secret, a hidden agenda, a mistake, or an unintended action that has made the situation worse? Did a shortcut become a short circuit?
These are beneath-the-surface questions that ask about miscues, mistakes, and missed signals. My favorite is:
“How do you know?”
A bonus trick is to ask someone to quantify their level of certainty with a bet, i.e. “would you bet your life on it?”
Remember in high-school algebra when you solved for (x) and then went back and checked your answer? You should do the same here.
Step 4. Check your work.
Once you have diagnosed the problem, it’s time to check your work.
Double-check the sources of information. Are they reliable? Does the source have an agenda? Is the source qualified to provide the information? What’s their track record? Don’t be shy here. Ask for an explanation about their process and what their conclusion is based on.
If the stakes are really high, triangulate your results. This is a fancy way of saying corroborate your source. Remember, you can always consider a second opinion to validate what you learned.
As a paramedic, I was trained to elicit the right information by asking diagnostic questions. By connecting symptoms and patterns to knowledge and experience, I was able to diagnose a problem to provide life-saving treatments.
I asked diagnostic questions, identified the problem, and saved a life.
My patient was in cardiac arrest (his heart had stopped). I used a defibrillator to restart his heart and transported him to the hospital.
A few days later, he was talking to his family.
You can adapt this pattern of questioning — describe, compare, quantify, connect — to virtually any situation where you are trying to determine what’s wrong and why.
It helped me save a life.
Who knows where it might take you.