pride ourselves on advocating for our patients based on what our medical knowledge, clinical experience, and our patients’ preferences suggest are the right choice. That’s not a bad thing. But other approaches might lead to more creative decisions. One of those approaches, inquiry in decision-making, has changed the way I view patient advocacy.1
Inquiry vs. advocacy
When you approach a decision as an advocate, you express your views. Disclosing feelings, expressing a judgment, and urging a course of action are all forms of advocacy. But advocacy risks selectively presenting information that reinforces your view while diminishing the input of others. Advocacy becomes harmful when you dismiss alternative options and suppress divergent views about the best way to proceed with a decision.
Inquiry welcomes dissent and involves asking questions. With genuine questions, the speaker seeks information that broadens his or her perspective. Inquiry involves gathering information from a wide array of individuals to ensure that you’re getting the whole picture. The goal of inquiry is to generate multiple alternatives, foster the exchange of ideas, and produce collective ownership of a decision.
What mode are you in?
|Concept of decision making||a contest||collaborative problem solving|
|Purpose of discussion||persuasion and lobbying||testing and evaluation|
|Participants' role||spokespeople||critical thinkers|
|Patterns of behavior||
strive to persuade others
defend your position
present balanced arguments
remain open to alternatives
accept constructive criticism
|Minority views||discouraged or dismissed||cultivated and valued|
|Outcome||winners and losers||collective ownership|
A tool for shared decision-making
I recently saw the power of an inquiry approach while caring for a baby with complex congenital heart disease and severe immunodeficiency. The patient just transferred out of intensive care, where he spent his first months of life with the goal of surviving to thymus transplant at Duke University Hospital. Our hospitalist team set to work to help coordinate the transfer, only to learn he was not a candidate for the procedure. Up to this point, his care team and family were focused on this single outcome, a transplant, and now we had to figure out an alternative. The cardiothoracic surgeon proposed heart surgery, and the immunologist proposed bone marrow transplant, as the next steps.
In the absence of a healthy and robust discussion (an inquiry approach), various care team members were pushing for what they believed would be the best option (an advocacy approach). We convened a family care conference, engaging in a vigorous debate about the evidence and potential sequencing and outcomes of each alternative. As we narrowed in on a treatment pathway that included heart surgery and bone marrow transplant, I distinctly recall an impeccably timed question from the palliative care social worker, who had been silent for most of the meeting. What would be the outcome if we chose not to intervene? Ultimately, after a thoughtful discussion of all the options, the family chose to take their baby home on hospice.
Health care providers are commonly asked to facilitate difficult decisions in patient care, but too often we develop tunnel vision. We recommended a specific treatment course, when more than one alternative, including no treatment at all, might exist. Recognizing intervention bias in medicine is critical to delivering high-value care by reducing unnecessary, potentially harmful interventions.2 Shared decision-making requires presenting accurate information about alternatives in an unbiased way, so individual preferences and values can be integrated with the best available science. In a situation like the one we had with our young patient, the desire to intervene in any way possible could have easily led our team to make recommendations that were not in the best interest of the patient or his family.
Acknowledge when you’re in what mode and why
Even with all of its advantages, inquiry needs to coexist with advocacy. Advocacy remains a valuable communication tool from an individual perspective when you need to attract attention and influence others. It can be particularly important for keeping our patients safe. One of the biggest challenges is knowing when you’re in advocacy mode, and understanding how to switch to inquiry mode when appropriate. There are five key components to a successful inquiry approach:
- Present multiple alternatives – it encourages debate and avoids the pitfall of settling on an easy or obvious answer
- Test your assumptions – examine things that may seem obvious on the surface; avoid making assumptions about “facts” that are not based on complete information
- Define your goals – knowing and clearly outlining goals keeps everyone focused and frames the discussion in the direction of progress
- Allow dissent and debate – encouraging (even requiring) dissenting opinions avoids groupthink, gives everyone a voice, and creates room for critical analysis
- Make the process fair –people remain engaged in the process when they feel their opinions are heard and valued (even if they’re not eventually adopted)
Combining an inquiry orientation with team-based care is well suited to our volatile, uncertain, complex and ambiguous (VUCA) world in health care. That’s because inquiry is a respectful process that challenges the status quo while encouraging exploration and creativity. When you are comfortable with inquiry, you’re at ease asking questions. You dive deeper, discover knowledge gaps, and seek a range of perspectives. The results are clearer understanding, more options, and stronger partnerships with patients, families, and one another.