Arthur Kleinman
The Eight Questions
The last one asks what you are afraid of
Kleinman, Eisenberg and Good, Culture, Illness, and Care, Annals of Internal Medicine, 1978
What to ask, and what to be asked, in a consultation. Why Kleinman's list has these eight questions on it.
What actually happened?
In 1978 Kleinman and two colleagues published a short set of questions for clinicians, since known as the explanatory model interview. What do you call this problem. What do you think caused it. Why did it start when it did. What does it do to you, and how. How severe is it, and how long will it last. What treatment should you have. What trouble has it caused you. And last: what do you fear most about it. Seven of them ask how the person understands the thing. The eighth asks what frightens them, which is usually what is actually in the way.
They ask about the person, not the pathology
Not one of the eight asks about symptoms, because the clinician can find those without help. They ask after the explanation the person is carrying around: cause, timing, consequence. That explanation can be wrong and it still governs every decision they make afterwards.
Someone who believes the tablets are damaging his liver will not take them for three months, whatever he is told.
The fear and the clinical priority rarely match
What the clinician is watching and what the patient is dreading are usually different objects. The clinician has the numbers. The patient may be afraid of never lifting a grandchild, of becoming a burden, of losing the job. Unasked, every reassurance lands beside the point.
The doctor keeps repeating that it is controllable. What he is afraid of is what the office will think.
The list works on yourself and on your family
It is not reserved for clinicians. Run it before you take someone to an appointment and you know what to ask on their behalf. Run it on yourself and the fear and the judgement come apart. The written answers are usually shorter than the dread was.
Ask a parent what frightens them most before the appointment. It is worth more than asking where it hurts.
How do I use it today?
Where you are: you are taking a family member to an appointment, or carrying a long problem you cannot describe.
Ask first: how many of the eight can I answer? The last one above all. Write down exactly what frightens you.
Where it goes wrong: using it to challenge a doctor for not asking. The structure of a clinic makes it hard for them. And do not turn it into an interrogation. It is an opening, not a form.
Lines to keep
What do you fear most about this illness?
Seven questions ask for understanding. The eighth asks for the fear.
Fear is usually the thing actually standing in a person's way.
Same situation, other people are asking
My parents got old and I don't know what I can do.Taking care of him has emptied me out.There are four of us and I'm the only one doing it.Two years of caring for her and I broke first.Caring for a parent · all 6 questions →If this one named what you are going through,
send it to someone who needs it, or keep it somewhere you will find it again.