Ask Me 3…other questions?

I do some work on health literacy and it’s often recommended that patients use the Ask Me 3 approach. The idea is that a patient who comes into a doctor’s office prepared to ask 3 questions will have a more productive visit and a better understanding of their health issues. The 3 questions are:

  1. What is my main problem?
  2. What do I need to do (about the problem)?
  3. Why is it important for me to do this?

Do the AM3 questions really make a difference?

In a recent study, 834 patients in 20 different practices were randomly assigned to either an AM3 intervention group or a control group (Galliher et al., 2010). In the AM3 intervention, patients were given pamphlets including the AM3 questions and were even reminded by nurses on the way to the exam room to ask the questions. The control group received no pamphlets and no reminders.

Interestingly, the researchers found no difference between the AM3 and control patients in their rate of asking questions. Both groups seemed to include highly motivated patients so the question-asking rate was high in both groups (about 92%). There also was no difference in the rates of either filling or taking prescriptions. Control patients were actually more likely to recall that their physician recommended a lifestyle change (68% vs 59%, P = .04).

The authors concluded that the literacy levels of the patients were simply too high to show the success of the intervention and that you would have seen bigger differences if the patients had poorer health literacy. (This prompted a rather terse response by a public health activist which is worth reading.) The researchers also noted a potential Hawthorne affect: Patients in both the AM3 and control groups were informed that this was a study on communication and were not likely to forget this given that there was a tape recorder in the exam rooms.

My takes

The idea of prompting patients to prioritize questions and to focus on the most essential ones is a good one, but not an end in and of itself.  Though of course it would be interesting to evaluate the value of the questions in diverse populations, I found it interesting that the study provided little data on the types of answers being provided by the physicians. Communication, after all, is a two-way street and merely being able to memorize or read questions from a sheet is just the start of the process (and maybe even only an illusory bandaid). We learn that the physicians underwent training on data collection but were specifically asked not to change their communication practices; we learn nothing further about what these communication practices were. A common perception is that when it comes to health literacy, the “problem” is generally one that belongs to the patient, and I thought this was unintentionally reflected in this research.

I also think the questions themselves should be revisited if further studies are being undertaken. Having recently reviewed some papers on patient-centered care, I noticed how doctor-centered the AM3 questions are even though they’re written from the patient’s point of view and use personal pronouns like “I” or “me.” For example, a patient asks the doctor to tell her what her problem is, what she needs to do, and why it is important, but the questions leave no room to remind the patient to tell the doctor about her important quality of life and cultural values– values which should modulate the doctor’s response to all of these questions. Perhaps the second question should be rewritten as “What do I need to do, given my particular experiences and personal situation?” which should prompt the doctor to ask her own questions, starting with “Tell me more about this….

Reference

Galliher, J.M., Post, D.M., Weiss, B.D., Dickinson, L.M., Manning, B.K., Staton, E. W., et al. (2011). Patients’ question-asking behavior during primary care visits: a report from the AAFP National Research Network. Annals of Family Medicine, 8, 151-159.

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