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I have a confession to make.
It has been 10 years since Michael Barry, MD, and Susan Edgman-Levitan wrote their groundbreaking 2012 New England Journal of Medicine article in which they introduced the concept of asking, “What matters to you?” in addition to “What is the matter?” in the context of implementing shared decision making. While others — like IHI’s President Emerita and Senior Fellow Maureen Bisognano — immediately recognized the significance and the brilliance of that reordering of those four words, I must admit I wasn’t so sure.
I’m a skeptic by training. As a clinician, I’ve learned to ask for the evidence. So, when Maureen first told me about the “What matters to you?” idea, I thought it sounded interesting, but I wasn’t initially persuaded that it was a powerful change idea. Skeptics need to see for themselves.
Shortly after my conversation with Maureen, I remember very clearly that I was on one of the wards at Weill Cornell Medical Center. I don’t recall my patient’s admitting diagnosis, but I recall we were facing a dilemma about the next steps in his care.
After doing my clinical assessment and ticking all the boxes on my mental checklist of what I thought was most important for the patient, I said, “I have another question for you.” I figured it couldn’t hurt to put this “What matters to you?” idea to the test.
I asked the question. And the patient stared at me in what appeared to be disbelief. I remember thinking that perhaps I’d made a grievous mistake.
But then an incredible thing happened. After pausing a moment, he turned to his adult grandson who was sitting at his bedside and said, “Well, now there you go. Here’s a real doctor.”
I was so surprised. This patient’s definition of a “real doctor” was not about whether I was proficient at addressing all the clinical details of his condition. He assumed I was going to do that. What mattered to him was that he mattered to me. It was about seeing him as an individual and taking the time to learn what was truly important to him.
It sounds so simple, but when I reflect on that moment, I wonder why I was so doubtful. Why didn’t I think asking what matters would make a difference?
I believe it’s because we spend so much time in medical school, nursing school, or other health professions programs learning all there is to know about the technical approaches to better clinical care — all of which is, of course, vital — but we don’t necessarily train on or practice how to build relationships with our patients. It’s as if we need to remind ourselves that what makes or breaks the therapeutic relationship is the relationship part of it. Asking “What matters to you?” signals to the person in the hospital bed, exam room, nursing home, or rehab center that your goal is my goal. That is a powerful statement of alliance. It’s a powerful way to start building trust.
Resistance to Asking “What Matters To You?”
Since my own “conversion” experience, I’ve encountered many people who have been similarly doubtful about the significance of this deceptively simple turn of phrase. I remember, for example, at the start of the Age-Friendly Health Systems initiative when we did a review of all the practice models for taking the best possible care of older adults. After reviewing the evidence, we concluded that we had to focus on four things: medication adverse events (Medication); ensure mobility and functional capability (Mobility); attend to cognition and mental status (Mentation); and learn what matters to the older adult so that you can build care plans consistent with those priorities (what Matters). These came to be known as the Age-Friendly Health Systems 4Ms.
When we started working on the Age-Friendly 4Ms with clinicians and providers, they were comfortable working on mobility, medications, and doing dementia assessments and delirium screenings and interventions. But asking what matters gave them pause. It made many of them deeply uncomfortable. It’s interesting because, in many ways, this is the intervention for which you don’t need to go to medical school or have other specialized training. But time and again, clinicians would balk at asking this most human of questions.
Some of their challenges were based on skepticism like I had earlier in my career. Some wondered how to ask the question or how to bring it into a routine clinical interaction. A lot of the hesitation, however, had to do with anticipating the answer. Specifically, many worried that patients’ answers would be far out of the scope of a typical encounter.
The truth is that simply asking, “What matters to you?” builds trust, and this is therapeutic unto itself, and so it is fully within the bounds of a clinician’s endeavor. In other words, asking what matters — making a patient feel part of the process and prioritizing their thoughts, needs, and concerns — is part of the healing process.
Are there times we can’t accommodate what’s most important to the patient? Sure, it happens. But this is vanishingly rare. Patients ask for simple things — like seeing a family member, listening to a particular song, or having company in the quiet and lonely evenings in the hospital. And when someone asks for something that we can’t do, we can say, “I hear what you’re looking for. I can’t deliver this on my own, but we can help you get there.” This is where connecting with people in a patient’s life is essential because they might know how to assist.
Why “What Matters” Is Important for Equity
There are often common themes in answers about what matters most. We want to be comfortable. We don’t want to be in pain. We want to be, by and large, close to family. We want to spend time on things that give us joy. We want the benefits of medical treatment, but we want to avoid the burdens, if possible. But it’s also important to remember that we shouldn’t assume that what matters to us is the same for our patients.
I believe it’s safe to say that how we ask and whom we’ve asked, “What matters to you?” has often been — and too often continues to be — inequitable. Are we asking this question of our patients who may never have been asked what matters to them about their concerns and their needs? Are we then building systems capable of meeting those needs?
We must consider not only what has already been expressed, but also the needs that have not yet been stated where there has been systematic underrepresentation or intentional exclusion of what matters to communities of color and other historically oppressed and marginalized populations. As we ask, “What matters to you?” in the coming 10 years, asking it more equitably will be essential for developing systems of care capable of delivering on the promise of health equity.
Editor’s note: Look for more each month from IHI President and CEO Kedar Mate, MD, (@KedarMate) on improvement science, social justice, leadership, and improving health and health care worldwide.