Dr Debra Stulberg. Professor and Chair of Family Medicine, University of Chicago
When I decided to go to medical school, a big part of my motivation was to help teens find a trusted professional they could talk to about sexuality, reproduction, and family planning – primarily when looking to delay pregnancy. I knew that an open conversation about sexual topics was often considered taboo. If I could use plain language when working with patients, and provide a comfortable environment to chat – along with a range of family planning options – then they would be able to plan their lives before becoming parents.
I have come to learn that it can be equally awkward – and sometimes even more taboo – for a person to share with their clinician that they do want to become pregnant. We health professionals make assumptions far too often – e.g., that a person who is young, single or living in difficult financial circumstances must want to avoid or delay pregnancy. Likewise, when seeing the forty-something with five children, or the person with a health condition that could be worsened by pregnancy, we assume they have no desire to become pregnant. These beliefs may not only be untrue, but also deeply biased. This can lead to bad or inappropriate ‘care’.
What matters to me is what matters to my patients. I have come to realise that the only way to know what they want – particularly when it comes to future childbearing – is to ask!
I am acutely aware that primary care services are overwhelmed right now. There are not enough hours in the day or staff to dedicate to follow-ups. I am equally aware that rising maternal and infant mortality rates in the US offer compelling evidence that the status quo is not sufficient. We need a process that better supports healthy pregnancies.
In primary care, we routinely ask intake questions to screen for conditions that can affect a person’s health, including but not limited to: tobacco use, depression, and intimate partner violence. A person’s wishes regarding future pregnancy should have an impact on the care we provide. We have to take into consideration what medications are safe, how much (if any) alcohol is recommended, and what vitamins to take, as well as when to start taking them.
Unfortunately, we often assume some other clinician will offer the reproductive health services critical to avoiding, delaying, or becoming pregnant. A national survey of outpatient visits conducted in the US showed only 14% of these encounters involved preconception or contraceptive care.
Dr Debra Stulberg in clinic
When I learned about the simple approach – One Key Question®(OKQ) – I had an ‘Aha!’ moment. [The founder of OKQ, Michele Stranger Hunter, has been a consultant on QNIS’ Healthier Pregnancies, Better Lives programme for the past two years.]
If we routinely asked everyone what their wishes were, then we would stop making assumptions. Rather than “Are you using birth control?” or “Can I help you with pregnancy prevention?”, One Key Question® prompts clinicians to ask: “Do you want to become pregnant in the next year?” The patient can answer yes, no, I’m not sure, or I’m okay either way.
Based on each person’s answer, we can then provide the appropriate counseling and follow-up, whether that’s focusing on preconception health, pregnancy prevention, or both. As a clinical tool, OKQ is simple, and aligns with the values of providing comprehensive, compassionate, patient-centered care.
In using this with my patients, I have learned all sorts of nuanced information that has proved invaluable in guiding the care I provide. I find many patients feeling uncertain or ambivalent about their pregnancy wishes. In those cases, OKQ prompts great discussions about their reproductive preferences. Some patients don’t want to become pregnant, but feel even more strongly that they don’t want to use birth control. Others love their birth control method and want to continue it, even though they are comfortable about conceiving. For many people, relationship dynamics – such as how often they spend time with their primary partner, or how longstanding and trusting the relationship is – determine a person’s choice of whether (and how) to actively prevent or prepare for pregnancy.
Besides using One Key Question® in my own practice, I have also led research about its implementation and effects when used in several different primary care settings. Much like the information the question elicits from patients, the findings from this research are nuanced.
One of my biggest take-homes from the research is that it’s not just whether a practice uses One Key Question® that matters, but how they implement it. In a study where we randomized primary care and Ob/Gyn practices to implement One Key Question® (while other clinics in the study continued to provide usual care), 95% of clinicians and staff who responded to our survey about One Key Question® said it addressed an important clinical need, and the vast majority felt it did not slow check-in time (90%) or room turnover in clinic (93%) excessively.
Follow-up qualitative research with clinicians and staff indicated that the main factors in facilitating the implementation of One Key Question® were the support of clinic leadership and the time spent on training, pre-implementation. Ongoing barriers to implementation included competing demands during the patient visit, and the concern that asking about reproductive health could detract from the reason the patient came to clinic. Nonetheless, in this study, patient satisfaction increased significantly in the clinics employing the One Key Question® process, which was not true in the usual care practices.
I believe that it is critical to invest the time in training clinicians so that they can provide high-quality, unbiased counseling. This training is available virtually in the US from Power To Decide, the organization that currently hosts One Key Question®.
Asking One Key Question® to open the conversation is an evidence-based approach that puts the patient’s wishes first. Exploring the possibility of developing an effective, Scotland-specific version of OKQ would be a good idea for Partners in the HPBL Coalition to explore.
