My mother is a very smart woman.  I see it in the way she solves problems, creates complex crafts, and navigates hard conversations. She can’t, however, add fractions. She was never very good at math, she says.

“I was never very good at math” is a dirty phrase that garners much attention in my household.  My husband, a sixth-grade math intervention teacher, spends just over 170 days each year attempting to undo that misconception among low-performing public middle school students.  When I ask him what the most important factor is to help students improve, he says it all comes down to having the confidence to ask questions and the willingness to make and learn from mistakes.

As a family doctor, I believe it is my responsibility to create a doctor-patient relationship in which my patients are just that: confident enough to ask questions and feeling safe enough to tell me when they’ve made and learned from mistakes.  Did you agree to join Weight Watchers at the last office visit and still haven’t signed up? No, this isn’t a failure, but it may not be the right goal right now.  Then we talk about barriers and confidence for change and set SMART (specific, measurable, achievable, realistic, and time-phased) goals and schedule follow up.

In particular, I have been humbled by the questions my patients — or often, their family members, the people who help them stay healthy the other 8,764 hours of the year when they aren’t in my office — ask.  As a resident on an overnight call shift, I met a patient in the ED to perform a history and physical for hospital admission.  She had just received narcotics and was tired, but arousable and speaking, however slurred.  One minute into our conversation, I received a call from a nurse that a laboring patient upstairs was having a prolonged deceleration on fetal monitoring.  I needed to go immediately.  I hesitated, but the patient had received narcotics. Surely that explained her mental state and her speech. It’s always so frustrating when a patient has been over-medicated and I can’t get a history.  But in the seconds before I ran out the door, the patient’s sister asked, “Can we check her blood sugar? She sounds like that when it’s low.” It was 29.  I am so thankful that her sister was there and was willing to ask that question.

In recent years, my mother’s parents have fallen ill, and my mother has taken on a new role as advocate and health care navigator for several family members.  She tells me about the appointments she attends, the questions she asks, what she looks up on the Internet before she goes, the things the doctor doesn’t understand about our family member’s home life and why the treatment plan will be difficult.  She is an empowered patient and family member, and I find it intriguing.

“When you were in math, in middle school,” I ask her, “did you ask questions, like when you didn’t get it?”

“No. Of course not,” she says.

“Hmmm. So what makes you have the confidence to ask all those questions to the doctor now?”

“Becoming a mother,” she says. “As a mother, I had to ask questions, to take care of my kids.  It was my responsibility. And I guess I got a taste of that when I was a kid with five younger brothers and sisters.”

This reminds me, once again, how much work occurs outside of the four walls of my clinic, both to promote and undermine good health.  How the homeruns in little league softball twenty years ago make a patient more comfortable stepping onto a treadmill.  How a fight to overturn high school policy ten years ago taught another that they can drive change.  How a conscious decision to gain weight to become unattractive to avoid sexual harassment drove unhealthy behavior.  How not having enough food to eat was the cause of a lower A1c.  How becoming a parent or having a sick parent empowers patients and family members.

Though this realization illustrates that my role in my patients’ behavior is smaller than I once thought, it doesn’t leave me hopeless for change.  It leaves me evermore aware that our wellness is the result of our communities, our neighbors, our families, our policymakers.  It leaves me eager to learn how we break down the walls between my clinic, my husband’s school, our neighborhood grocery store and beyond to join together to pursue health.

Aimee Falardeau English is a family physician who blogs at Primary Care Progress.