1. Effective Questioning
Promoting higher order thinking and reasoning
Our residents are problem oriented, self directed learners. They learn best on a “need to know” basis related to the clinical situations they encounter. Part of our role of teachers is to be a source of knowledge and information. A more important role, however, is to be a guide, helping the resident use the knowledge they often already possess to understand and properly manage clinical situations. This module discusses how to question residents to maximize their learning experience.
University of BC
Faculty of Medicine
Department of Family Practice
Post Graduate Program

2. Good Questions
Determine students’ learning needs and direct the teacher to an appropriate level
Stimulate curiosity in the subject
Clarify concepts and emphasize key points
Stimulate and engage learners
Guide clinical reasoning
Encourage reflection
Good questions are appropriate to the learners level of education. Family Practice residents should have a solid knowledge base from medical school which they now need to learn to apply to clinical practice. Our questions should stimulate interest in the clinical topic and emphasize the understanding necessary to manage the clinical situation. We should ask questions that emphasize key points and clinical concepts that help the resident build a framework for similar clinical encounters. Questions should draw on the resident’s knowledge and previous experience to reflect on the present situation.

3. Good Questions Clear Brief (one question at a time) Single focus
Divergent (allow more than one acceptable answer and broad thinking)
Open-ended (short answers are insufficient)
Questions should be clear and brief so that the resident works on the answer rather than understanding the question. Try to avoid “Guess what I’m thinking” questions. ( “Do you know what I usually do in this situation?” ) Questions should be open ended, requiring explanation rather than a short answer. A good question can have many correct answers. Use the residents responses to guide him or her to the concept you want to impart.

4. Levels of questioning Yes/no Factual Recall Application of knowledge
Analysis of knowledge
Synthesis
Simple “Yes and No” questions require the least involvement from the resident. All residents (and their teachers!) will have knowledge gaps that can be discovered with simple questions of fact. Although useful, this type of question doesn’t address the resident’s level of understanding. Higher order questions allow the resident to “use” the facts to understand the clinical situation.

5. Hierarchy of Questions
How would you manage this patient in this clinical situation? How do these findings exclude other Diagnoses? What do these findings mean? What causes this problem Is this true?
Synthesis
Analysis
Application
Factual Recall
Yes/No

6. Here is an example: Patient with Headache
Ms. P is a 23 woman who presents with a six month history of headaches. The resident sees you and reports that Ms. P has had occasional headaches for several years but in the last six months they have become more regular and persistent. She has been missing work on occasion. She takes acetaminophen and ibuprofen with some benefit. The headaches are occasionally associated with nausea and tend to improve or resolve after sleep. With this limited history, what would be your approach with the resident?

7. Give an example of a question regarding headaches at each level of the questioning hierarchy
Yes/no:
Factual recall:
Application of knowledge:
Analysis:
Synthesis:
Examples given were modified from those in “Medical Teaching in Ambulatory Care” second ed. By Warren Rubenstein and Yves Talbot, Springer Publishing 2003 page 26.
There is an unlimited number of questions that could be asked in this case. Your aim is to help the resident acquire a comprehensive and clinically effective approach to the patient with a headache. Spend a few minutes to think of a question at each level of the questioning hierarchy and discuss with your group how each question might encourage growth and reflection in the resident. How do higher level questions promote greater understanding?
Examples:
Yes/No:
1/ Do you think this woman is having migraine headaches?
2/ Is nausea a typical symptom in migraine headaches?
Factual recall:
1/ Tell me the common triggers for migraine headaches?
2/ What medications are commonly used to treat migraine headaches?
Application of Knowledge:
1/ Why do you think that migraines are often related to a woman’s menstral cycle?
2/ How do triptans work to relieve migraines?
Analysis:
1/ Why do you feel this woman is getting more migraine headaches now?
2/ Tell me how you differentiate migraine and tension headaches?
Synthesis
1/ Using evidence based medicine, how would you manage this patient?
2/ Knowing Ms. P’s other medical issues, what would be the best approach to her headaches?

8. Now you practice:
A patient presents for review of their diabetes. Question your resident about the patient they have seen at each “level of questioning”
Consider the level of your resident. You may chose to start with a simple factual question and then progress to questions of a higher order. Remember that the learner can easily look up factual information. To impart factual knowledge is a minor role of the teacher. The teacher should be a guide who allows the learner to use the knowledge they already possess to analyse and understand clinical situations and apply the knowledge in a useful way.

9. A little more practice:
As a group challenge each other to ask a higher level question for:
Abdominal Pain
Asthma
Chest pain
Fatigue
Depression

10. Adult Learners
We learn more from what we “don’t know” than what we “do know”
Problem based learning is most effective.
Effective questioning allows the learner to amalgamate the knowledge they already possess into useful clinical understanding. Small additional pieces of knowledge added by the teacher in a clinical situation which allows the learner to improve their overall understanding of the situation is much more likely to be retained than information which is simply presented on it’s own. Effective questioning allows the learner to discover the pieces they don’t know and more effectively use the information they already possess.

11. The One Minute Preceptor
1/Get a Commitment
2/Probe for Supporting Evidence
3/Reinforce What Was Done Well
4/Give Guidance About Errors and Omissions
5/Teach a General Principle
The question you ask when using “The One Minute preceptor” can be at a “higher level”. Your initial question may be to get a commitment of a diagnosis but your probe for supporting evidence could require higher levels of analysis and synthesis. Consider how you might use different levels of questioning when using the One Minute Preceptor technique.
Examples for a patient presenting with a sore throat:
What do you think this patient’s problem is?
Factual recall: What are the characteristics of a strep throat?
Application of Knowledge: What signs and symptoms support your conclusion that this is a strep throat?
Analysis: With this mother’s reluctance to use medication, what are your management options?
Synthesis: Knowing the incidence of complications of streptococcal pharangitis, what do you feel is the cost/benefit ratio of treatment with penicillin.

12. SNAPPS* The Student: Summarises the case
Narrows the differential diagnosis
Analyses the differential diagnosis
Probes (asks the teacher about areas not understood)
Plans management; and
Selects an issue for self directed learning
*Wolpaw TM et al. SNAPPS: a learner centred approach for outpatient education. Acad. Med 2003; 78:
SNAPPS is a similar process that is led by the learner. After presenting the case the student discovers areas of weakness or gaps in understanding which made their analysis difficult. These areas are probes by questions to the teacher who may supply information or knowledge or redirect the probe with further questions or give suggestions for self directed learning.

13. Readiness
Is the learner at the appropriate level for the questions being asked?
Are there other issues involved which interfere with the residents performance?
There are many reasons that learner has trouble with questioning. The teacher must be sure that they are asking questions at a level appropriate to the learners level. A student would have trouble discussing the ethical issues of disease management if they did not understand the natural course of the disease.
The learner may personal issues or problems which prevent him or her from dealing with a clinical situation. Did a similar situation go badly in the past? Are there moral or ethical issues involved which might be difficult for the learner. It is necessary to stop and deal with these issues before questioning can continue.

14. Questioning a group Pose, pause and pounce Spread the questions around
No answer is “stupid”
Allow silence
Expect the unexpected
Be aware of different levels of learners
Teaching a group requires new sensitivities. All learners fear embarrassment. It is important that all learners feel safe. After posing questions give adequate time for the learners to reflect. “Dead air” is not a bad thing. Be prepared to deal with unexpected responses and be sure the group respects the efforts of each of it’s members. When you have learners at different levels it is often best to start questioning with the most junior learner and “move up”. This gives the more senior learners a chance to be “the teacher” and reduces the likelihood of a more senior learner being embarrassed or “one-upped” by on of their juniors.

15. You’re with a 2nd year resident, a 4th year med student and a first year med student.
After seeing an older man with increasing shortness of breath and a long history of smoking,
How would you question the group?
Who would you ask first
Give an example of the questions you might ask each learner.
Questions should encourage participation by the whole group and avoid embarrassment. It is usually best to ask a question of the most junior learner first. The first year medical student might be asked what some of the symptoms of asthma. (factual recall). The fourth year student could be asked the differential diagnosis of this presentation and the resident could be asked for an investigation and management plan. Use the opportunity of having learners together to encourage learners to teach one another. If a learner has trouble with a question, see if the more senior learner can answer. It helps learners to appreciate what they know and see how they have advanced relative to their juniors.

16. I don’t know An excellent answer:
Remember the “I don’t know” if often the most appropriate response to a question. It is important that learner not feel that giving this response reflects badly on themselves. In this situation the teacher may supply the answer or may choose to take the question to a simpler level which allows the learner to assess knowledge they do have. The teacher then guides the learner from the simpler answer to the more complex initial question.

17. Remember
Effective questioning allows your residents to mature in their clinical skills and understanding. Higher level questions require greater thought and reflection and move the resident closer to their goal of being an independent effective clinician.

18. Thank You
This module was written as an aid to the Preceptors in the Postgraduate Family Practice Program at the University of BC.
Study credit is available to groups of preceptors who complete the module
Please give us your feedback on the module so that we may improve it for others.
you comments to Dr. Christie Newton, Faculty Development, UBC Family Practice