1. Promoting higher order thinking and reasoning 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

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)

4. Levels of questioning Yes/no Factual Recall Application of knowledge Analysis of knowledge Synthesis

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. Patient with Headache

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.

8. A patient presents for review of their diabetes. Question your resident about the patient they have seen at each “level of questioning”

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.

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

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; 78:893-898.

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?

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

15. You’re with a 2 nd year resident, a 4 th 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.

16. An excellent answer: I don’t know

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. Email you comments to Dr. Fraser Norrie, Faculty Development, UBC Family Practice fraser.norrie@vch.ca