Asking Questions in the Clinical Learning Environment
Part 2: “Bad Questions”
By: Geoff Stetson, MD
Let’s get “pimping” out of the way. The term is outdated, carries terrible connotations in a non-medical sense, and infers using questions as a form of humiliation or establishing a hierarchy.4-6 Hopefully, you recognized from my first post in this series that I am harping on creating a safe learning environment. Questions, when used correctly, are an effective tool to teach, as well as to build relationships, camaraderie, and psychological safety. This will be how we think about inquiry from here on out. We will also assume that readers of this post care about their learners as people and are hoping to put them in the best position to succeed.
That being said, even if we have the best intentions in the world, and we are trying our best to ask “good questions”, they can sometimes come out “bad”. Where most people run into trouble is asking the infamous “guess what I am thinking” question. It is really hard to define this type of question. Kost and Chen define it as, “testing knowledge so obscure that only the questioner would know the answer.”1 This has not been my experience. I would say that this approach is more along the lines of the “P-word.” Probing students regarding esoteric facts doesn’t sound like a very supportive pedagogical approach.
What I typically see play out is that an educator has a learning point pop into their head during the course of clinical care. If you watch closely, you can sometimes see the point of inception. The teacher is excited and wants to share their knowledge. They also want to allow their students to shine and engage them in the learning. So rather than just deliver their learning point, they try to get someone else to say it for them, by “leading the witness” to the answer. You can see the good intentions in action. The result is ultimately a confusing mess. Let’s look at an example:
A student delivers a presentation of a patient coming in with acute on chronic sinusitis. They tell a concise and convincing story and devise a reasonable treatment plan for run of the mill acute on chronic sinusitis including a prolonged course of antibiotics with the caveat to consider MRSA coverage if not improving. Not bad. But the teacher wants the learner to think about diseases in which chronic sinusitis is one part of a more systemic syndrome. A very worthy thought exercise and differential diagnosis to consider. Here is how that might go poorly:
- Teacher – Clear and concise presentation. Bravo. I really liked the contingency planning in case the patient’s symptoms don’t resolve at the rate at which we expect. To take this a step further, what if we were to get a UA on this patient and we find hematuria and/or proteinuria? What might you think about then?
- Student – Hmmm. Good question. Maybe Diabetes?
- Teacher – Well, sure! Good idea! Diabetes can give you protein in the urine, and patients with diabetes can be immunosuppressed leading to frequent infections. But what if the patient also had palpable purpura on their lower extremities?
- Student – Hmmm [anxious fidgeting]. I’m not too sure.
- Teacher – That’s okay! Saying “I don’t know” is totally fine.
- Student – Any specific vasculitides you can think of?
- Student – [Contemplative looks…more anxious fidgeting…shakes head no]
- Teacher – No worries! A patient with chronic sinus infections, active urine sediment, and palpable purpura may have granulomatosis with polyangiitis, or GPA. This is all to say that sometimes chronic sinusitis is part of a syndrome and not an isolated condition. Let’s build a differential of syndromes that might present with chronic sinusitis.
You can see in this example that the teaching point was a good one, and good intentions were present, but the method of getting there was sub-par. What this instructor did, and this is how I view “guess what I am thinking” questions, is that they were asking a very specific question with a very specific answer. They also were making some mental leaps that would not be obvious to many others, a hallmark of very bad questions. But, any question with a specific “right” answer is a quick way to get yourself into trouble. You put your learners in a situation where they will either feel good (if they get it right), or bad (if they get it wrong), there is no neutral option. You also don’t learn much about your students. Do they know this factoid or not? You don’t observe how they think, how they build on their foundational knowledge, or how they identify their own learning needs. Here is a simple way this teacher could have gotten the learners wheels turning without putting them on the spot for any specific answers.
- Teacher – Clear and concise presentation… Sometimes chronic sinusitis is a part of a syndrome. Do you know of any syndromes in which chronic sinusitis may play a role?
- Student – Yeah! I remember learning about some childhood immune deficiency that presents with recurrent sinusitis and pneumonia. I think is was IgA deficiency. Also, I am pretty sure there are some vasculitides that can have recurrent sinus infections, but I can’t remember which ones.
- Teacher – Great! That is a great place to start. I tend to think of GPA and MPA as the vasculitides that might present with chronic sinusitis. And I forgot about IgA deficiency! Nice call! Let’s build a differential of syndromes that might present with chronic sinusitis.
Rather than asking for any specific answer, the teacher used a relatively open-ended question to start a conversation and promote recall. They also could use this question and answer set as a targeted needs assessment, the topic of post #3. See you then!
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