Asking Questions in the Clinical Learning Environment
Considering the Needs Assessment
By Geoff Stetson, MD
After covering general rules to asking questions, and what is a “bad question”, it’s time to get into some of the specific ways in which questions can be used effectively in the clinical learning environment. In my health professions education training, I was brought up with the “Kern Six-Step Approach” to curriculum development in medical education1. Those of us who use it, tend to know it backwards and forwards. In figure 1, you can see a conceptualization of the six steps. After building a few curricula and beginning to apply this model on a regular basis, I began to think about all of my teaching in the general framework of:
- Identify a learning need
- Determine my objectives
- Plan teaching interventions that meets my objectives
- Get feedback
And when I say all of my teaching, I mean ALL of my teaching. Whether it is dropping a pearl on rounds, giving a 15-minute “chalk talk” to my inpatient wards team, presenting at a conference or grand rounds, I always use this basic approach.
Figure 1. Kern’s Six-Step Approach to Curriculum Development in Medical Education.2
As you can see, the first step in my approach is identifying a learning need. There are many ways to identify learning needs in the clinical arena. The best way I know is to listen to what the learner’s are saying. Their presentation typically reveals what they know about a topic and what they do not. Pay close attention, and you should be able to identify gaps in knowledge that you can fill. A second way to identify a need is through the learner’s questions. Here, the learner is laying bare the point at which their knowledge ends (for now). Remember from my first post, this kind of honest and humble approach to the limits of understanding needs to be celebrated. The last way that I routinely identify needs is through asking questions (that’s why you’re here, right?).
When asking questions as a needs assessment, your goal is to find the gap in knowledge so that you can fill it in. It is important that you state this as your intention and make clear that their responses will not be used as part of their evaluation (Post 1 – Rules 1 & 2). The best way to perform a needs assessment through questions is to keep your line of inquiry broad and open-ended. What do I mean by broad? Think of your question as an invitation. You are inviting your learner to share with you the knowledge they possess, ideally up to their limits. What do I mean by open-ended? It would be difficult to answer the question with a “yes”, “no”, or any single word. For clarification, here are some categories and specific examples of question stems:
- Open Invitations/Conversation Starters
- What has been your experience with… [insert disease process, syndrome, management decisions, specific patient population, etc.]?
- What have you been taught about…?
- Clinical Reasoning Specific
- How do you think about…?
- What is your approach to…?
- Questions focused on individual patients
- What would make you worried overnight?
- Why do you think this patient is presenting with… [insert discrepant piece of data from typical illness script]?
- How would you determine if we made the right diagnosis and management decisions?
- What is the next step in your diagnostic/management plan?
- What is your question for [insert consultant]?
This is a short list. As you can imagine, there are hundreds of questions that one could ask that fit these similar principles. Each of these questions is broad and open-ended, which is mostly accomplished by using the words “how”, “what”, or “why”. “How” and “why” questions are particularly difficult to answer with only a few words. “What” questions need to be well crafted such that you are not asking for an answer that is particularly specific.
Another aspect of all of the above question stems is the word “you”. Why is that important? Because you (the teacher) are assessing the needs of the specific learner. It is their specific knowledge gap that you are trying to determine. So, it is important to find out how they, specifically, think about and approach various clinical scenarios. For example, take a look at the following questions with the word “you” changed, compared to the examples above:
- Why is this patient presenting with… [insert discrepant piece of data from typical illness script]?
- What is the next step in the management plan?
- What is the question for the gastroenterologist?
Can you see the difference between these questions and those that include the word “you”? When omitting “you” it implies there is a right answer that the learner should attempt to produce. If you really want to find the gap in a learner’s knowledge (so that you can fill it), including the word “you” is key.
- All good teaching starts with a needs assessment
- Use broad and open-ended questions
- Use “how”, “what”, and “why” questions
- Always include “you”
See you next time for questions as retrieval practice.
1. Thomas PA, Kern DE, Hughes MT, Chen BY. Curriculum development for medical education : A Six-Step Approach. Third edition. ed. Baltimore: Johns Hopkins University Press; 2016.
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