Teaching Lifelong Learning: Using Questions to Learn and Teach

Lifelong learning, the ability to acquire, interpret, and apply new information for use in clinical practice, is one of the key skills we want to teach students and residents. Over the last 10-15 years, leaders in the area of evidence based medicine have developed a variety of tools and frameworks to enhance lifelong learning skills such as formulating clinical questions, performing effective literature searches, appraising literature, and applying results to patient care.

We have chosen to focus this session on the effective use of questions by learners and teachers for several reasons: (1) learners must be able to recognize the need to ask a question—the need to acquire more information—in order to provide optimal patient care, (2) learners must be able to formulate questions in a way that will enhance their ability to find an answer, (3) teachers can use questions to model lifelong learning skills, and (4) teachers can use questions to probe learners’ level of understanding and enhance the educational value of rounds.

During this session, we will examine the use of questions in three situations:

(1) How to use questions to model identifying and addressing knowledge gaps

Learning Objectives:

(a) list the five main types of knowledge gaps (b) define background and foreground questions (c) list the four components of a structured clinical question (d) list four questions that can be used during attending rounds to elicit knowledge gaps and clinical questions

(2) How to ask questions of consultants

(a) list three teaching triggers to discuss consult request skills (b) identify four criteria for a well developed consult (c) describe the benefits of using the four component structured question when requesting a consultation

(3) How to ask questions of learners

(a) define clarifying and probing questions (b) define knowledge, application, and problem solving questions (c) incorporate situation-appropriate probes to maximize education value 2

(d) us a brief self-evaluation tool to reflect on question asking/modeling behavior during attending rounds ______

Using Questions to Model Identifying and Addressing Knowledge Gaps1,2

Review of the EBM model of knowledge gaps and formulating questions

1) Knowledge gaps a) Most commonly in the following areas i) Clinical evidence: how to gather clinical findings properly and interpret them ii) Diagnosis: how to select and interpret diagnostic tests iii) Prognosis: how to anticipate the patient’s likely course iv) Therapy: how to select treatments that do more good than harm v) Prevention: how to screen and reduce the risk for disease b) Other categories include differential diagnosis, etiology/risk/harm 2) Types of clinical questions a) Background questions i) Tend to be general and basic ii) Used when you don’t know much about a topic iii) Usually find answers in textbook chapters, review articles iv) Example: You send a patient for a knee x-ray. The report says that the patient has a fabella. You have never heard this term before. Your background question is “What is a fabella?” b) Foreground questions i) Tend to be specific and advanced ii) Should be categorized and structured iii) Often find answers in primary sources (1) Categories of foreground questions (a) Can be categorized into the same categories as knowledge gaps (b) Doing so enhances ability to use “clinical queries” in OVID and PubMed (pre-designed, evidence based search strategies that are grouped according to question category, e.g. therapy, diagnosis, etc) (2) Structuring a clinical question (a) Facilitates searching for a precise answer (b) Has four components (i) The patient or problem being addressed (ii) The intervention or exposure being considered (keep in mind this can be a test or risk factor, not just a therapy) (iii) The comparison intervention or exposure, when relevant (iv)The clinical outcomes of interest iv) Examples (1) Background: What are the complications of gallstone pancreatitis? 1 Richardson WS, Wilson MC, Nishikawa J, Hayward R. The well-built clinical questions: a key to evidence-based decisions. ACP J Club. 1995;123:A12. 2 Lesky LG, Hershman WY. Teaching skills for promoting the practice of evidence-based medicine. Workshop, SGIM Annual Meeting, May 1995. 3

(2) Foreground, unstructured: Does my patient need an ERCP today? (3) Foreground, structured: In patients with gallstone pancreatitis, does early ERCP, when compared to medical therapy, result in fewer episodes of biliary sepsis or death?

Using the EBM model during attending rounds

1) Explicitly model the EBM process a) “Our patient had a TIA while on aspirin. I don’t know if we should continue the aspirin therapy, or add warfarin. Let’s structure this therapy question so we can find an article to answer it.” b) “In patients with recurrent TIAs, does aspirin plus warfarin, when compared to aspirin alone, reduce the rate of additional TIAs or stroke?” 2) Ask questions that will help the team identify their knowledge gaps and construct questions a) What decisions need to be made in this situation? b) What are the key clinical questions? c) What additional information do we need? d) What options are available for further evaluation or treatment? e) How do we know which is the best approach? f) How do we know that this will help and not harm the patient? g) What do we expect to be the long term outcome for this patient? ______

Obtaining and Teaching Effective Consultation The Consult Request

One major route of answering clinical questions is through the use of colleagues. When done formally, we request a consult from a colleague. Although this is among the most common methods used to answer clinical questions, learners are generally provided with minimal education on how to best ask consultant questions. Particularly in an academic setting, consultations can serve to not only affect the care of the patient, but also provide a rich educational opportunity. While not extensive, there are some data to support specific strategies in requesting consults that can provide a better response.

Key components to requesting consultations effectively

3) What do you want from your consultant? a) Clinical Assistance

b) Education

c) Continuity of Care

4) Structuring your consult request 4

a) Provide relevant clinical and background information

b) Provide an initial impression

c) Provide an explicit request that addresses the specific knowledge gap

i) Clinical Question ii) Educational Question

d) Provide relevant urgency—not all consults are STAT

e) Request the consult politely

5) Structuring the Explicit Clinical Question—The PICO format

TEACHING TRIGGERS

The Vague Question

The “Painful Consult”

The “Unhelpful Consult”

Related References:

Go S, Richards D, Watson W. Enhancing medical student consultation request skills in an academic emergency medicine department. J Emerg Med. 1998;16(4):659-662.

Kunkle EC. Communication breakdown in referall of the patient. JAMA. 1964;187:63.

Rudd P, Siegler M, Byyny RL. Perioperative diabetic consultation: a plea for improved training. J Med Educ. 1978;53:590-6.

Saunders TC. Consultation-referral among physicians: practice and process. J Fam Pract. 1978;6:123-8.

Guertler AT. Cortazzo JM, Rice MM> Referral and consultation in emergency medicine practice. Acad Emerg Med. 1994;1:565-71.

Holliman CJ. The art of dealing with consultants. J Emerg Med. 1993;11:633-40.

Bergus GR, Randall CS, Sinift SD, Rosenthal DM. Does the structure of clinical questions affect the outcome of curbside consultations with specialty colleagues? Arch Fam Med. 2000; 9(6):541-547. 5

How to ask questions of learners3,4

Attending physicians ask questions during rounds for a variety of reasons: to obtain data about the patient, to clarify facts, to probe learners’ understanding, and to provoke thought. This section will review several different, somewhat overlapping, models for categorizing questions, and will provide a vocabulary for use in thinking about the types of questions you ask during rounds.

1) Model 1: clarifying vs. probing questions a) Clarifying questions i) Elaborate facts about the patient ii) Elicit simple definitions iii) Necessary to obtain essential information, check basic knowledge iv) Examples (1) How did she describe the pain? (2) What meds is she on? (3) What was his creatinine? (4) What is the definition of a transudate? b) Probing questions i) Determine learners’ level of understanding ii) Provoke thought iii) Take more time than clarifying questions iv) Examples (1) “Given these results, what should the next diagnostic or therapeutic step be?” (2) “Why does she have a fever?” (3) “What would you do at this point?” (4) “What if this patient were 85 instead of 25?” 2) Model 2: levels of questions a) The knowledge level i) First level of questioning ii) Generally concrete questions with clear right or wrong answers  do not assess understanding iii) Similar to clarifying questions b) The application level i) Second level of questioning ii) Determine whether learners can use the information recalled at the knowledge level in a specific context iii) Example (1) “How do you interpret the pleural fluid results?” 3 House BM, Chassie MB, Spohn BB. Questioning: an essential ingredient in effective teaching. J Continuing Education in Nursing. 1990;21:196-201. 4 Weinholtz D, Edwards, J. Teaching during rounds: a handbook for attending physicians and residents. Johns Hopkins University Press, 1992, pp 40-47. 6

(2) This question assumes the learner knows the definitions of transudate and exudates, and asks him/her to apply that knowledge in the specific context of the patient’s test results c) The problem solving level i) Third and highest level of questions ii) Responses require broad knowledge base, the ability to synthesize information, consider possible applications, and evaluate alternatives iii) The EBM questions listed above are all problem solving questions 3) Model 3: responding to the answers a) In this model, “probing questions” are follow up questions that allow the teacher to pursue preliminary learner responses; they are used to expand or alter information presented in a previous response b) Types of follow up probes i) Extension probes (1) Ask learners to elaborate on a response given to an earlier question and to provide more information than offered in the original response (2) Give the message that the original response was target, but insufficient (3) Example (a) Original question: “What is your differential for shortness of breath in this patient? (b) Answer: “CHF, COPD, pneumonia” (c) Extension probe: “What else do we need to think about?” or “What else is on the differential?” ii) Clarification probes (1) Ask learners to rephrase the initial response or to clarify the original thought (2) Used when the initial response is unclear, incomplete, or confusing (3) Guide learners to find appropriate answers (4) Example (a) Original question: “Why do you think this patient may be at high risk for developing pressure ulcers?” (b) Answer: “She is elderly and frail.” (c) Clarification probe: “What clinical characteristics of elderly, frail patients increase their risk of pressure ulcers?” or, “What do you by ‘frail’?” iii) Justification probes (1) Ask learners to provide rationale for particular responses (2) Provide insight into learners’ thought processes (3) Can reveal depth of knowledge and errors in thinking (4) Example (a) Original question: “Should we consider changing any of the medications on this patient’s list?” (b) Answer: “We should consider stopping the amitriptyline.” (c) Justification probe: “Why do you want to stop that medication?” iv) Prompting probes (1) Provide additional data to elicit the correct response 7

(2) Used when learners do not respond to the initial question, respond incorrectly, seem confused, or miss the point (3) Example (a) Original question: “In this patients admitted from a long term care facility with pneumonia, what antibiotics would you choose to treat the pneumonia?” (b) Answer: “We always use Tequin, and he doesn’t have any allergies, so that should be ok.” (c) Prompting probe: “We do often use Tequin for community acquired pneumonia. However, there can be different organisms causing pneumonia in patients from long term care facilities, compared to those from the community. What are those additional organisms, and how should we cover for them?” v) Redirection probes (1) Ask for alternative responses to a given question from a number of learners (2) Useful in eliciting a variety of options or opinions (3) Example (a) Original question: “So, in this 78 year old patient with several cariac fisk factors and a history consistent with atypical chest pain, what should be our next step?” (b) Answer: “We should do a stress thallium.” (c) Redirection probe: “Well, that is certainly one reasonable option. What do other people think? Are there other options, and how do we decide what to do?”