A Faculty Development Newsletter

November, 2000

The theme of this November newsletter is "Using questions in the clinical setting to stimulate learning."  Perspectives on using question in the clinical setting are based on an interview with Bridget Wagner, D.O., who was interviewed by Robbin Kirkland, Ph.D., Coordinator of Faculty Development.      

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Our preceptor highlight for this month is Bridget Wagner, D.O., Director of the Family Practice Residency Program at St. Joseph’s Hospital in Warren, Ohio.  Dr. Wagner is also a graduate of the OUCOM Academic Leadership Fellowship program and currently a participant in the Osteopathic Heritage Health Policy Fellowship.  As a preceptor, Dr. Wagner is a strong advocate of using clinical questions to stimulate learning and discussion and has outlined several key components that can be employed in the clinical setting.  

First, Dr. Wagner suggests that learning, and in particular the opportunity to ask clinically relevant questions, are dependent upon establishing a climate that is “non-threatening” to the trainee.  In this regard, she notes that it is important for the trainee to feel comfortable, at ease, and not intimidated by responding to questions and asking questions.  Dr. Wagner mentioned that she takes the first step towards creating a “non-threatening” climate by getting to know trainees and initially spending about an hour engaged in general dialogue regarding the trainee’s interests, goals, family, strengths and possible deficiencies.  In essence, Dr. Wagner feels that the initial and on-going dialogue helps to dissolve the “hierarchy” in the learning experience and develops a spirit of mutual sharing and collaborative learning.  Second, Dr. Wagner suggests the use of “open-ended” questions that will encourage strong clinical discussion and exploration of the trainee’s thought process.  Third, the learner must be given time to respond to questions and trainers are encouraged to reframe questions when necessary. Fourth, Dr. Wagner discourages “putting the trainee on the spot”, particularly in the presence of the patient.  Fifth, determine what you want to get from your questions so that the response from the trainee can be correctly focused.  In conclusion, Dr. Wagner suggests that trainees should be encouraged to ask questions that will help drive the trainee’s interest in seeking knowledge. 

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Research On Asking Questions in the Clinical Setting

While commenting specifically regarding clinical education, Westberg and Jason (1993) suggest that asking questions serves as the “foundation” of teaching and learning.  Among their “key reasons for making question asking central to teaching”, Westberg and Jason believe that questions tend to place significant responsibility on the trainee and stimulates further reflection, exploration and self directed learning.  Having learned how to ask clinically appropriate questions, the trainee may be more equipped to ask clinically relevant and probing questions when interacting with patients.  Instead of asking questions that result in nothing more than the “recall of facts”, Westberg and Jason suggest asking questions that will help drive complex or “higher “ levels of thinking.  The use of “open-ended questions, as noted by Westberg and Jason (1996), can help to stimulate discussion among the trainees and “gives learners maximum freedom to express what they are thinking and feeling.” From a similar perspective, Westberg and Jason encourage trainers to “help learners examine’ their own thoughts by “probing”, “challenging assumptions”, and “asking questions that test the reasoning” associated with their responses. Douglas, Hosokawa, and Lawler (1988), suggest that the “resident”, and we may add other trainees as well, “should be taught and led by questions, specific and stated clearly”.  They further state that “if our goal is to encourage problem solving, then more of our questions must be open questions that allow for a range of appropriate responses”.  Douglas, Hosokawa, and Lawler propose that the most commonly asked questions could be classified as “lower level” and “higher level” with emphasis placed on the level of the trainee.  Specifically, “lower level questions require knowledge, comprehension or application”, while “higher level questions require analysis, synthesis, or evaluation”.   Overall, the use of questions can add considerably to the learning experience and stimulate self-directed learning on the part of the trainee. Clinical teachers should also keep in mind that questions should be matched with the level of the trainee.

Clinical teachers and trainees are encouraged to review these and other studies in more detail.  Please continue to add to your teaching/learning “tool kit”.

References

Douglas, K., Hosokawa, M., and Lawler,F. A Practical Guide to Clinical Teaching In Medicine. 1988.p.14& p.71.

Westberg, J., and Jason, H. Collaborative Clinical Education. 1993. pp. 229-255.

Westgerg, J. and Jason, H. Fostering Learning In Small Groups. 1996. pp. 83, 136,142, 148,172,173&217. 

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Tips to Enhance Teaching with the Use of Questions

1. Develop a climate that will help foster trust and mutual sharing.
2. Encourage trainees to ask questions without fear of judgment.
3. Engage in asking questions rather than telling.
4. On occasion, before responding to a question raised by a trainee, first solicit responses from other trainees in the group.
5. Utilize “open-ended” questions as much as possible with the intent of stimulating exploration of viewpoints, discussion and complex thinking.
6. Avoid putting the trainee “on the spot” especially when engaged in bedside teaching.
7. Practice good listening skills.

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Additional resources on strategies for using questions in the clinical setting can be found at http://stfm.org/teacher/1998/jan/jan.html.  This URL will take you to the Society of Teachers of Family Medicine (STFM) web site where articles on clinical teaching are available in full length. The particular article at the above URL is entitled, "Levels of Questioning for Learners."

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Students in the first year of the Clinical Presentation Continuum (CPC) curriculum recently completed an introduction to basic science concepts which consisted of three weeks of presentations by the basic science faculty.  This represents a modification  in the curriculum designed to bring all the students up to a level of basic science knowledge to enable them to be successful in the remainder of the curriculum that focuses on clinical presentations. These students are now in the Blood and Immunity Block which will be followed by the Dermatology Block.

Students in the second year of the CPC are currently in the EENT Block.  Some of the clinical presentations they are presently studying include, Red Eye, Decreased Visual Acuity and Mouth Pain.

Something new in the area of evaluation was instituted this year as part of the weekly synthesis and integration sessions (S & I).  S & I is a 2-hour session designed to help the students bring together information learned in lectures, labs, and small groups. The first hour of S & I focuses on basic science and clinical questions the students have remaining after the week of study.  A panel of clinicians and basic scientists are present during this hour and they attempt to clarify information for the students.  At the end of this hour a basic science question is asked which the students must answer and submit. Thus far, these questions have primarily been short answer.  During the second hour of S & I, a clinical leads a discussion on an undifferentiated case by revealing one component of the case at a time. At some point in the case, the clinician asks the students a question such as, "What would be your differential at this time?  Explain your reasoning."  The case discussion stops and students write their answers and submit them.  Frequently, students are permitted to use their books and notes to help them answer the question.  The case discussion is then continued.  The S & I evaluations constitute about 15% of the grade for the quarter.

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Education Day programs for November, 2000 are as follows.

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Academic Leadership Fellowship (ALF) conducted their October session at Doctors Hospital North.  Their next session will be in Athens on November 18-19.  This will be the last meeting of the quarter and the session will focus on curriculum development principles, theories of learning, and development of a curriculum project.

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The next faculty development session will be on November 13th.  The session will be presented by Dennis Baker and Cheryl Riley and will focus on informing faculty about the 8-week family medicine clerkship.  Although the clerkship has been in existence for several years, it exemplifies many of the principles of the PCC and CPC curricula. These features will be highlighted and discussion will focus on how some of the features can be applied to other required clinical clerkships/courses.

The Academic Leadership Fellowship (ALF) will meet in Athens on November 18-19.

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