Promoting higher order thinking and reasoning

University of BC Faculty of Medicine Department of Family PracticePost Graduate Program

Good QuestionsDetermine students’ learning needs and

direct the teacher to an appropriate levelStimulate curiosity in the subjectClarify concepts and emphasize key

pointsStimulate and engage learnersGuide clinical reasoningEncourage reflection

Good QuestionsClearBrief (one question at a time)Single focusDivergent (allow more than one acceptable

answer and broad thinking)Open-ended (short answers are insufficient)

Levels of questioningYes/noFactual RecallApplication of knowledgeAnalysis of knowledgeSynthesis

Hierarchy of QuestionsHow would you manage this patientin this clinical situation?

How do these findings exclude otherDiagnoses?

What do these findings mean?

What causes this problem

Is this true?

Synthesis

Analysis

Application

Factual Recall

Yes/No

Patient with Headache

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.

A patient presents for review of their diabetes. Question your resident

about the patient they have seen at each “level of questioning”

A little more practice:As a group challenge each other to

ask a higher level question for:Abdominal PainAsthmaChest painFatigueDepression

Adult LearnersWe learn more from what we “don’t know” than what we “do know”

Problem based learning is most effective.

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

SNAPPS*The Student:

Summarises the caseNarrows the differential diagnosisAnalyses the differential diagnosisProbes (asks the teacher about areas not

understood)Plans management; andSelects an issue for self directed learning

*Wolpaw TM et al. SNAPPS: a learner centred approach for outpatient education. Acad. Med 2003; 78:893-898.

ReadinessIs the learner at the appropriate level for the questions being asked?

Are there other issues involved which interfere with the residents performance?

Questioning a groupPose, pause and pounceSpread the questions aroundNo answer is “stupid”Allow silenceExpect the unexpected Be aware of different levels of learners

You’re with a 2nd year resident, a 4th 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 firstGive an example of the questions you might

ask each learner.

An excellent answer:

I don’t know

RememberEffective 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.

Thank YouThis 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 modulePlease 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