CHAMP Teaching on Today’s Wards Session 5 - Teaching Lifelong Learning Skills Using Questions to Learn and Teach

1. CHAMPTeaching on Today’s WardsSession 5 - Teaching Lifelong Learning Skills Using Questions to Learn and Teach Diane Altkorn, MD Chad Whelan, MD

2. Why focus on questions? • Learners and questions • Must recognize need to ask a question • Must formulate effective questions • Teachers and questions • Can model lifelong learning skills • Can probe learners and enhance educational value of rounds

3. Outline of Session • Modeling identification and addressing of knowledge gaps • Obtaining effective consultation • Asking effective questions of learners • Self assessment of “questioning behavior”

4. Using questions to model identifying and addressing knowledge gaps

5. EBM question model • Knowledge gaps • Types of clinical questions • Using the EBM model during rounds

6. Categories of knowledge gaps • Clinical findings • Diagnosis • Prognosis • Therapy • Prevention • Other (harm, differential diagnosis, etc)

7. Knowledge gaps exist for all patients!

8. Types of clinical questions: background questions • General and basic • Used when you don’t know much about a topic • Usually find answers in textbook chapters, review articles • Example: What is a fabella?

9. Types of clinical questions: foreground questions • Specific and advanced • Often find answers in primary sources • Should be categorized and structured

10. Categories of foreground questions • Same as knowledge gap categories • Helps you know what kind of article to look for, how to search Medline

11. Structuring a foreground question • Four component, “PICO” model • Patient • Intervention • Comparison • Outcome

12. Examples • Background • What is gallstone pancreatitis? • Foreground, unstructured • Does my patient need an ERCP today?

13. Examples • Foreground, structured • In patients with gallstone pancreatitis, does early ERCP, when compared to conventional therapy, result in fewer episodes of biliary sepsis or death?

14. Using the EBM model during rounds • Explicitly model the EBM process • “Our patient had a TIA while on aspirin. I don’t know if we should add warfarin. Let’s structure this question so we can find an answer.” • “In patients with recurrent TIA’s, does aspirin + warfarin, when compared to aspirin alone, reduce the rate of TIA or stroke?”

15. Using the EBM model during rounds • Use open ended questions • What additional information do we need? • What options are available for further evaluation or treatment? • How do we know this will help and not harm the patient?

16. Obtaining and teaching about effective consultation • Asking Other People

17. Reasons for Consultation on Inpatient Service • Acutely Ill Patients • Multiple Problems from Multiple Specialties • Increased Attention to Efficiency: • Financial constraints • Duty hour reform

18. What Do You Want From a Consult? • Clinical Assistance • Educational Value

19. Clinical Assistance • Procedure • Bottom Line Answer YES or NO • Help with a specific decision • General input on management • Provide continuity of care

20. Education Teach by seeing endpoint only Teach by describing decision making process Teach by interactive conversation about decision making process Teach by provision of explicit educational material

21. How to get what YOUneed from a consultant

22. COMPONENTS OF AN EFFECTIVE REQUEST • State your name and who you are • Pause to wait for acknowledgement • State key patient demographic information • Provide appropriate clinical information • State initial impression • Provide explicit reason for consultation • Provide urgency of the consultation • Use specialty appropriate language • Courtesy Matters

24. Results of Intervention

25. Are Structured Questions Better? In medical consultation requests, do more structured medical questions, when compared to less structured ones, result in more definitive consultation responses?

26. Do Consult Requests use the PICO Format? • 708 outpatient e mail consultations • 71.1% had an intervention • 28.2% had a comparison • 48.4% had an outcome of interest • 17.2% had none of the above

27. Quality Score Examples

28. Consult Responses by Quality Score • Quality Score 0 29.4% Non-definitive • Quality Score 1 18.3% Non-definitive • Quality Score 2 10.0% Non-definitive

29. CONCLUSIONS • Consults Skills Can Be Taught Simply • Improved Questions Can Improve Responses • Major Emphasis on Explicit Questions • Clinical Questions • Educational Questions

30. TEACHING TRIGGERS • THE VAGUE QUESTION • THE “PAINFUL CONSULT” • THE “UNHELPFUL CONSULT”

31. THE VAGUE QUESTION • “The creatinine is going up, let’s get renal involved” • “Since this is an HIV patient, we should have ID following along with us” • “This patient is followed by Dr. Johnson”

32. The “Painful Consult” • “Do we need a neurology consult, they will only say get an EEG, MRI, and LP?” • “If we get rheumatology involved, we will end up ordering a thousand obscure tests”

33. The “Unhelpful Consult” • “Well psych came by and saw the patient, but their recommendations are not very clear” • “The surgery consult team didn’t really answer our question about need for indications for surgery in our patient with pancreatitis, but they did say she should be on TPN”

34. How to ask questions of learners

35. Three Models • Clarifying vs. probing • Levels of questions • Responding to the answers

36. Model 1: clarifying vs. probing • Clarifying questions • Elaborate facts about the patient • Elicit simple definitions • Necessary to obtain essential information, check basic knowledge • Examples • What was Mr. Smith’s creatinine? • What is the definition of an exudate?

37. Model 1: clarifying vs. probing • Probing questions • Determine learners’ level of understanding • Provoke thought • More time consuming! • Examples • What should the next step be? • Why does she have a fever? • What if this patient were 85, instead of 25?

38. Model 2: levels of questions • Knowledge: the 1st level • Similar to clarifying questions • Application: the 2nd level • Determine whether learners can use information in a specific context • Example: “How do you interpret the pleural fluid results?”

39. Model 2: levels of questions • Problem solving: the 3rd level • Responses require broad knowledge base, ability to synthesize information • Examples: open ended EBM, probing questions

40. Model 3: responding to the answers • Follow up probes • Allow teacher to pursue preliminary responses, expand or alter presented information • Types • Extension • Clarification • Justification • Prompting • Redirection

41. Extension probes • Ask learners to elaborate on a response • Give the message that the original answer was on target, but insufficient

42. Extension probe example • Original question: “What is your differential for shortness of breath in this patient? “ • Answer: “CHF, COPD, pneumonia” • Extension probe: “What else do we need to think about?” or “What else is on the differential?”

43. Clarification probes • Ask learners to rephrase initial response, or clarify original thought • Used when initial response unclear, incomplete, or confusing • Guide learners to find appropriate answers

44. Clarification probe example • Original question: “Why do you think this patient may be at high risk for developing pressure ulcers?” • Answer: “She is elderly and frail.” • Clarification probe: “What clinical characteristics of elderly, frail patients increase their risk of pressure ulcers?” or, “What do you mean by ‘frail’?”

45. Justification probes • Ask learners to provide rationale for their responses • Provide insight into learners’ thought processes • Can reveal depth of knowledge and errors in thinking

46. Justification probe example • Original question: “Should we consider changing any of the medications on this patient’s list?” • Answer: “We should consider stopping the amitriptyline.” • Justification probe: “Why do you want to stop that medication?”

47. Prompting probes • Provide additional data to elicit the correct response • Used when learners don’t respond to the initial question, respond incorrectly, seem confused, or miss the point

48. Prompting probe example • Original question: “In this patient admitted from a long term care facility with pneumonia, what antibiotics would you choose?” • Answer: “We always use Tequin, and he isn’t allergic, so that should be ok.” • 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?”

49. Redirection probes • Ask for alternative responses to a given question from a number of learners • Useful in eliciting a variety of options or opinions

50. Redirection probe example • Original question: “So, in this 78 year old patient with several cardiac risk factors and a history consistent with atypical chest pain, what should be our next step?” • Answer: “We should do a stress thallium.” • 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?”