Art of Questioning

Effective questioning, with a stance of curiosity, is at the core of good debriefing. A general rule for debriefing is that the debriefer (or co-debriefers if there are two) should talk about 30% of the time and learners 70% of the time. To facilitate discussion (and stay away from lecturing), the debriefer needs to spend most of their time asking questions. Unfortunately (or fortunately, depending on how you look at it), asking good questions is an art, not a science and it may take you years to become a true expert at asking useful questions.

The first step to asking effective questions is to create a psychologically safe environment. Learners are used to being ‘quizzed’ or ‘pimped’ and may look at your questioning as a ‘verbal test of knowledge’ or the like. The goal of creating a safe environment is to ensure that learners believe and feel that you are truly curious, and want to know what they were thinking (or why), and that the information will not be used against them. Questioning and debriefing should be part of a formative learning approach, which means that it is not about getting something ‘correct,’ but learning to improve in the future. Keep in mind that learner experiences with other facilitators/educators will impact their willingness to share with you, so you may have to remind them frequently if your style and environment are different from the ‘norm’ (i.e. if you are truly asking questions because you are curious, while your peers are still ‘pimping’ students, then students have to mentally ‘switch’ between mental models of educators and environments each time).

To build a safe learning environment, questions need to feel safe and have a stance of curiosity. Some questions may be barriers to a safe environment and curiosity:

  • Closed questions: Did you make the correct diagnosis?
  • Guess what I am thinking: What else could be wrong with this patient?
  • Dirty question: That wasn’t what you meant to do, was it?
  • Hint and hope: Is there anything else you can do for the patient (as the teacher slides a medication towards the learner).
  • Interrogation: Why in the world would you do that?

 

Most facilitators can catch themselves asking closed vs. open questions. If the question has a yes/no answer, it is a closed question. Any question we ask should be inviting reflection and discussion. A variation of the closed question may be a simple what question (i.e. what are the signs and symptoms of CHF?). Simple “what” questions requiring a quick recall of facts are essentially closed questions. Many facilitators and preceptors are annoyed when a student looks up an answer on their phone. If they can find the answer on their phone you have asked a ‘what’ question rather than ‘why’ and they should look it up. Good, open questions talk about what someone was thinking, and for what reason, rather than facts, or yes/no.

Guess what I am thinking questions are a bit more insidious and widespread. I find that facilitators often believe they are doing good Socratic questioning when they are playing the guess what I am thinking questions. In the example question, “What else could be wrong with this patient?” the student spends more time worrying about what the teacher thinks was wrong with the patient as the truly honest answer to this question would be, “I don’t know what else is wrong, if I did then I would have done it obviously.” If you find your students ‘guessing’ at the answer, it is a clue you have asked the wrong question. The better way would be to provide the student with what you are thinking and ask what the difference(s) is between what you think and what the student thinks, followed by a why question. (e.g. the patient presented with CHF and you thought they were experiencing pneumonia. What clinical findings led you to choose pneumonia over CHF? For what reason(s) (why) did you believe this patient had pneumonia over CHF?)

The dirty question, and hint and hope questions are ones that are most obvious in our personal life, and often used by educators. To use a personal example, the question “You didn’t mean to put the dish in the sink rather than the dishwasher, did you?” is a classic. At the same time, a hint and hope might be as simple as, “Aren’t you hungry?” (Which we all know means our spouse is hungry, and it is time for dinner). In clinical practice, often facilitators who are trying to be ‘nice’ and ‘lead’ the student down a path have difficulty with a dirty question and hint and hope. In a safe learning environment, it is ‘nicer’ to ask the student a ‘real’ or ‘direct’ question than to ‘save’ them, as you won’t be there to save them always (and may cheat them out of their learning opportunity).

Interrogation and ‘pimping’ go hand in hand. For those unfamiliar with pimping, it is a commonly used tool in medical education where the attending (or senior resident) ‘quizzes’ the residents or medical students to identify areas of weakness, or to test their readiness to handle a certain patient. There is a place for quizzing students, but it is not in an environment of curiosity or when you are trying to do formative learning rather than summative assessment. Proponents of pimping or interrogation say that it helps the learner identify their weaknesses, but most learners don’t need that hard of a shove. Pimping or interrogation is probably the quickest way to erode a safe learning environment.

Good questions, on the other hand, open up discussion and help both the learner and facilitator to understand the learner’s mental models to shape them for future practice (for more information on identifying and shaping mental models see learning cards 5 and 14 and the reflections on both). We see the surface (action or result), and our goal of questioning is to help understand the structure of the mental model that leads to that action. Asking good questions, therefore, is simply a process of observing an action by the learner (or result in the patient) and asking “why” (or for what reason…) the learner took that action. Sounds simple, but here is where the art begins.

The first step of asking good questions is actually in observation. While the learner is in a learning experience (real or simulated), the facilitator should be observing for actions that concern or delight them that they may want to ask questions about. Sometimes these actions may actually be inactions (e.g. the learner did not start CPR), or results (e.g. a negative impact on the patient), but the bottom line is that what we are observing should be something concrete that we can see or hear, and cannot be debated (e.g. an observation may be that they did not do CPR; don’t jump to conclusions or assumptions about why, as we need to ask questions to understand the learner’s mental model, which is not readily visible). Ideally, these actions would be directly related to the learning objectives, but often they may not. Realistically, a facilitator will be able to dive deeper into 3-5 areas in a debriefing, so observations need to be prioritized. Prioritizing into the top 3 areas to ask questions about will also prevent rapid fire questioning (which can quickly turn into interrogation).

With our actions or results in hand, we now need to ask questions that get to the “why” of that action or result. We can only ask questions about things we saw, and should not make assumptions, or imply feelings/reasoning on things the learners did (e.g. “I saw you wandering around the room” is a valid observation while, “You seemed confused” is an assumption about a mental model). The goal is to help the learner understand the why of what led them to that action, and if we make assumptions about the why we may not only be wrong, we may end up arguing with the learner as they feel like they have to defend themselves.

To get to the structure of the mental model, we can simply follow the ‘5 Whys.’ The 5 Whys were popularized in Lean thinking, but can be seen practiced expertly by most small children. The reason kids ask why so much is they are truly curious and want to understand (e.g. why is the sky blue). We need to embrace this stance of true curiosity while not driving our learners crazy just asking “why” 5 times. Essentially, we are asking the core question of, “what were you thinking?” but need to be very careful not to come across accusatory, or with a sense of interrogation.

 

An example of how this works: (for more info see the reflection on Learning Card 5)

 

Situation – A Paramedic student has misdiagnosed congestive heart failure as pneumonia (identified in the defusing).

 

Q: Why did you diagnose this patient as having congestive heart failure?

A: The patient presented with difficulty breathing, productive cough, swollen ankles, and difficulty breathing at night.

Q: Given those findings, help me understand why you chose CHF over Pneumonia as a diagnosis?

A: This patient had nocturnal dyspnea.

Q: Why did the nocturnal dyspnea lead you to a diagnosis of CHF?

A: <pause> Well, last week I treated a patient with pneumonia who also had nocturnal dyspnea.

Q: Why did this patient have nocturnal dyspnea?

A: <pause, then learner bangs his hand on the table> *$!@, that was CHF. This patient lays back; the fluid bubbles up, and he can’t breathe.

 

In the above case, it only took 4 “whys” for the learner to identify their mental model, and then they were able to shift it (part of deepening) on their own. Facilitators need to be comfortable digging deeper and not letting the learner stop at the surface.

 

Digging deeper requires not only great skill at asking good questions, but great skill in listening. The facilitator needs to listen actively and truly want to understand the learner. Active listening includes things like reflection, mirroring, embracing silence, and not ‘saving’ the learner. The last may be the hardest as if a learner is struggling with a question; the natural tendency may be to jump in and save them. Let their peers come to their rescue. If no one can answer the question, then try rephrasing the question. (An example might be, “For what reason(s) did you diagnose, or prescribe…?)

Building skills in effective questioning can be difficult, and you will need feedback (Learning Card 15). To provide feedback, a peer could observe you debriefing and keep a tally of each time you ask a ineffective question (i.e. what am I thinking) or effective question (why, what if, etc.) and compare that to the amount of time you make statements. Your questioning should outweigh your statements and over time, your ‘good’ questions should outweigh the ‘bad’. Give yourself time, and remember that questioning is an art, not a science, no one method is perfect, and everyone can continuously improve.

 

Application Exercise:

 

Time to complete: 30 – 60 minutes

Participants: 6-10

 

Materials needed: A video of a simulation or other experience (I recommend using the “Fire Drill clip from the Office” as it provides a non-clinical example and is FUNNY!)

 

Directions: Practice observing actions/results and asking effective questions will help you build skills

 

  • Everyone should watch the video and observe for actions that concern or delight them. Each person is to write down his or her observations.
  • As a group, share actions or results that were identified. **Watch to make sure that each action is something that can be seen or heard, not an assumption about mental models.
  • Have each participant take a moment to write down a question about one of the actions or results they are interested in.
  • Each participant will then take turns asking a question or role-playing one of the participants in the video. Those who are role-playing someone from the video should feel comfortable answering the question, however they see fit. Allow the participant to ask follow-up questions as appropriate
  • Provide feedback on the questions and if they were able to identify effectively the role-player’s mental model.

 

This part of a series called “Learning That Works” by Jay Zigmont, PhD, CHSE-A (jay.zigmont@gmail.com). For a video on this topic and more information, visit http://L13.LearningInHealthcare.com. The principles above are part of the core content (Learning Card 13) of the Foundations of Experiential Learning Manual (http://FEL.LearninginHealthcare.com ).

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