Teaching with our learners questions
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Teaching With Our Learners’ Questions
W. Scott Richardson, MD Mark C. Wilson, MD, MPH
Thomas G. McGinn, MD, MPH
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Ask
Acquire
Appraise
Apply
Act & Assess
Patient dilemma
Principles of evidence-based Clinical practice
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7#%3)3'28+9(%"#$%&'%
Process of EBCP
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They’ve just seen a patient:• 67M, admitted for breathlessness• 2 weeks: !! weight, progressive edema• 3 days: fever, cough, purulent sputum• Past: Rheumatoid arthritis, Felty’s
syndrome, heart failure• Rx: Steroids, furosemide, metoprolol• Exam: lung crackles, splenomegaly
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Now, listen carefully …
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Chest Radiograph
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‘Hoot Groups’ Task
• Groups of 2 –
3 • Discuss what you
noticed about this encounter
• Be ready to report to group >
1 item
• Return in 2 minutes
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What you noticed …• Senior directing to
think, yet didn’t give junior time
• Force EBM on ACEI• Friendly, yet
unfocused• Prompted learner• Missed opportunity• NNT not important• Priorities?
• Learner excited about things, but teacher didn’t exploit
• Teacher did fun parts alone
• Too many learning points
• Limited time• Learner unfocused,
yet may not know
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What was missing?
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What was missing?• Did the teacher identify the
learner’s questions?
• Did the teacher use the learner’s questions in teaching?
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Isn’t it all about me?
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Why don’t we use their Q?• Don’t know answers• Embarassment?• Prestige, power
from knowing things• Learners expect me
to pontificate• Forgotten learners
view –
so basic• Our own agenda
dominates
• Don’t want to lose control
• It’s all about me• Ain’t
no time
• Have to move quickly
• Scary, out of comfort zone
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FAQ: What if I don’t know the answer to their questions?
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Emotions in Not KnowingReady to … Feeling Behaviors
Flee Fear LeaveInvisible
Fight Anger DisruptUndermine
Cry for help Distress Stop tryingBody stress
Withdraw Sadness InattentionDetachment
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What can teachers do …
?
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What can teachers do …
?• Acknowledge emotions of not knowing• Minimize hidden curriculum• Help learners build adaptive responses
– Don’t hide when you don’t know– Use emotions to help pursue questions
• Point out the ‘positive’
emotions of learning and knowing …
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Emotions in Knowing• Satisfaction: Self image of “knower”
meets reality of “knew this”• Curiosity: the wind in the sails• Joy: knowing and/or learning brings
benefits to others• “Zero gravity”
or “flow”: when learning
engages the mind fully without self consciousness
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FAQ: Where do Q come from?
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10 Common Questions• Clinical findings• Harm/etiology• Differential
diagnosis• Manifestations• Diagnostic tests• Prognosis
• Therapy• Prevention• Experience,
Meaning• Learning
(Not exhaustive or mutually exclusive)
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‘Background’ Questions• About the disorder, test, treatment, etc.• 2 components:a. Root*
+ Verb: “What causes …”
b. Condition: “…
swine flu?”• * Who, What, Where, When, Why, How
• ‘RVC’
= Root, Verb, Condition
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‘Foreground’ Questions• About patient care decisions and actions• 4 (or 3) components:a. patient, problem, or populationb. intervention, exposure, or maneuverc. comparison (if relevant)d. clinical outcomes (including time horizon)
‘PICO’
= Patient, Intervention, Comparison, Outcomes
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Background & Foreground
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FAQ: How do I recognize Q?
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Recognizing Questions• Listen with both ears• Diagnose case and self/learner• Compare to inner model –
how it
should sound• Notice your/learner’s cognitive
dissonance & other responses• Use map to locate questions
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Now, listen carefully …
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‘Hoot Groups’ Task• Groups of 2 –
3
• Share questions you recognized
• Pick one –
best to teach this learner
• Be ready to report to the group
• Return in 3 minutes
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Questions You Want to Teach• How to present• Patient’s agenda• Family’s agenda• Patient’s need• Learner’s need• Differential
diagnosis of leg pain and swelling
• Selecting short list for differential
• Long term vs. short term
• Examine leg• What you worried
about • Teaching where?• Organize, prioritize,
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Selecting QuestionsConsider:• What is illness?• What is role?• What are learning
needs?• What are
available resources?
Of these, select:• Most urgent• Most interesting• Most feasible to
answer• Most likely to
recur
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FAQ: How do I coach on Q?
• Try building up from ‘raw’
question to more complete anatomy (rather than tearing their efforts down)
• Consider 2 stages:• “Sounds like you’re asking a question
about …
(therapy, prognosis, etc.)”• “What would be the …
(missing
anatomy) you would want to know?”
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Teaching with Questions
• Recognize: your learners’
questions• Select: which questions to pursue• Guide: how to ask and answer• Assess: how well & what to improve
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FAQ: Why should I bother teaching with learners’
questions?
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FAQ: Why Bother? 1• Respect learners• Relevant to clinical
needs• Relevant to learning
needs• Improve
comprehension
• Plan searches• Recognize answers• Awaken curiosity• Have some fun!
• Any evidence?
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FAQ: Why Bother? 2RCT: !! explicitness of questions:#**)&%6")(%-()*(;<=(<>?@<(ABBCD(CE(FG
RCT: ! frequency of searches=)0%**(%-()*(HI><(ABBCD(CJE(KLKG
Before-After Trial: ! precision of search;++-2(%-()*(;6**(<MN(ABBBD(KKE(ALOG
RCT: ! quality of search, evidence foundP+,%&0%35(H(P(=+**(Q28,(M(COOKD(LAE(RRS.
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FAQ: “Got no time …”
• Sorry, we don’t have time to address this one …
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FAQ: “Got no time …”• Acknowledge real time limits • Pick one thing to teach, anything, but
NOT everything• Get past misperception –
time is tight
no matter whose question it is• Takes gumption …• Just do it!
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Your Questions about ‘Q’?
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Thank You!