Questioning as a Teaching ToolMichele Long, MDa, Rebecca Blankenburg, MD, MPHb, Lavjay Butani, MD, MACMc

Questions are a central part of the practice,and teaching, of medicine. Throughquestioning, we diagnose patients, reflectupon our own practice, assess learners, andteach. This article provides an approach toquestioning for the purposes of studentassessment and teaching by considering theDreyfus and Bloom frameworks. The authorsoffer practical ways to use questions todiagnose students’ understanding, to teach,and to model life-long learning.

Susan Bannister, Editor-in-Chief, Council onMedical Student Education in Pediatrics

Monthly Feature

This article is part of the Council onMedical Student Education inPediatrics series on strategies andtechniques used by great clinicalteachers. Herein we explore howeducators can best use questioningstrategies to promote learning in theclinical setting. Teachers commonlyask questions to assess learners’knowledge.1,2 When used strategically,questioning can engage learners bystimulating active participation in thelearning process, guide them towardthe understanding of deeper concepts,promote peer–peer collaboration, andbuild their confidence.1 Moreover,through questioning, clinicians canstimulate critical thinking whileactively modeling the process ofinquiry and life-long learning.1

Questioning is a challenging teachingtool and even experienced, well-meaning educators occasionally makemistakes. Teachers often rely heavilyon recall-based questions that failto stimulate deeper thinking andcan cause learners to disengage.3,4

Questions that are mismatched tolearner level can be equally

problematic; asking novice learnersunrealistically challenging questionscan lead them to lose self-confidenceand interest and asking advancedlearners fact-based questions candemotivate them. Finally, questionsposed in a seemingly confrontationalmanner (which can cause anxiety inlearners and may be perceived as“pimping”) can adversely affect thelearning climate.1,5 We providea framework for matching questionsto a learner’s ability and providesuggestions for formulating questionsto both challenge learners and maintaina supportive learning environment.

CONSTRUCTING QUESTIONS BASED ONLEARNER ABILITY

Different learners and teachingsituations require different types ofquestions. One approach to effectivequestioning takes into considerationthe developmental stage of the learnerand the learning objectives best suitedfor the stage.

The educator first classifies thedevelopmental stage of the learnerbased on his or her competence,confidence, and motivation by usingthe Dreyfus model of skillsacquisition.6 The 4 Dreyfus stages mostrelevant to clinical educators arenovice (learners function by usinga limited rule-based knowledge systemwithout a clinical context), advancedbeginner (learners have an expandedrepertoire of clinical rules and may justbe getting exposed to a clinicalenvironment), competent (learners userules of thumb and are in the processof getting invested in the actual care oftheir patients), and proficient (learnersshow increasing initiative in patient

aDepartment of Pediatrics, University of California, SanFrancisco, San Francisco, California; bDepartment ofPediatrics, Stanford University School of Medicine,Stanford, California; and cDepartment of Pediatrics,University of California Davis Medical Center, Sacramento,California

Drs Long, Blankenburg, and Butani conceptualizedthe article and wrote the first draft of the article. Allauthors contributed to the literature search,reviewed and revised the manuscript, and approvedthe final manuscript as submitted.

www.pediatrics.org/cgi/doi/10.1542/peds.2014-3285

DOI: 10.1542/peds.2014-3285

Accepted for publication Oct 15, 2014

Address correspondence to Michele Long, MD,Department of Pediatrics, University of California,San Francisco, 513 Parnassus Ave, San Francisco,CA 94143. E-mail: michele.long@ucsf.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,1098-4275).

Copyright © 2015 by the American Academy ofPediatrics

FINANCIAL DISCLOSURE: The authors have indicatedthey have no financial relationships relevant to thisarticle to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors haveindicated they have no potential conflicts of interestto disclose.

PEDIATRICS Volume 135, number 3, March 2015 MONTHLY FEATURE by guest on July 10, 2018www.aappublications.org/newsDownloaded from

care and use intuitive clinicalreasoning based on their previouslygained clinical experience).6

Generally, most students will be in thenovice to advanced beginner stage,whereas most residents will be in theadvanced beginner to competentstage. Some residents and manyfellows may be in the proficientphase, but few are likely to be at thehigher stages of expert or master andthese stages are not addressed in thisarticle.6 These generalizations canbreak down for some trainees (suchas a particularly experienced medicalstudent) and in some situations (suchas a senior resident encounteringa patient with a specific or raredisease for the first time). Therefore,getting to know your learner byasking about their background andexperiences and probing theirknowledge base is very important.7

The next step is to think about thetype of question to ask, by matchingthe assessed developmental level ofthe learner to the learning objectivesfor that stage of learner.1,2,8 Oneframework for formulating specificquestions matched to each of thelearner levels uses Bloom’staxonomy.1,2,6,8 Bloom’s taxonomy isa hierarchy widely used by educatorsthat places thinking skills at 6 levels:knowledge (lowest level),comprehension, application, analysis,synthesis, and evaluation (highest

level).2,8 The most relevant to clinicalquestioning of students and residentsare the levels from knowledge toanalysis. Due to limited clinicalexperience, novice learners benefitmost from simple questions focusedon factual knowledge.1 Thesequestions are often phrased ina direct manner and have a singlebest answer. Advanced beginnerlearners are working on linking factsthey may have learned in isolation, soquestions should prompt them toconnect information and demonstrateunderstanding of concepts andcomprehension. Competent andproficient learners are applyinginformation to common clinicalsituations, so questions can be morecomplex and prompt them to applytheoretical knowledge to a specificclinical situation in the decision-making process. Learners can be askedto analyze a situation or to compareand contrast 2 or more options formanaging a patient’s medical issues.Questions may also pose alternativesto what the learner proposed, followedby an exploration of their thoughtprocess. Specific examples ofquestions using the Bloom frameworkmatched to developmental stage(Dreyfus) are listed in Table 1.

Although fact-based questions aregood for building confidence andassessing knowledge, especially fornovice learners, clinical teachers

should avoid the common pitfall ofrelying on “low level” questionspromoting rote memorizationwithout true understanding ofconcepts.1,3,4 Even with novicelearners, one can use a step-upapproach and ask increasinglycomplex follow-up questions tosimultaneously engage and challengelearners and create “constructivefriction,”9 provided questioning doesnot become too challenging orintimidating.2 For more advancedlearners, questioning can start ata higher level and be open-ended, witha step-down to simpler questions iflearners struggle finding answers.2 Ingroups or with multiple levels oflearners, such as on ward rounds, it isoften easiest to begin the questioningprocess directed toward the primarylearner taking care of the patient.However, remember to keep the groupengaged by asking questions of all orseveral of the team members, matchedto their developmental level.2

QUESTIONING WHILE MAINTAININGA POSITIVE LEARNING ENVIRONMENT

Although questioning inherently putsthe learner “on-the-spot,” it ispossible to minimize discomfortwhile promoting a positive learningenvironment. First, set theexpectation with learners that youwill be asking questions. Explain thatyour goal is to explore their

TABLE 1 Asking Questions Based on Learner Developmental Level

Developmental Stage ofLearner (Dreyfus)

Objectives for Questions toFocus on (Bloom)

Goal of Questioning Stems toConsider Using

Sample Question(s): Based on a PatientWith a Possible Urinary Tract Infection

Novice Knowledge Build knowledge List List the 3 ways a specimen can beobtained for urine culture.Define

What are the diagnostic criteria fora urinary tract infection?

Name

Advanced beginner Comprehension Promote understanding ofconcepts

ExplainDescribe

Explain why a urine culture is indicatedin a febrile infant.

Competent Application Stimulate application of knowledgeto a clinical context

Interpret Here is our patient’s urinalysis … whatdo you think this tells us and why (orinterpret these results)?

Proficient Analysis Break down complex concepts intotheir component parts

Compare andContrast

Compare and contrast the need fora urine culture in a febrile male infantand a febrile female teenager, bothwithout localizing signs andsymptoms.

2 LONG et al by guest on July 10, 2018www.aappublications.org/newsDownloaded from

understanding and build upon whatthey already know.1,2

Great clinical teachers pay particularattention to how questions are asked.They avoid asking questions ina rapid-fire sequence, and instead askquestions one at a time. Allowinglearners between 3 and 5 seconds torespond with an answer has beenshown to increase both the likelihoodof getting a response and also thelength of the response.2,10

Importantly, avoid interruptinglearners while they are formulatinga response and wait after receivinga response before asking a follow-upquestion.1

To further promote a positivelearning environment, teachers canask open-ended questions thatincrease the chance of their learnerbeing able to find an acceptableanswer, on which they can thenelaborate (“Can you explain to theteam your thought process?”).11 Theteacher can also restate the learner’sanswer to confirm respect for his orher thoughts (“You’ve brought upa good point …”). In a group setting,directing questions to other learnerson the team can simultaneouslyreduce the pressure on the learnerwho is presenting information andengage others in learning. Gettinga commitment on the same questionfrom all learners before revealing theanswer is another way to involve theentire team in the learning process.Finally, resist the temptation toprovide answers to all of the learners’questions; challenge learners toresearch the question and reportback.

If the learner’s response to a questionseems noncommittal or is incorrect,guide them while maintaining

confidence in their abilities, especiallyin front of patients. As alluded toearlier, this is another time whenopen-ended brief clarifying questionscan be asked instead of answering thequestion or turning to others (“Canyou tell us more about that?”).1,11

Similarly, when a learner is initiallyincorrect, guiding them to the correctanswer by using a gentle approach isa way to challenge learners withouthumiliating them (“That’s aninteresting thought. If that was thediagnosis, how would you explain theabsence of…?”).12

Lastly, if the opportunity arises,think about asking the learnersthemselves to generate and posequestions to the team, to furtherengage them. These can then beresearched individually or asa group and discussed the nexttime the team comes together.

SUMMARY

The Dreyfus and Bloom frameworkscan help the great clinical teachercraft questions that are learner-centric and appropriately challenging.Employing strategies to ask the rightquestions in the right way can furtheradd to the effectiveness of usingquestions as a valuable teaching,learning, and assessment tool.

ACKNOWLEDGMENTS

The authors thank Drs Robert Dudas,Christopher Maloney, and SusanBannister for their thoughtful reviewand editing of the article.

REFERENCES

1. Tofade T, Elsner J, Haines ST. Bestpractice strategies for effective use of

questions as a teaching tool. Am JPharm Educ. 2013;77(7):155

2. Sachdeva AK. Use of effective questioningto enhance the cognitive abilities ofstudents. J Cancer Educ. 1996;11(1):17–24

3. Phillips N, Duke M. The questioning skillsof clinical teachers and preceptors:a comparative study. J Adv Nurs. 2001;33(4):523–529

4. Sellappah S, Hussey T, Blackmore AM,McMurray A. The use of questioningstrategies by clinical teachers. J AdvNurs. 1998;28(1):142–148

5. Brancati FL. The art of pimping. JAMA.1989;262(1):89–90

6. Carraccio CL, Benson BJ, Nixon LJ,Derstine PL. From the educational benchto the clinical bedside: translating theDreyfus developmental model to thelearning of clinical skills. Acad Med.2008;83(8):761–767

7. Raszka WV Jr, Maloney CG, Hanson JL.Getting off to a good start: discussinggoals and expectations with medicalstudents. Pediatrics. 2010;126(2):193–195

8. Bloom BS. Taxonomy of EducationalObjectives: The Classification ofEducational Goals: Handbook I: CognitiveDomain. New York, NY: David McKayCompany, Inc; 1956

9. ten Cate O, Snell L, Mann K, Vermunt J.Orienting teaching toward the learningprocess. Acad Med. 2004;79(3):219–228

10. Schneider JR, Sherman HB, PrystowskyJB, Schindler N, Darosa DA. Questioningskills: the effect of wait time on accuracyof medical student responses to oral andwritten questions. Acad Med. 2004;79(suppl 10):S28–S31

11. Spencer J. Learning and teaching in theclinical environment. BMJ. 2003;326(7389):591–594

12. Ramani S. Twelve tips to improvebedside teaching. Med Teach. 2003;25(2):112–115

PEDIATRICS Volume 135, number 3, March 2015 3 by guest on July 10, 2018www.aappublications.org/newsDownloaded from

originally published online February 2, 2015; Pediatrics Michele Long, Rebecca Blankenburg and Lavjay Butani

Questioning as a Teaching Tool

ServicesUpdated Information &

014-3285.citationhttp://pediatrics.aappublications.org/content/early/2015/01/28/peds.2including high resolution figures, can be found at:

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtmlin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or

Reprintshttp://www.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:

by guest on July 10, 2018www.aappublications.org/newsDownloaded from

originally published online February 2, 2015; Pediatrics Michele Long, Rebecca Blankenburg and Lavjay Butani

Questioning as a Teaching Tool

http://pediatrics.aappublications.org/content/early/2015/01/28/peds.2014-3285.citationlocated on the World Wide Web at:

The online version of this article, along with updated information and services, is

ISSN: 1073-0397. 60007. Copyright © 2015 by the American Academy of Pediatrics. All rights reserved. Print the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

by guest on July 10, 2018www.aappublications.org/newsDownloaded from