Transcript Slide Presentation - Curriculum for the Hospitalized Aging Medical

CHAMP
Teaching on Today’s Wards
Session 5 - Teaching Lifelong Learning
Skills
Using Questions to Learn and Teach
Diane Altkorn, MD
Chad Whelan, MD
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
Outline of Session
• Modeling identification and addressing of
knowledge gaps
• Obtaining effective consultation
• Asking effective questions of learners
• Self assessment of “questioning behavior”
Using questions to model
identifying and addressing
knowledge gaps
EBM question model
• Knowledge gaps
• Types of clinical questions
• Using the EBM model during rounds
Categories of knowledge gaps
• Clinical findings
• Diagnosis
• Prognosis
• Therapy
• Prevention
• Other (harm, differential diagnosis, etc)
Knowledge gaps exist
for all patients!
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?
Types of clinical questions:
foreground questions
• Specific and advanced
• Often find answers in primary sources
• Should be categorized and structured
Categories of
foreground questions
• Same as knowledge gap categories
• Helps you know what kind of article to
look for, how to search Medline
Structuring a foreground question
• Four component, “PICO” model
–
–
–
–
Patient
Intervention
Comparison
Outcome
Examples
• Background
– What is gallstone pancreatitis?
• Foreground, unstructured
– Does my patient need an ERCP today?
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?
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?”
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?
Obtaining and teaching about effective
consultation
• Asking Other People
Reasons for Consultation on
Inpatient Service
• Acutely Ill Patients
• Multiple Problems from Multiple
Specialties
• Increased Attention to Efficiency:
– Financial constraints
– Duty hour reform
What Do You Want From a Consult?
• Clinical Assistance
• Educational Value
Clinical Assistance
• Procedure
• Bottom Line Answer YES or NO
• Help with a specific decision
• General input on management
• Provide continuity of care
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
How to get what
YOU
need from a consultant
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
MEDICAL STUDENT TELEPHONE CONSULTATION
WORKSHEET
The purpose of this worksheet is to help you be a more effective telephone
communicator to consultants:
1. Hello Dr. ______________, this is ___________________ from
___________________. I have a patient I’d like to present to you
please.
2. (Pause for acknowledgement by consultant)
3. Mr./Mrs./Ms. _________ is a ________ year old ______________who
comes in today complaining of _______________.
4. Give relevant history and data:
5. I think the most likely diagnosis is ____________________________
6. This is what we’ve done for him already. ______________________
7. I’d like you to evaluate him for ______________________________
8. His condition right now is __________________________________
9. Thank you
Total time should be less than one minute.
(Go, et al, 1998)
Results of Intervention
Components
Students % Residents %
(n=42)
(n=50)
State who you are
95
56
Pause
95
80
Patient demographics 98
62
Clinical information 100
94
Impression
90
66
Explicit reason
74
44
Urgency
62
12
Appropriate language 95
94
Courtesy
86
64
p value
<0.005
0 .06
<0.005
0.30
0.01
0.008
<0.005
0.64
0.03
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?
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
Quality Score Examples
Quality Score 0
I have a 32 year old female with chest pain in November
who was found to have a bicuspid aortic valve with a
gradient of 16. She is now pregnant with her third
child. Is there any need to do anything else?
Quality Score 1
A 43 year old man with hyperlipidemia asked if he
should get his homocysteine levels checked. If elevated,
should he receive folate supplements?
Quality Score 2
I have a 50 year old female with hypopituitariasm
secondary to a MVA 14 years ago. She has low free T4
with an inappropriately low TSH. I have been going
up on the Synthroid dose. Since we are not absolutely
sure if she has sufficient corticotropin, if I keep going
up on the Synthroid, am I in danger of putting her into
a adrenal crisis?
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
CONCLUSIONS
• Consults Skills Can Be Taught Simply
• Improved Questions Can Improve
Responses
• Major Emphasis on Explicit Questions
Clinical Questions
Educational Questions
TEACHING TRIGGERS
• THE VAGUE QUESTION
• THE “PAINFUL CONSULT”
• THE “UNHELPFUL CONSULT”
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”
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”
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”
How to ask questions of learners
Three Models
• Clarifying vs. probing
• Levels of questions
• Responding to the answers
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?
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?
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?”
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
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
Extension probes
• Ask learners to elaborate on a response
• Give the message that the original answer
was on target, but insufficient
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?”
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
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’?”
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
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?”
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
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?”
Redirection probes
• Ask for alternative responses to a given
question from a number of learners
• Useful in eliciting a variety of options or
opinions
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?”
Original question
Learner response
appropriate,
correct
disorganized,
weak, incomplete
inappropriate,
incorrect
extension,
justification,
redirection
clarification,
prompting,
redirection
prompting,
redirection
Self assessment of “questioning
behavior”
Brief Self-Evaluation Tool for Questioning:
Today, did I:
1. Use both probing and clarifying questions and/or different
levels of probing questions?
2. Help the team identify knowledge gaps?
3. If appropriate, did I use the PICO format when discussing
questions today?
4. Use different types of knowledge gap questions (Therapy,
Diagnosis, Prognosis, Harm/Risk Factors, Screening)?
Plans for next session:
Topics for discussion
• Why should we screen inpatients for
depression and who is at risk?
• Atypical presentations of depression in
the elderly
• Review screening tools
• Discuss pharmacotherapy
• Planning for continuity after discharge