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Friday, March 11, 2011
The Page 2 Blog-Education: Let me ask you a question!
How much time is spent in the classroom and clinical setting asking students questions? The unequivocal answer is, “A significant amount and most of it is devoted to answers that only demonstrate the students’ rote memorization of facts and simple comprehension of knowledge.” The best anesthesia patient care demands less of a trivia quiz atmosphere and more of a Socratic questioning process.

The American Board of Anesthesiology (ABA) outlines 6 components of teaching-learning that, when judged to have met established criteria, define a practitioner as certified. The 6 components include: 1) knowledge; 2) skill (clinical competence); 3) ability to apply knowledge; 4) using judgment to explain and justify the applied content; 5) adaptability to changing situations; and 6) effective communication. The  first component is tested by the ABA Part 1 Examination and the faculty teaching and evaluating the clinical practice of the resident attest to the fulfillment of the second component. Components 3 through 6 are assessed by the Part 2 Examination of the ABA, the Oral Board Examination. Evaluating the components, especially 3 through 6, is dependent on teachers asking students the proper types of questions, namely those questions that require higher order analysis. Anesthesiologists are problem solvers who interpret patient physiology and synthesize perioperative monitoring data to formulate the initial anesthetic plan and evaluate its effects and necessity for modification when the patient status changes.

How do we ask the proper questions of students in order to drive their thinking to a deeper level and lead them to deal with complexity rather than relying on the skill of rote memorization? Benjamin Bloom gave us much of the answer to this question when he defined the taxonomy of educational objectives in the 1950s.(1, 2, 3) From simple to complex, knowledge represents comprehension, application, analysis, synthesis, and evaluation of the facts. Marvel at how well Bloom’s construct and the ABA’s evaluation-certification process mesh together. Anesthesiology faculty teach residents by asking questions to review facts, to verify understanding about the patient for care, to assess readiness to develop an anesthetic plan judged best through consideration of the benefits and risks of clinical alternatives and to evaluate the ability to adapt to changes in the clinical scenarios. Watch brief clips from “Star Wars” as an example of how the student, Luke Skywalker, used Bloom’s taxonomy to evolve from simple to sophisticated learning through increasingly  complex questioning.

So, how must we ask questions of our students? We must ask questions that fit the specific kinds of responses we want to receive from our students.

Closed questionsreference solicit a finite range of possible correct answers that are predictable, require very limited thought and can be blurted out with a single word or brief phrase. Closed questions only test the student’s ability to recall factual information. “What is the mg per kg dose of vecuronium for endotracheal intubation?” While closed questions are efficient, requiring little time to gain an answer, they yield very little, if any, information about the actual understanding of knowledge by the respondent. A somewhat higher level question type, though still in the closed question category, is the convergent question: “How is muscular strength affected by vecuronium?” This question requires the student to recall facts but additionally to organize those facts into relationships. The convergent (closed) question doesn’t ask for analysis, interpretation and other higher level thinking skills; convergent (closed) questions simply ask how and why.

Open questionsreference, on the other hand, encourage problem solving, evaluating information and employing judgment when crafting answers. Open questions allow for a range of appropriate responses, encourage development of hypotheses, expect the student to predict or interpret information included in the question and identify the pertinent variables that lead to one answer but away from another. The open question often receives an answer that is an assumption rather than a fact; this assumption is based on the student’s ability to utilize reasoned judgment to think about the issues and alternatives and subsequently infer an answer. “A patient undergoing resection of an abdominal aortic aneurysm experiences arterial oxygen desaturation. You treat the patient with increasing levels of PEEP and the pulse oximeter still displays lower saturation. Why might the PEEP have been ineffective?” There are two types of open questions. Process questions are the problem solving exercises that use the scientific method with which we are all so familiar; evaluation questions require that the student take any position that can be defended. “What might the following blood gas data mean?” is an interpretation (process) question. “What do you think is the most effective means of securing the airway in a pregnant patient who was in an auto accident and has a fractured mandible that requires immediate surgical repair?” is an evaluation question.

How do you ask questions when you are teaching an anesthesiology resident and taking care of a clinical patient at the same time? What types of questions work best for you in which clinical teaching situations and why are they effective? My question to you is, “Can you tell us how you use questions to teach our specialty?” Send us a note.

Reference:  Foley RP, Smilansky J: Teaching techniques : a handbook for health professionals New York, McGraw-Hill, 1980, p 15-26.

Posted by Alan Jay Schwartz, M.D.,MSEd
Alan Jay Schwartz
George A. Smnowski MD said:
What a fascinating commentary on the art of education. I hope to see more of these posts in the future. Do you think it appropriate, though, to ask questions of a resident while a case is ongoing where a patient may have recall?
About the Author

J. Lance Lichtor, M.D
J. Lance Lichtor, M.D. is a professor of anesthesiology and pediatrics at The University of Massachusetts Medical School. He is the web editor and an associate editor for Anesthesiology.

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