ARTE Module ONE – Student Questions

Students and faculty work together to create a safe environment for students to ask questions.
Better student questions lead to better student learning, and teacher learning, as well. Asking questions is an important part of learning medicine. Getting good questions answered by experienced physicians is a hallmark of excellent clinical training.
Asking good question that lead to good learning opportunities is a skill that can be learned, practiced and improved. Much like the skills we learn in asking questions of patients, asking good questions of teachers, consultants and team members are marks of a curious, courteous physician.
Asking effective questions about important issues requires a trusting relationship between learner and teacher. Make this relationship a goal of your clerkship, the sooner the better. Discuss directly with your preceptor how to make your questions fit best into the flow of their practice.
The suggestions summarized below come from experienced medical students and family medicine clerkship teachers.
Strategies for Students

  1. Contract with your preceptor on a specific Question Time each work period to ask questions that did not get addressed during the busy flow of patient care.
  2. Keep a Questions Card (“Q Card”) in your pocket to note questions to ask when time allows. Record the most useful questions that arise over the course of your clerkship.
  3. For difficult questions, be willing to allow some time to pass for both the teacher and the student to process the issue. Good questions do not always have easy answers. Be sure to return to the questions.
  4. Remember, every situation is different. These are patients, not cases. Do not presume that there is only one good approach to taking care of patients.
  5. Focus questions on the doctor’s areas of special interest. Figure out what you can learn fromthis physician.
  6. Try to balance the focus of your questions between biomedical facts and the process of patient care.
  7. Ask for feedback on the questions you ask: the tone, content and form. Plan to discuss questions at your mid-clerkship review.

Tips for Students – How to ask effective questions

  1. Use a positive, inquiring tone, not a negative, challenging one.
    Question: Why didn’t you do a serum porcelain test to rule out a zebranoma?
    Better Question: This seems like a tough diagnostic challenge. What are the possibilities that are most important to rule in and rule out? Would a serum porcelain test be appropriate to rule out a zebranoma?
  2. “What” questions are less threatening than “why” questions.
    Question: Why didn’t we refer this patient to a rheumatologist?
    Better Question: What are your criteria for when a paitent needs a rheumatology referral?
  3. Avoid “should” questions; they imply value judgments.
    Question: Shouldn’t we get a VQ scan on this patient with acute shortness of breath?
    Better Question: I know a VQ scan is important for ruling out a pulmonary embolus in patients with shortness of breath. Would that test be useful in this patient?
  4. Ask about what was done, rather than what was not done.
    Question: Don’t you send your diabetics for nutrition education when you first start them on an oral agent?
    Better Question: This is the first time I have seen a patient with newly-diagnoses diabetes. I understand the choice of the oral agent. Where does diabetes and nutrition education fit into the picture?
  5. Share your observation to introduce your question.
    Question: Why did you withhold antibiotics for this ear infection, after you gave amoxicillin to the kid with the earn infection this morning?
    Better Question: I noticed that you withheld the antibiotic for this child’s otitis media and spent quite a bit of time with the mother explaining your rationale for watchful waiting. This morning we gave amoxicillin to the child with a similar picture. Can you help me understand the difference between the two cases?
    Question: Shouldn’t we consider depression in this patient?
    Better Question: When she was taking about her fatigue, Mrs. Anderson mentioned problems with sleep. I felt that she seemed be a bit down. Is depression a consideration in this patient?
  6. Ask the doctor to explain her reasoning, not justify her decision.
    Question: Why didn’t you do a chlamydia test on this patient while she was here for her Pap smear?
    Better Question: Some guidelines recommend routine chlamydia tests for all young women who are sexually active. How do you decide which test to recommend to women in for their health maintenance exams at this age?
  7. Avoid criticism as part of the initial question.
    Question: You did not say anything to this patient about his smoking. Don’t the USPSTF guidelines call for counseling on tobacco use for every smoker?
    Better Question: You have quite a few patients who are smokers. How do you approach tobacco counseling and smoking cessation with your patients with so much to do in such a busy practice?
  8. Do not presume that there is only one good approach to taking care of patients.
    Question: On my medicine rotation at the VA, the attending always made us do Doppler exams on the feet of smokers over age 50. Won’t we miss vascular disease if we don’t do universal screening?
    Better Question: Mr. Smythe is a smoker and I am concerned about the possibility of asymptomatic peripheral vascular disease. What approach do you recommend to assess risk in patients like this?
  9. Provide a “scaffold” to help the teacher know where your question is coming from.
    Question: Why do you prescribe an antidepressant for a patient complaining of chest paint and palpitations?
    Better Question: This patient complains of chest paint and palpitations. We have ruled out MI and the Holter monitor test did not show and dangerous arrhythmias. So the problem may be panic attacks. I would think that an anti-anxiety drug would be used in this situation. I also worry that antidepressants can sometime make cardiac rhythm disturbances worse. What is your thinking behind your choice of antidepressant for this patient?

Student Exercises – Asking Better Questions
Reformulate each of these questions into a form that is likely to lead to a better learning opportunity.
Question 1. Doctor, why didn’t you auscultate for abdominal bruits? At the University we were taught that the abdominal exam requires listening for bruits to find renovascular disease.
Exercise: How would you rephrase the question?
Question 2. Shouldn’t we get PFTs on this patient with a history of exercised-induced bronchospasm? Testing is the only objective way to assess current airway function.
Exercise: How would you rephrase the question?
Question 3. Why wouldn’t you prescribe birth control pills this patient? She is 18 years old and seemed well informed about her choices for contraception. Is that professional?
Exercise: How would you rephrase the question?