Questions, Questions, Questions
Over the last fifteen years I’ve noticed that the more I learn about medicine, the more I realise I really know very little and the more questions I ask. There was a glorious moment about two months into my first year of university when I felt really smart*. I’ve never quite managed to get that feeling back.
The more I learn about medical education, the more questions I ask of learners, not because I think they know as little as me but because I really want to understand how they see things and how they come to make the decisions and judgements they make in the ED.
As an educator, I bet you too love asking questions. Most of the educators I know love asking questions. And of course you already know how to ask questions – you’ve been doing it all your life, haven’t you? Well, maybe asking questions isn’t as straightforward as it seems…
But I bet, like most educators, you know you can be better at it.
Questions give us the opportunity to clarify, probe, explore and challenge, to expose process errors and ultimately to improve ourselves and provide better clinical care (which is, at heart, what all this medical education stuff is about). Reflective enquiry helps us to cognitively process events, separate out areas of uncertainty and begin to delve into tacit knowledge, an exploration which is harder to undertake and assess in more formalised ways.
As smarter EM clinicians and educators we have moved towards understanding not simply what we should do in certain clinical situations but why we make decisions the decisions we make, how they are influenced and what we can do to act in different ways in future.
So we put lots of thought into asking questions; framing the context, being specific while still leaving questions open, choosing syntax carefully. But what do we expect to happen once this perfect question is posed? And what do we do when that doesn’t happen?
I’ve worked hard at asking better questions (I’m still bad at it).
However, I am completely terrible at letting people answer questions. If there’s one trait common to Emergency Physicians, I reckon that it’s a very short attention span and so I suspect you might struggle with this too.
I don’t think this is an uncommon problem but luckily for me (or for us?) it is something that has been explored in the medical education literature. The concept is called “wait time” and it occurs in two phases. Wait time 1 occurs after the question is posed (usually by the educator). Wait time 2 occurs after the respondent has stopped speaking and is the time between the end of the answer and the next thing the educator says.
What’s interesting is how long we are prepared to allow these silences to hang in the air. Record yourself, listen back and measure the time. I bet it’s not as long as you’d think.
Typically when we ask a question we allow less than one second for the person to answer. And the same is true when we think they’ve finished answering.
There are a couple of papers on this worth looking at. Mary Rowe wrote about “wait time” in 1986 and described an increased incidence of what she called “speculative thinking” (a concept which reflects our ideas of deeper cognitive processing) when wait times 1&2 were longer. She describes “pronounced changes” in both language and logic used by students when they were allowed a longer uninterrupted period after being asked a question. And how long should we wait?
The Magic Number
It turns out that three is the magic number.
Kenneth Tobin felt that where there is a “wait time” (for an answer to a question – here he is referring to wait time 1) of more than three seconds, this reflects “higher cognitive level learning”.
Both authors also advocate pauses of more than three seconds after student responses and suggest that in allowing this increased processing time we enable deeper engagement with the question rather than accepting an initial, almost automatic, response.
Three seconds. THREE seconds. When you’re up there in front of a crowd, that’s a LONG time.
OK, maybe not on paper, but this is something I definitely struggle with. How do I know? Well, I recorded myself and checked. As part of a medical education course I recorded a conversation I had with a trainee about a patient (with her consent). Have a listen below – it’s not a long snippet.
What really struck me when I listened back was the balance of the question/answer interactions. I have a transcript of the discourse so it’s easiest to understand the issues when we listen to the conversation itself. Believe me when I say I didn’t realise this was a problem until I listened to the recording. Recording yourself is definitely something you can do – painful but powerful!
To be fair, here’s a little context – we are talking through the APLS guidelines for anaphylaxis after seeing a paediatric patient with an allergic reaction. The trainee was kind enough to allow me to audio record the discussion we had so that I could work on improving the quality of educational encounters I facilitate with trainees. The recording was only ever about my self-improvement as an educator (rather than evidence of her competence or otherwise) and it’s important to clarify this from the outset. In this clip, she’s already told me some airway, breathing and circulatory symptoms and signs of anaphylaxis and I’m asking about other signs which might lead you towards thinking the presentation was anaphylaxis rather than simple allergy.
You might have to believe me on this, but after the last contribution the learner makes there is exactly three seconds before I chip in with the answer. The time feels awkward to listen to and I think that’s what drives our discomfort and the perceived necessity of reply.
So. as I suspected, I’m pretty terrible at this. Reassuringly, William Carlsen found that we can learn to change verbal strategies for responding and reacting.
The idea of standing in silence in front of a whole roomful of people is faintly terrifying so it’s probably easiest to practice in one-to-one or small group work; I reckon that in these situations you’ll get a clearer idea of whether it’s working as the one-to-one nature of the interaction affords the luxury of thinking and waiting time without fear of external interruption from someone else in the room.
How Can We Change?
So how can we change? Awareness, analysis, reflection and practice.
When Swami, Simon and I talked about what makes a good educator, one of our recommendations was that you should record yourself and critically review your performance. This is something I find absolutely fascinating and wholeheartedly endorse and I challenge you to measure your wait times; then stretch them out and see what happens.
Record yourself often. Get used to it. Get trainees to do it using Google Glass (Rob Rogers can show you how! Is it even still a thing?) or GoPro, or simply a Dictaphone. Try it in different contexts and teaching environments. Are the answers better? Does the learner respond differently? Do you ask different – better – questions if you stop and listen for those extra seconds?
I’ve been trying hard to be better at this over the last four years – I think I’m getting there but I’m probably due a recording session soon (trainees, you’ve been warned).
But here’s the real twist – if you can translate this skill of allowing extra time to answer into your clinical encounters with patients, I reckon it might make you a better doctor too.
I’d love to hear what you think.
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*I suspect this historical moment reflects the very depth of my unconscious incompetence. But who knows? It’s unconscious – so maybe I’m actually (still) there right now…