Instructor’s Guide: Questioning as a Tool in Teaching

Montefiore Medical Center – Albert Einstein College of Medicine

Ellen Tattelman, MD, Arati Karnik, MD, Alice Fornari, EdD

1) Description

We created a teaching tool to be used in a number of different venues. It can be used

within a program of accessible faculty development for community-based clinical faculty.
In a revised, longer presentation, it can be used for an interactive faculty development
session or as part of a Resident as Teacher curriculum.

An academic detailing model (Soumerai, 1990, Moser, 2004) was established to educate
community preceptors with limited faculty development resources and this session is
part of a series of sessions offered to community preceptors. The literature has shown
that targeted use of questioning can help evolve critical thinking skills in the learner
(Myrick, 2002). Combining this concept with the modified Bloom’s Taxonomy that
classifies the hierarchy of learning levels, we have developed this teaching handout to
demonstrate the use of questioning to nurture the learner into higher levels of intellectual
thinking, focused on clinical reasoning and decision making.

While there is much available material about questioning in education and Bloom’s
Taxonomy, we felt there was a need for an education tool that could be used in a faculty
development session. This two paged color handout introduces questioning strategies
that are aligned with the modified Bloom’s Taxonomy. The second page illustrates a
concrete clinical example of how questions can be posed to learners to escalate to
higher levels of thinking evident in Bloom’s Taxonomy. This handout was developed to
be posted or readily available in precepting areas as an accessible reference tool in
busy clinical environments.

As a complement to the handout, we’ve created an interactive PowerPoint presentation,

geared towards residents in a Resident as Teacher session or toward faculty in a more
detailed, interactive faculty development session. During these presentations, the
participants will observe a precepting demonstration that uses the modified Bloom’s
Taxonomy hierarchy of questioning. They will then actively take part in developing
questions at all levels and role-play a typical clinic precepting case to practice what has
been introduced.

2) Learner audience

The handout and presentation are targeted for primary care community preceptors and
faculty teaching medical students and residents, as well as residents teaching medical
students and peers in various settings. The topic can be used in any faculty practice
where residents and medical students are in training. Clinical cases can be modified to
fit the area of interest or specific disciplines represented by attendees.

3) Session objectives

Objective #1: Discuss the concept of a hierarchy of questioning as a model of teaching

and learning.

Objective #2: Illustrate the use of questioning with a common clinical case.

Physician Faculty Development in Primary Care HRSA Grant # D55HP08354

Instructor’s Guide: Questioning as a Tool in Teaching
Montefiore Medical Center – Albert Einstein College of Medicine

Objective #3: Recognize opportunities to use questioning in various teaching settings.

Objective #4: Practice the use of questioning in a supportive, non-confrontational

manner.

4) Session time – Two different educational strategies based on setting and

time

Session Time/Min Topic

Academic Detailing
Model for Community
Based Preceptors
Resident as Teacher or
Faculty Development
Session
25 min Community Precepting Teaching Tips: Questioning as a
Tool for Effective Precepting, with reference to background
article: Myrick F, Yonge O. Preceptor Questioning and
Student Critical Thinking. J Prof Nurs. 2002;18(5):176-81.
60 min Questioning as a Tool for Effective Teaching –
PowerPoint
presentation with notes, role play and discussion.

5) What the packet contains

Materials Resource file Description

Educational Questioning Two page handout titled: Community Precepting Teaching
handout teaching Tips: Questioning as a Tool for Effective Precepting. The first
tips.doc page of this handout describes the modified Bloom’s
Taxonomy and what specific verbs can be used in questioning.
It also contains general questioning tips that teachers should
keep in mind while eliciting information through questioning
(Spencer 2003). The second page uses a common clinical
case to demonstrate specifically the different levels of
questioning.
PowerPoint Questioning 24 slide PowerPoint presentation titled: Questioning as a Tool
slides with presentation.ppt for Effective Teaching. This presentation utilizes the same
speaker notes content as the handout in a more detailed and interactive
format. The goal is to demonstrate to participants how to pose
and advance questions to achieve higher level thinking skills
and then apply what they’ve learned to a clinical case. Time
at the end is left for discussion and wrap-up.
Script for Questioning To be demonstrated during the PowerPoint presentation. Note:
demonstration script for The demonstration case requires two presenters. If the
case demonstration presenter is alone, the vignette can be pre-recorded and
case.doc viewed by the group.
Practice case to Questioning Clinical case for the participants to role-play to practice the
role-play role-play hierarchy of questioning.
practice
case.doc
Evaluation card Evaluation Brief 4-question card evaluating immediate
card.doc effectiveness/helpfulness of material covered (Kirkpatrick’s
Level 1 and 2).

Physician Faculty Development in Primary Care HRSA Grant # D55HP08354

Instructor’s Guide: Questioning as a Tool in Teaching
Montefiore Medical Center – Albert Einstein College of Medicine

6) Detailed plan

Timeline for Academic Detailing Model for Community Based Preceptors

TIME TASK RESOURCE FILE
1 min Introduction of handout titled: Community Precepting Questioning teaching
Teaching Tips: Questioning as a Tool for Effective tips.doc
Precepting.
 Describe goals and objectives of session
 Pass out Questioning handout for faculty to follow
along
3 min Introduce second page clinical case example
 Illustrate hierarchy of questioning with example on
sheet
6 min Clinical case example from one of the community preceptors
recent precepting encounters
 Have participants cover sheet and see if they can
come up with appropriate questions
 Uncover each section as you discuss each level,
so participants can view the examples of
questioning.
2 min Stop midpoint to clarify points or answer questions
5 min Review Bloom’s Taxonomy and 6 levels of questioning using
the first page of the handout
 Review examples of verbs that illustrate each
concept.
 Discuss strategies for posing questions in a
supportive, non-confrontational manner as
opposed to the “pimping” style of questioning often
used in medical education
3 min Different question types
 Discuss different types
 Discuss how certain types of questions can be
used depending on the level of the learner.
2 min Review ‘Tips for Using the Questioning Strategy’
3 min Wrap up
 Answer questions
 Reference background article: Myrick F, Yonge O.
Preceptor Questioning and Student Critical
Thinking. J Prof Nurs. 2002;18(5):176-81.
 Hand out evaluation cards Evaluation card.doc

Timeline for Resident as Teacher or Faculty Development Session

TIME TASK RESOURCE FILE

Physician Faculty Development in Primary Care HRSA Grant # D55HP08354

Instructor’s Guide: Questioning as a Tool in Teaching
Montefiore Medical Center – Albert Einstein College of Medicine

1-2 min Objectives of PowerPoint presentation: Questioning as a Questioning

Tool for Effective Teaching. presentation.ppt
5 min Case with writing questions on cards
15 min Bloom’s revised taxonomy with demonstration case Questioning script for
demonstration
case.doc
5 min Fit the participants questions from cards into the Bloom’s
question hierarchy
12 min Practice Case Questioning role play
 Break into groups of 3 (1 playing resident, 1 practice case.doc (for
playing preceptor and 1 observing). those playing the
 Instruct group to play out clinical case as if they resident)
were in clinic and to try to stay true to your role Questioning teaching
(“think like a resident”) tips.doc (for those
playing the preceptor)
10 min Discussion
 Have observers summarize what happened in their
role play
 Discuss challenges
 Were there flow issues?
 Things that were helpful/worked well
 Ask participants how they would rephrase
questions in a less confrontational manner
5 min Review questioning tips
3 min Conclusion
 Review 3 main conclusions
 Discuss opportunities for trying out this teaching
method with learners
 Hand out Questioning teaching tips Questioning teaching
 Answer any questions tips.doc
 Hand out evaluation cards Evaluation card.doc

7) Evaluation/Assessment

See attached evaluation card adapted from the One Minute Paper (Angelo, 1993) and
adjust for your own institution. Evaluation cards ask the following questions:
1. Cite one thing you learned during this session?
2. In your next encounter with a learner, what would you do differently?
3. What is one way this session could be improved?
4. Do you have any requests for future sessions?

8) Instructor qualifications

Physician Faculty Development in Primary Care HRSA Grant # D55HP08354

Instructor’s Guide: Questioning as a Tool in Teaching
Montefiore Medical Center – Albert Einstein College of Medicine

The instructor should be a chief resident, fellow or clinician educator faculty member with
an interest in education and knowledge of the terms and theories being utilized. S/he
should also be familiar with ambulatory practices and the role of precepting in the
learner’s development of knowledge and skills. Particular clinical knowledge is not a
requirement, but familiarity with the clinical case examples used in the handout and
PowerPoint is ideal. The instructor needs to be skilled at conveying information,
answering questions and creating an interactive atmosphere. The instructor should
believe in the philosophy that questioning can be done to enhance critical thinking in
learners and can be done in a supportive, non-confrontational manner.

9) Facilities

Questioning handout: This was created for a small group discussion to be done on-site
at clinics where faculty work to support an academic detailing model of faculty
development. A small conference room or precepting room is required for a group of ~5
people (1 table with 6-7 chairs). Ideally, bring refreshments.

Questioning PowerPoint: This will require a computer with PowerPoint and projection
capabilities in a larger room (holding 20-30 people). If demonstration case is not done
live, AV equipment to play pre-recorded precepting demo will be needed. Internet
access not required.

10) Instructional materials

Session Materials
Academic Copies of handout titled: Community Precepting Teaching Tips: Questioning
Detailing Model as a Tool for Effective Precepting for participants
for Community Evaluation cards
Based Preceptors
Resident as PowerPoint slides
Teacher or Copies of handout titled: Community Precepting Teaching Tips: Questioning
Faculty as a Tool for Effective Precepting for those playing faculty preceptor during
Development role-play and for all participants at the end of the session
Session Practice case role-play sheet for those playing the resident
Evaluation cards

11) Advanced preparation

Physician Faculty Development in Primary Care HRSA Grant # D55HP08354

Instructor’s Guide: Questioning as a Tool in Teaching
Montefiore Medical Center – Albert Einstein College of Medicine

Day/Week Tasks 
Prior to Complete
Event
Academic Detailing Model for Community Based Preceptors
1 month, 1 Send email to clinical site faculty
week
1-2 weeks Reserve room at clinical site
2 days Make color copies of handouts
2 days Make copies of evaluation cards
2 days Collate all into a packet for each participant

Resident as Teacher or Faculty Development Session

1 month Reserve room for presentation, pre-record demonstration
case if not enough presenters available for live demo
2 days Make copies of handout for participants
2 days Make copies of practice case role-play sheet
2 days Make copies of evaluation cards
2 days Test out equipment (computer, PowerPoint, TV/computer to
play pre-recorded demonstration if needed).

12) Relationship of this session to other educational materials

This teaching tool is designed in a shorter format for community-based preceptors and in
its longer presentation as part of a resident as teacher series or as an interactive faculty
development session

The shorter model is to be used with other academic detailing sessions for community
preceptors. Faculty development for community preceptors who do not attend traditional
workshops is difficult to arrange. “Academic detailing”, a short, focused, face-to-face
faculty development session at the community preceptors’ clinical site, has been an
effective approach (Moser, 2004). This model, adapted from the office detailing of
pharmaceutical companies’ representatives, includes defining clear educational
objectives, referencing unbiased sources of information, stimulating active physician
participation and using concise educational materials (Soumerai, 1990).

Questioning is a very effective tool to develop and enhance critical thinking but
questioning in medical education has often been confrontational in a “pimping” style.
Aggressive “pimping” is set up as rapid-fire questions until the learner is stumped, with
the teacher often looking for a specific answer or trivial knowledge in a “read my mind”
format (Wear, 2005). This type of questioning is often focused on evaluating a learner’s
performance and not on the process of learning (Oh, 2005). Learners may be pushed to
be more prepared by this style of questioning but this comes at a cost (Weinholtz, 1983).
Although most learners never forget the answers to questions they missed when
“pimped”, the anxiety, humiliation, and competitiveness engendered by this method of
questioning can inhibit learning.

The format of non-confrontational questioning presented here along Bloom’s hierarchy of

learning levels is designed to stimulate critical and creative thinking while the learners

Physician Faculty Development in Primary Care HRSA Grant # D55HP08354

Instructor’s Guide: Questioning as a Tool in Teaching
Montefiore Medical Center – Albert Einstein College of Medicine

build confidence as they formulate answers. Identifying areas of strength and gaps in
understanding through questioning also builds the learners’ self-assessment skills with
the goal of encouraging higher level questioning of themselves and self-directed learning
as a continual component of their professional training and career.

13) Evaluation and lessons learned

We have used these materials in four academic detailing sessions with community
preceptors in different sites. In our initial session, we began the session with Bloom’s
taxonomy and the verbs to use in questioning at each level. We then applied these
concepts to a case presented by one of the community preceptors. This approach was
too abstract for the preceptors to follow so we modified the session to start with the case
example and then we presented the theory. This new approach has been very effective
with the community preceptors; they have been very satisfied with the session and have
committed to using questioning for higher order thinking in their next precepting session.

When we revised our materials for the faculty development and resident as teacher
sessions, we developed a demonstration case to start the session to be sure the
teaching points would be grounded in a case. We have used these materials in one
resident as teacher session. The residents were enthusiastic and particularly active in
the role-play activity. They felt this questioning approach would be helpful in their
teaching of other residents and medical students.

We have presented two faculty development sessions in different sites and both were
very well received. When presenting to the residency faculty, as opposed to the
residents in the resident as teacher session, we had time for excellent in depth
discussion on using these techniques with different types of residents and students. The
faculty committed to using these techniques in their next precepting sessions.

Although we have only Kirkpatrick level 1 (reaction) and level 2 (learning) data from the
evaluation cards handed out after each session we have presented, we will be collecting
new evaluation data as we continue to present these sessions to community preceptors
and residents with our new HRSA faculty development grant. We are designing an
evaluation system that will be longitudinal and will achieve data collection at Kirkpatrick
level 3 (behavior change of our learners) based on feedback from preceptors, residents
and students.

14) References

Angelo TA, Cross KP. Classroom Assessment Techniques: A handbook for College
Teachers, 2nd ed. San Francisco: Jossey-Bass; 1993:119.

Anderson, LW, Krathwohl, DR, Eds. A taxonomy for learning, teaching, and assessing: A
revision of Bloom’s taxonomy of educational objectives. New York: Addison Wesley
Longman; 2001.

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

Detsky AS. The art of pimping. JAMA. 2009;301:1379-81. Erratum in: JAMA. 2009;
301(13):1770.

Physician Faculty Development in Primary Care HRSA Grant # D55HP08354

Instructor’s Guide: Questioning as a Tool in Teaching
Montefiore Medical Center – Albert Einstein College of Medicine

Greenberg LW. Pimping perspectives: response to Wear. Teach Learn Med.

2006;18(1):87.

Kennedy TJ, Lingard LA. Questioning competence: a discourse analysis of attending

physicians' use of questions to assess trainee competence. Acad Med. 2007;82(10
Suppl):S12-5.

Moser S, Dorsch J & Kellerman R. The RAFT approach to academic detailing with
preceptors. Fam Med, 2004;36(5):316-8.

Myrick F, Yonge O. Preceptor questioning and student critical thinking. J Prof Nurs.
2002;18(5):176-81.

Oh RC. The Socratic method in medicine—the labor of delivering medical truths. Fam .
Med. 2005;37(8):537-9.

Soumerai SB, Avorn J. Principles of educational outreach ('academic detailing') to

improve clinical decision making. JAMA. 1990;263(4):549-56.

Spencer, J. Learning and teaching in the clinical environment. BMJ.

2003;326(7389):591-4.

Wear D, Kokinova M, Keck-McNulty C, Aultman J. Pimping: perspectives of 4th year

medical students. Teach Learn Med. 2005;17(2):184-91.

Weinholtz D, Directing medical student clinical case presentations. Med Educ.

1983;17(6):364-8.

Williamson KB, Kang YP, Steele JL, Gunderman RB. The art of asking: teaching
through questioning. Acad Radiol. 2002;9(12):1419-22.

http://www.apa.org/ed/new_blooms.html

14) Acknowledgments

We thank Sandra Braganza, Dalia Brahmi, William Jordan, Sharyn Miskovitz and Angela
Vidal for their contributions to this work in the fellowship supported by Physician Faculty
Development in Primary Care. This publication was made possible by Grant Number
D55HP08354 from the Health Resources and Services Administration (HRSA), U.S.
Department of Health and Human Services. Its contents are solely the responsibility of
the authors and do not necessarily represent the official views of the HRSA.

Physician Faculty Development in Primary Care HRSA Grant # D55HP08354