#KeyLIMEpodcast 143: Wagging the Dog – Student approaches for managing questioning by their preceptors [KeyLIME Live! @CGEA Conference, Part 1]

Lawrence L & G. Regehr. 2017. Medical Students’ Understanding of Directed Questioning by Their Clinical Preceptors. Teaching and Learning in Medicine. 29 (1):5-12.

Reviewers: Anna Cianciolo (@anna_cianciolo) & Brian Mavis

Background

During clinical training, questioning by preceptors is a primary educational activity. However, learner strategies for managing questioning has yet to be explored. Lo and Regehr conducted semi-structured interviews with 4^th year medical students to explore this phenomenon. The authors found that learners had specific strategies for attempting to manage situations where they were directly questioned by preceptors. These strategies suggest that students’ engagement in questioning prioritizes image management, but also seizes opportunities to optimize learning.

Type of Paper

Research: Qualitative (interviews)

Key Points on Methods

Lo and Regehr apply a sociocultural lens to examining clinical teaching and learning. Through this lens, which is being adopted more and more often in medical education, learning is viewed as a social activity shaped by its participants and their cultural context. Lo and Regehr conducted semi-structured interviews with a convenience sample of nine 4th year medical students who had already matched for residency training but had not yet been acculturated into a particular specialty. These students also were thought to be less concerned about “looking good” to researchers asking them about what they did as clinical learners. Interview transcripts were coded thematically via iterative and recursive analytic reading. As noted by Lo and Regehr, it would be interesting to explore questioning dynamics further with observational study..

Key Outcomes

• Students had two main priorities when dealing with preceptor questions they couldn’t answer: optimizing their learning and managing their image.

• Students generally reported seeing questioning as an opportunity to learn (vs. “pimping”), and they described using partial answering strategies to help preceptors set the bar for future questions just high enough to usefully test knowledge.

• Strategies for image management depended on students’ perceptions of the preceptor’s intent. If students sensed that questions were raised with the intent to teach, their answering strategy involved appearing knowledgeable yet also appearing to be a “good learner.” A “good learner” could simultaneously convey, by talking confidently about what they did know, that they had reached the boundary of their knowledge and that they were eager and able to cross it.

• If a preceptor’s questions were perceived as assessment, students reported giving short, confident answers to efficiently convey that they had in fact learned, so that the teaching team could move on.

• Other contextual factors affected students’ image management strategies, including who else is present, whether the specialty was one to which the student aspired, and the student’s stage of training.

• Questioning perceived as a dominance display was patiently endured by students, who recognized themselves as being at the bottom of the hierarchy and having little choice in the matter.

• An intriguing finding was that students reported using strategies to set themselves up for success. These strategies included directing conversation to a topic the student knew well, timing participation in questioning for when the student could most likely volunteer a correct answer, and avoiding eye contact in order to convey a lack of receptiveness to answering questions. Although image management strategies occasionally clashed with the priority to optimize learning, they do reflect the agency students have in this highly prevalent teaching strategy thought to be controlled by preceptors.

Key Conclusions

The authors conclude…

• This study provides an important initial step toward determining the limits, uses, and consequences of questioning in clinical education.
• Students use various strategies during questioning to manage their image and also identify opportunities to optimize their learning.
• When confronted with direct questioning, students may prioritize image management.

Spare Keys – other take home points for clinician educators

• Educators should observe and reflect on what factors that affect students’ approach to managing questioning and the effect of students’ image management strategies on preceptors.
• In qualitative studies, selection methods matter and context matters. Learners from other cultures may use different strategies to manage clinical questioning.
• Observational methodologies are called for to explore preceptor questioning across various learning contexts, learner groups, and specialties.

Shout out

• Hugh Stoddard at Emory for is work on psychological safety (KeyLIME 128) and questioning strategies in Medical Education
• Heeyoung Han at Southern Illinois University College of Medicine and her parents from South Korea

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