Not too long ago a med student on Twitter asked how to ask questions during rounds. Why, what an excellent question! So let’s dive in.
Tips for Good Questions
- Let the senior/attending know you’re not following the plan
- Demonstrate what you DO know and understand of the problem
- Ask a focused, specific question (now is not the time for an open-ended, vague question, save those for patient histories)
Now, we’re going to do three scenarios, followed by a “too vague” or “too easy” question, then some examples of more direct or focused questions that can help your senior residents and attendings give you a real answer.
Scenario 1: Let’s pretend you’re on a very busy medicine service with lots of respiratory patients. Rounds are going fast, the attending seems inpatient and the plan you and your senior came up with got changed by the attending, who made a different antibiotic choice. So you ask…
- Why did you choose antibiotic XY over antibiotic ZW? – this is a generic, easy question. And makes it seem as if you put no thought into the asking. It also gives your attending no direction for teaching, as they may have two or three reasons, and can’t take the time to teach them all (rounds HAVE to end at some point, folks).
- Did you choose antibiotic XY for coverage of a specific organism, or because of a concern of a known side-effect of antibiotic ZW? You’ve let them know you’ve thought about why they may have made the change, and they can give you targeted information on that decision. Nice!
- I thought antibiotic XY was ideal for this type of pneumonia, and there are no new micro results or change in our patient, so why did you choose ZW? Ah-hah! Your attending now knows you know that changes of an ABX can occur when a) there is a change in cultures or other labs b) or change in patient status. So why DID they do that? Maybe they’ll tell you.
- What do I need to look for to make a decision on narrowing antibiotic treatment? Would anything make you broaden it further? This question may come at the end of the patient’s presentation, but helps you prepare for the future, and demonstrates you can plan for disposition. This is more senior-level.
The reality is that the learning above is something that doesn’t come out of a textbook or while studying for Steps. It’s typically learned on-the-go during rounds, and if your medical school rotations weren’t up to snuff you may feel lost on the service. It’s always okay to ask for help in these situations.
Scenario 2: Earlier in the day the plan for your patient was for discharge tomorrow. Now it’s mid-afternoon and your senior comes in and tells you to start the discharge summary, but offers to do the discharge process – and before you can ask for details there’s another admit. At the end of the day you ask…
- What changed, why are we discharging? Again, vague and too much. Your senior is juggling a lot responsibilities and will reply with a vague and useless answer.
- What improvement did Ms. Potato have that moved up her discharge? It’s almost identical to the first, but specific. Your senior can say “She doesn’t need home O2, her ambulatory pulse ox was great and her home health got approved and setup already!” This also helps you do that D/C summary.
Scenario 3: You admit a patient and try to build a differential with your senior. You then present to the attending, who quickly dismisses your top diagnosis of LM and tells you it’s actually diagnosis PQ, which was low on the list you made with the senior. The floor nurse calls to say the patient’s already on the floor with no orders. Your senior goes to put orders in, while your attending goes to see the patient. Five minutes later she returns and asks if you have any questions.
- What did I miss? You already know I’m gonna say this is too vague.
- I thought this was LM because of X, Y and Z. Can you help me understand what should have led me to think of PQ instead? Direct, focused and let’s the attending know what you (think) you know.
- I realize both LM and PQ present with shortness of breath, but LM also has tachycardia, so what should have pointed me to PQ in this case? This is HARD. You may not have a clue about LM or PQ, but in that space of a few minutes your attending was gone, it’s a great time to look up both on UpToDate, or in your Tarascon pink book, and look for the clinical symptoms they share, and those they don’t.
Again, this is learning that doesn’t come out of a book. If you have a senior who was coached and taught by attendings who are skilled educators, lucky you! Those skills will be passed on. But if not, don’t despair. You still have #MedTwitter and us.
These are just a couple examples, and I’d love to see folks out in #MedEd demonstrate other examples of basic asks (medical student level) versus more skilled inquiries (intern level) in the academic medicine service setting (or in the ED or ICU).
Keep asking those questions, wear PPE and stay safe!