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Kennedy TJT, Lingard LA. Questioning competence: A discourse analysis of attending physicians' use of questions to assess trainee competence.Academic Med 2007;82(10 suppl): SI2-S I5.

Kennedy TJT, Lingard LA. Questioning competence: A discourse analysis of attending physicians' use of questions to assess trainee competence. Academic Med 2007;82(10 suppl): SI2-S I5.

Reviewed by Bill Varade

What is the problem and what is known about it so far?
Supervising physician-teachers in the clinical setting must assure patient safety and quality of care at the same time that they foster the development of independence and autonomy in their trainees that is appropriate to their level of competence. In many clinical settings the assessment of trainee competence is made during the case presentation to the supervising resident or attending physician. How this assessment of competence is made is the subject of much interest and study.

Why did the researchers do this particular study?
The purpose of the srudy was to explore the process of assessment of competence used by attending physicians that informed the degree of independence allowed to lminees in the clinical setting for case-specific encounters.

Who was studied?
This article studied 4 attending physicians, 5 residents, and 5 medical students in the emergency department of an urban Canadian teaching hospital. This report represents one phase of an ongoing larger project of clinical supervision practices. How was the study done? 10 sessions of audio-recorded observations (30.5 hrs) ofattending physician and trainee interactions in the emergency department were transcribed yielding 26 discrete case presentations. These were analyzed in a qualitative fashion for the auending physicians' use of questioning strategies. Provisions were made to account for gender, level of experience of participants, time of day, workload, acuity of patient problems, and to allow for saturation of the data. Analytic categories of questioning strategies were proposed by the first author and challenged and confinned through data sessions with the second author, an educational scientist with expertise in discourse analysis.

What did the researchers find?
Questioning strategies used by attending physicians during case presentations were of two types: clarifying questions that ensured the attending's understanding of the clinical situation, and probing questions. used to detennine the extent of the trainee's knowledge or understanding. The latter were subdivided into 3 types of questions: case┬Črelated probing questions used to explore a trainee's understand ing of issues specific to the case, including diagnosis or management; knowledge┬Črelated probing questions used to test a trainee's medical knowledge (usually triggered by a problem or inconsistency in the clinical information presented); and challenging questiolls used to challenge a tminees assumption ofshared knowledge and demonstrate that the trainee actually has the presu med shared knowledge.

What are the limitations of the study?
An observer effect could influence the nature of the interactions between attending and trainee, though attempts were made to minimize this. The sessions took place in an emergency department and the findings may not be transferable to other clinical settings.

What are the Implications of the study?
This study adds a new category, challenging questions, to Weinholu 's framework of questioning styles used for clinical teaching but focuses on the use of questioning to assess competence. These findings support techniques proposed in the RIME model for assessing trainee level and in the J-Minute Preceptor model of leaching. The deconstruction of questioning strategies to determine level of clinical competence suggests that these strategies could then be taught to supervisors in faculty development sessions to improve their own competence in trainee assessment and evaluation.

Ed. Note: This article is imponant in that it not only adds to the medical education literature by expanding upon Weinholtz's framework of questioning, but the authors provide constructive ideas on using these findings to educate both attending physicians and trainees on how to better ask and respond 10 questions following a case presemation. SB

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