The Socratic Method in Experiential Medical Education

By Miguel Franquiz, PharmD, PGY-1 Pharmacy Practice Resident, University of Maryland 

The delivery of medical care in the modern era is increasingly specialized¹, involving numerous, numerous systematic approaches have been developed to aid the already overburdened clinician in fostering clinical reasoning among medical learners.² One of the oldest and most prevalent is the Socratic method.

professionals working collaboratively within their respective skillsets to achieve optimal outcomes. Physicians, nurses, pharmacists, dieticians, respiratory therapists, physical therapists, occupational therapists; all of these disciplines make medical decisions which are informed by a vast body of clinical evidence and an understanding of physiology.  Years of experience impart critical thinking skills at the apex between evidence-informed and intuition-based medical decisions, which results in care delivery that cannot be found in a textbook, yet at the same time is based in objectivity. The task of building such clinical intuition for oneself alone is daunting, and even seasoned clinicians will struggle periodically with patients who defy both objective and intuitive convention. But because consistent clinical practice is the only way to truly develop this skillset, the clinician is additionally responsible for imparting critical reasoning to junior trainees within their discipline.  This is assuredly a monumental task, and because of this

Baseline knowledge is often insufficient to provide excellent care in medicine. Instead, baseline knowledge applied within a framework of understanding that recognizes key patient specific factors will optimize medical decision making.³ The Socratic method is centered around a philosophy that assumes medical learners have the baseline knowledge required to approach therapeutic decision making, but lack sufficient experience to apply such knowledge appropriately. The Socratic method is then achieved by sequential, probing questions which allow the learner to critically appraise the validity of the assumptions they used when making a decision. In this manner, they will arrive at an optimal therapeutic plan on their own, using their own baseline knowledge, and simply guided by questioning from a more senior clinician. The aim of Socratic questioning should be clear, and focused on having learners examine the validity or fallacy of the assumptions they used in arriving at a treatment plan.

Unfortunately, this method is plagued by inherent disadvantage and often poor execution. To start, many learners perceive the repeated, probing questions used by this method as hostility. Coupled with the fact that this method is often carried out in the presence of other medical learners, the pupil may become quickly discouraged. Failure of the Socratic method in the learner may manifest with apathy in one extreme (“I don’t know, what’s the answer”) or over-analysis in another (learners who inappropriately second guess content they were previously confident to be true). Social dynamics no doubt play a role. Most learners will be uncomfortable “being wrong” in front of others. However, it should be noted that the complexity of medicine as a discipline demands humility, and even the most experienced clinician will encounter puzzling patients in whom they diagnose or treat incorrectly. Perhaps the Socratic method is helpful then in fostering some of this healthy anticipation of failure.

Additionally, delivering excellent patient care does not impart the clinician with excellent teaching skills. Many clinicians mistake the Socratic method for “pimping”, or simply asking repeated questions solely based in the regurgitation of rote memorization. Such questioning is not useful in fostering critical thinking skills and instead focuses on simple recall of prior knowledge, rather the building on the process of therapeutic decision making. Also, the clinician may fail to structure Socratic questioning in a way that helps the learner examine the assumptions of their reasoning. This most often manifests in a “guess what I’m thinking” approach, where the clinician produces a line of questioning that does not flow logically towards the desired conclusion.

Some strategies for appropriately executing the Socratic method include assessing the learners baseline knowledge, providing the rationale or goal of one’s questions, and linking the clinical context to the line of questioning in a way that allows the learner to understand the steps that were taken to reach the desired conclusion.⁴ By first understanding a learner’s baseline knowledge the clinician can assess whether or not the Socratic method should even be attempted, or the learner should be referenced to resources that will allow them to engage in critical thinking exercises in the future. Proceeding to the structuring of Socratic questioning, the clinician must themselves understand the assumptions made the learner in reaching a conclusion, and sequentially question the assumptions which lead to the improper conclusion (or key assumptions that lead them to the appropriate conclusion). The rationale for questioning should be briefly stated, so the learner does not immediately perceive their conclusions as incorrect, and so the learner perceives the questioning as comfortable academic dialogue. Next, the learner will arrive at the appropriate conclusion through Socratic questioning, or the clinician should explain incorrect assumptions and their own clinical rationale if the learner does not reach the desired conclusion. This description of this process is quite qualitative, so let’s finish by examining two examples.

Example 1: Poor execution of the Socratic method

Clinician: “Why do you want to give this patient with liver disease and an INR of 2.1 (without anticoagulation) Vitamin K?”

Learner: “To lower the INR and reduce bleeding risk”

Clinician: “How much Vitamin K will they need to reduce their INR and bleeding risk”

Learner: “I was going to give 10 mg”

Clinician: “What literature are you using to support this”

Learner: “I’m not sure my senior told me to do this”

Clinician: “How do you know this will lower bleeding risk”

Learner: “Ok, I’ll discontinue the order”

Notice how the clinician commits several mistakes in the execution of the Socratic method here. The level of baseline knowledge is not assessed. The line of questioning does not examine the learners understanding of the pathophysiology of coagulopathy in liver disease, which is key to reaching the desired conclusion. The questions are probing but do not flow logically together, and the learner quickly withdraws from the dialogue, assuming they are wrong. Let’s look at how this could be done better.

Example 2: Appropriate execution of the Socratic method

Clinician: “Why do you want to give this patient with liver disease and an INR of 2.1 (without anticoagulation) Vitamin K?”

Learner: “To lower the INR and reduce bleeding risk”

Clinician: “I’d like to discuss this decision, and understand your rationale. Do you feel comfortable in your understanding of the pathophysiology of liver disease, and specifically; coagulopathy?”

Learner: “Yes, patients with liver disease do not synthesize clotting factors appropriately due to destruction of their liver cells, which normally synthesize these factors. As related, the INR creeps up”

Clinician: “You are correct. Do you have an understanding of how Vitamin K might intervene on this pathophysiology?”

Learner: “Well I know we use Vitamin K to correct high INR’s in patients on warfarin, so I was applying the same principle.”

Clinician: “You are right about Vitamin K for correcting INR in patients on warfarin, but how is that different than patients with liver disease?”

Learner: “I think we use it in patients on warfarin because warfarin blocks enzymes which use Vitamin K, so we give Vitamin K to overcome the blockade.

Clinician: “And how might the situation be different in someone with liver disease?”

Learner: “I can see your reasoning now; for a patient with liver disease they just have cellular destruction and low synthesis of clotting factors as related. There’s no enzyme blockade, so using Vitamin K to correct blockade that is not there does not make sense.”

Clinician: “Excellent, so now you can see why correction of the INR with Vitamin K in someone on warfarin is much different than in a patient with liver disease.”

Notice how in this scenario the clinician assessed baseline knowledge, and questions appropriately, knowing that an understanding of the pathophysiology is key to reaching the desired conclusion.

Closing thoughts

Imparting critical thinking skills is undoubtedly one of the most difficult pedagogical exercises for the instructor, particularly because prior experience (which learners lack) is so essential in addition to prior knowledge. The Socratic method is a simple and systematic manner for teaching critical thinking, and with practice and appropriate structuring, effective for the busy clinician. Clinicians should be wary to avoid “Guess what I’m thinking” questions and “pimping”, which are often mistakenly implemented in an attempt to conduct Socratic questioning. The clinician should also be aware that their attempts at using the Socratic method will likely be rocky in the beginning, but with practice, eventually effective.

References

1. Goldbloom RB. Increasing specialization in medicine. CMAJ 1978; 118(11): 1347–1348.

2. Ker J. Teaching on a ward round. BMJ 2008; 337: a1930.

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

4. Carlson ER. Medical pimping versus the socratic method of teaching. J Oral Maxillofac Surg. 2017;75: 3-5.

5. Oh RC and Reamy BV. The socratic method and pimping: optimizing the use of stress and fear in instruction. Am Med Assoc J of Ethics. 2014;16(3): 182-6.