VitalNotes

Paramedic Thinking. Essential Ideas. One Page at a Time.

The Five Whys: A Simple Method for Better Clinical Thinking

Go Deeper Than the First Answer

Use this page after a scenario, when something didn’t feel right, or when you want to sharpen your reasoning—beyond just remembering facts.

In clinical learning, the real growth doesn’t come from getting everything right. It comes from pausing, reflecting, and asking better questions.

That’s where the Five Whys comes in.

Originally developed for problem-solving in engineering, this simple framework is just as effective in paramedicine. It helps you think past the surface—whether you’re analyzing a clinical decision, a patient presentation, or a missed cue during simulation.

It’s not flashy. But when used well, it sharpens judgment and reveals what drives your decisions.

How It Works

The Five Whys is exactly what it sounds like: a sequence of “why” questions—each building off the last—to explore what’s beneath your first assumption.

The goal isn’t to force every issue into a rigid template. It’s to think clearly through cause, context, and consequence.

You can use it:

  • Mid-scenario when something doesn’t add up
  • After a mistake, to reflect without shame
  • When a treatment worked—but you’re not sure why
  • During scenario debriefs or reflective journaling

Clinical Example: Why Are We Giving Salbutamol?

Wheezing is a sound. Salbutamol is a treatment. One doesn’t automatically justify the other.

Let’s build a Five Whys chain:

  1. Why was Salbutamol given?
    → Because the patient was wheezing.
  2. Why was the patient wheezing?
    → Because airflow through the lower airways was obstructed.
  3. Why was there obstruction?
    → Because of bronchoconstriction caused by smooth muscle contraction.
  4. Why did bronchoconstriction occur?
    → Because the patient has asthma triggered by cold air exposure.
  5. Why is Salbutamol appropriate here?
    → Because it’s a beta-2 agonist that relaxes bronchial smooth muscle.

In this case, the reasoning checks out. But not all wheezing is bronchospasm—so this reflection teaches a lasting distinction:

Salbutamol doesn’t treat wheezing. It treats bronchospasm.

Tip: Add a note to Obsidian:
Title: “Wheezing ≠ Bronchospasm”
Linked to: [[Bronchoconstriction Directive]], [[Asthma vs. PE]], [[CHF Differentials]]

Clinical Example 2: Stent + Chest Pain = ?

Scenario:
A patient with a recent coronary stent reports chest pain. It’s localized and reproducible on palpation. The vitals are stable.

Initial assessment: musculoskeletal pain.

Now apply the Five Whys:

  1. Why was the pain considered musculoskeletal?
    → Because it was localized and reproducible.
  2. Why was that considered significant?
    → Because MSK pain often presents that way.
  3. Why wasn’t cardiac involvement suspected?
    → Because there were no textbook ACS symptoms.
  4. Why was that assumption made despite the stent?
    → Because the responder leaned on pattern recognition.
  5. Why was pattern recognition prioritized over risk-based reasoning?
    → Because benign MSK pain is common—and familiarity shaped the impression.

The takeaway: familiarity isn’t the same as safety. The patient’s history should have weighed more than the absence of typical symptoms.

Example 3: Process-Based Miss — Narcan + No BP Recheck

Scenario:
Patient revived with Narcan. No BP reassessment performed post-intervention.

  1. Why wasn’t BP reassessed?
    → Because the patient appeared alert and breathing well.
  2. Why was alertness taken as stability?
    → Because LOC improved, and the scene shifted to transport mode.
  3. Why did vitals get skipped?
    → Because in previous experiences, reversals didn’t require more intervention.
  4. Why didn’t the provider stop to confirm with data?
    → Because they were caught in a task-shift and assumed outcome.
  5. Why does this keep happening in rapid-recovery cases?
    → Because there’s no internal cue to reassess post-reversal.

Next step:
→ Add BP reassessment to the “Post-Intervention Checklist” note in Obsidian
→ Consider creating an Anki card:
Q: “After Narcan, what vital sign must be reassessed before transport?”
A: “BP—due to potential hypotension rebound”

What This Does for Learning

The Five Whys isn’t just a clinical tool—it’s a learning method.

It moves your brain from:

  • Memorization → Mechanism
  • Recall → Reasoning
  • Outcome → Process

And it highlights where your knowledge becomes shaky. If you can’t answer the fourth or fifth “why,” it shows where deeper study is needed.

Use it to:

  • Debrief scenarios with a partner or instructor
  • Guide reflective journaling (if you use it)
  • Create deeper notes in Obsidian
  • Build better prompts for ChatGPT

How to Use It in Practice

The Five Whys works best when:

  • Something didn’t feel right during a call
  • You missed a red flag and want to know why
  • A decision felt automatic—but maybe not grounded
  • You’re reflecting on a pattern you keep repeating

You can write it out, think it through, or speak it into a voice memo. It doesn’t need a template—but you can create one if it helps your workflow.

Use ChatGPT if you’re stuck mid-chain:
“Can you help me continue this Five Whys chain from [your last question]?”

Final Thoughts

The Five Whys isn’t about overanalyzing or blaming yourself. It’s about understanding what drives your decisions—so you can improve the driver.

In fast-paced environments, small improvements in thinking can make a big difference in outcomes.

When a call feels off—or a cue was missed—don’t just ask what happened.

Ask: Why?

Then ask again.

I. Learning Foundations

Build a strong system for thinking, studying, and remembering in high-pressure fields.

II. Practical Application

Move from theory to field-ready practice. These tools help bridge simulation, lab, and real calls.

  • Scenario Days – Make Learning Stick
    How to get more from scenario practice using repetition, debriefs, and learning loops. Turn repetition into retention.
  • Mastering Directive Decision-Making
    A breakdown of how to use directives in real-time, with pattern recognition, logic triggers, and threshold thinking.
  • Reflecting Without Journaling
    Not everyone journals—this guide offers quick, low-resistance alternatives to build metacognition through regular reflection.
  • Lab Integration Guide
    Use lab sessions to build decision-making habits, not just check off skills. Includes scenario prep, debriefing, and error capture.

III. Clinical Reasoning

Develop clarity under pressure. These pages train your diagnostic eye, pattern sense, and mental workflow.

IV. Resources

Your support tools: guides, summaries, templates, and setup walkthroughs.

  • Summary
    Recap of the big ideas behind VitalNotes: learn reflectively, study actively, and build a system that supports decision-making under pressure.
  • Helpful Resources
    Downloadables and quick-reference tools: directive cue sheets, Anki decks, debrief templates, and scenario aids.
  • Anki Setup & Use Guide
    Step-by-step instructions for downloading, customizing, and optimizing Anki for long-term retention.
  • Obsidian Setup & Use Guide
    How to build a clinical note vault in Obsidian: folder structures, templates, and linking strategies.
  • Sources and References
    A list of research and literature that supports the methods taught in the blog, with commentary on their application to clinical learning.