HOW TO...
Use Small Groups in Medical Education ARIE ROTLM and PETER MANZIE
Med Teach Downloaded from informahealthcare.com by McMaster University on 01/09/15 For personal use only.
Arie Rotem, PH.D, is Lecturer in Medical Education and Peter Manzie, B A , MB.BS, FRACGP, is Senior Lecturer in Community Medicine at the Centre for Medical Education Research and Development, University of N e w South Wales, PO Box 1, Kensington, New South Wales, Australia
This is the first of a number of articles on the use of small-group methods i n medical education. T h e aim of this contribution is to introduce teachers to the underlying issues they must consider before embarking on a particular technique. T h e advantages of small-group learning are described and practical suggestions for facilitating effective small-group discussion are offered. Teachers are advised that the use of small groups for learning requires meticulous course planning. Specific examples of how small-group teaching methods can be used to advantage i n preclinical and clinical courses will be published i n future issues.
The study of small groups has blossomed into a distinct body of knowledge applicable to all spheres of human interaction. In educational settings some zealously advocate the use of small groups while others blame them for a variety of educational failures. This paper centres on the use of small-group learning in medical education. The emphasis is on practical considerations rather than theoretical foundations. In particular, we will consider learning groups which are created and maintained for specified educational aims. Such groups are typically led by teachers and differ from social and therapy groups. The dynamics of group development and interaction are not haphazard but predictable. As a teacher you may lack arbitrary control over the group; however, you can strongly influence its operation. By structuring activities and tasks you can create learning opportunities that are not otherwise available. The use of small groups for learning requires meticulous course planning. Small group learning should not be confused with open-ended, unintentional interactions. We believe that small-group learning can be, and for the medical curriculum must be, well-structured. This article indicates the advantages of small -group learning, reviews the primary attributes of small groups, and offers practical suggestions for group facilitators. 80
Why Use Education ?
Small-Group
Learning
in
Medical
Small-group learning enables students to become actively involved in the process of learning. Through interaction with each other and with teachers, they can explore, clarify and practise. Effective learning groups provide opportunities to ask questions, get feedback and share experiences, observations and insights. Assuming the role of active partners in the teaching and learning process, rather than that of passive absorbers of information, makes students more responsible for their own learning. In monitoring group discussion, teachers can provide educational inputs in accordance with students’ stage of development. Teachers observe and analyse learning difficulties, and identify areas of interest. On the basis of such observations teachers select problems and provide information which are meaningful to the students and which progressively expand students’ factual knowledge . and improve their reasoning capabilities. More specifically, it is claimed that appropriately structured small group activities are especially useful in the following areas: 1. Critical thinking and related cognitive skills. Because medical students cannot be taught everything they need to know, they must learn how to retrieve and apply information. Experienced clinicians make decisions by setting up early hypotheses and searching for evidence (Elstein et a1 1978). The process often begins with intuition-what Karl Popper (1972) termed ‘An act of imagination’. The process of generating hypotheses and eliminating alternative explanations for . a particular phenomenon can be learned effectively in small groups. The pooled experience and knowledge of group members enables a broader consideration of particular problems. Opportunities to pose questions, seek information, and get feedback enables students to exercise their ‘mental computers’ and to learn their strengths and weaknesses. 2. Ability to communicate. Medical practitioners need to
Medical Teacher V o l 2 No 2 1980
Med Teach Downloaded from informahealthcare.com by McMaster University on 01/09/15 For personal use only.
express themselves clearly and to understand accurately both patients and other health professionals. Discussion in a group setting cultivates communication skills. In effective groups students express ideas, seek and offer clarification, listen to others and help the less articulate members through feedback and encouragement. Teachers provide models of good listeners and effective presenters of information. 3 . Ability to perform as team members and leaders. Solution of problems confronting doctors often entails cooperation with colleagues and members of the allied health professions. The trend towards specialization increases interdependence, hence the need for team skills. Learning group experiences foster interactive skills. Students practise working together. They also get practice in negotiating goals and procedures, in resolving conflicts and in using each others’ contributions to promote the group goals. Such practice provides a good preparation for professional team work. Limitations of Small Groups There are five possible limitations to the use of small groups : 1. The use of small groups as a learning milieu does not guarantee the outcomes indicated above. Often, small groups are misused. The need for meticulous planning can be considered as a limiting factor in various learning settings. 2. Some of the major limitations of the learning group derive from logistics. Teaching is more costly in small
groups than in large lectures because it requires a higher ratio of staff to students. 3 , Group learning could be too slow for brilliant students (unless they are used as a resource for their peers) and inadequate for ‘loners’ and introverts whom the group might reject or harm in other ways. 4. Some educators find small-group teaching totally alien. Effective lecturers miss the opportunities to exhibit their special talents and become disenchanted with groups. Inexperienced teachers risk feeling intimidated by the unexpected directions in which groups might move. 5. Learning in small groups appears to be no more effective, when measured by traditional assessment procedures, than learning in lectures (Cox and Jaques 1976). However, research by Walton (1968) showed that students taught in small groups had more favourable attitudes towards psychiatry, judged their training as superior, felt more confident and were more interested in psychiatric patients. UnderlyingIssues Before offering guidelines for small-group teaching we should review the main attributes of small groups.
Group processes A group is made up of individuals who are interacting with one another. Interaction is thus a major attribute of groups. The dynamics of groups cannot be fully ex-
Figure 1: Processes of group formation.
Medical Teacher V o l 2 No 2 1980
81
appropriate. Berne (1970) has suggested that groups of over twelve divide into performers and audience.
tape/slides, film, video, etc. Such aids can provide an initial shared experience which serves to launch group activity.
2. Student Mix 4. Planning
Sometimes, it may be a good idea to mix more quick thinking students with those who are slower thinkers, particularly if the aim of the discussion is to solve a problem or to clarify issues which have already been learned more formally. In other cases, however, mixing extroverts with introverts may lead to the former dominating the discussion. Consultation with other members of staff may give you a better insight into students’ personalities and abilities (Cox 1979).
Med Teach Downloaded from informahealthcare.com by McMaster University on 01/09/15 For personal use only.
3. Physical Considerations You should decide what sort of room will best suit your discussion group: a classroom, tutor’s room, laboratory, etc. This, in turn, will depend on what sort of audiovisual aids you might wish to use: overhead projector,
You should find out what competencies students have acquired in previous courses so that you can introduce appropriate tasks (problems). Problems should be challenging but not overwhelming in relation to the group resources. Students’ previous experiences in learning groups should be considered in determining procedures for group work. You should also consider learning activities used in concurrent courses, in order to avoid overload or boredom. Even the most enthusiastic students might become disenchanted and bored in the absence of variety in format and style. Figure 3 illustrates a teaching plan that incorporates a variety of teaching approaches. Note that the plan includes, but is not limited to, small-group activities.
Figure 3: Teaching plan that incorporates a variety of teaching approaches.
Medical Teacher V o l 2 No 2 1980
Group activities are especially suitable when: (a) The learning task requires generation of ideas or recall of information. (b) It is possible for members to recognize and give feedback in relation to individual errors. (c) A division of labour is possible.
Med Teach Downloaded from informahealthcare.com by McMaster University on 01/09/15 For personal use only.
5 . The ‘ContTact’ initial group sessions are critical for establishing members’ commitment to group goals. It will be recalled that, at first, group members seek to establish relationships, bid for status, and formulate roles and norms. The group needs opportunities, and at times active facilitation, to form itself; members strive to know what is expected of them and explore what they want to do. Needless to say, you can strongly influence the formation of the group. You may well be advised initially to stress procedures, assignments and other expectations rather than content (Neilsen 1978). Starting a course with a loose structure can be cumbersomely ineffective, because it is hard to entice a straying group back to the path. If procedures and expectations are set at the beginning (say, during the first two sessions) and if goals of the course are clear, the need for teacher intervention and direction steadily decreases. Students are liberated to explore and discover within explicit boundaries. They depend less on the teacher’s telling them what to do. The learning group must achieve goals but also look after its own maintenance. You are responsible for the creation of meaningful tasks. You also have a role in the development of social and psychological support. The role should not be thought of as a fancy option but as an essential of group learning. Teachers who are reluctant to
facilitate the socio-emotional development of the group should perhaps steer clear of the small-group format. 6 . Varieties of Small-Group Activities
In deciding what type of small-group teaching you wish to use, you should consider how it is related to other learning activities in the course, where in the course it occurs, whether it is the best way of teaching a particular topic, what are the student’s expectations and needs, and what you perceive as your role in it. Figure 4 shows Bligh’s (1971) classification of smallgroup forms, between which there is considerable overlap. Some of these are considered briefly below, and we will return to them in future issues.
7. Facilitating learning You can facilitate learning by providing educational inputs and feedback. Specifically,you can do this by: (a) Focusing the activity so that the issues under consideration are clear and the aims of the activity are explicit, Irrelevant exchanges which sidetrack the discussion should be tactfully recognized and avoided. Opportunities for review and preview of material and activities are essential. (b) Clarifying ideas to ensure that they are understood by the group. You can help by providing analogies and examples and by rephrasing and simplifying complex statements. This may include probing the speaker to explain or elaborate. You can provide further information when necessary so that the group gains clearer understanding. (c) Promoting contributions by raising key questions, provoking, waiting quietly but expectantly and sup porting contributions by attentive listening and feedback.
Figure 4: Bligh’s (1 971) classzyication of small-group forms. After Varieties of Discussion in University Teaching, Institute ofEducation, 1971.
84
Thndata labetalol hydrochloride
Product information Presentation and Basic NHS Cost Trandate Tablets 100mg,Trandate Tablets 200mg and Trandate Tablets 400mg each contain 100mg, 200mg and 400mg labetalol hydrochloride, respectively In containers of 50 and 250 tablets. Basic NHS cost of 5 0 tablets of each strength is 23.78,26.10 and 29.70.
Med Teach Downloaded from informahealthcare.com by McMaster University on 01/09/15 For personal use only.
Indications Treatment of all grades of hypertension when oral antihypertensive therapy is indicated. Dosage and Administration The recommended starting dose is lOOmg three times daily. If necessary this may be increased gradually at intervals of one or two weeks. A daily dosage of 600mg is usually adequate but severe cases may require up to 2,400mg daily Once the optimum dosage is established a twicedaily dosage regimen can be used. Trandate Tablets should preferably be taken after food. For transfer of patients from other antihypertensive therapy see Data Sheet. Trandate therapy is not applicable to children. Contra-indications There are no known absolute contra.indications. Warning There have been reports of skin rashes and/or dry eyes associated with the use of beta-adrenoceptor blocking drugs.The reported incidence is small and in most cases the symptoms have cleared when the treatment was withdrawn. Discontinuation of the drug should be considered if any such reaction is not otherwise explicable. Cessation of therapy with a beta-adrenoceptor blocking drug should be gradual. Precautions Trandate should not be given to patients with uncompensated or digitalisresistant heart failure or with atrioventricular block. The presence of severe liver disease may necessitate reduced doses of Trandate. Care should be taken in asthmatic patients and others prone to bronchospasm. Unnecessaty administration of drugs during the first trimester of pregnancy is undesirable. Side effects If the recommended dosage instructions are followed side effects are infrequent and usually transient.Those that have been reported include: headache,tiredness, dizziness,-depressedmood and lethargy difficulty in micturition, epigastric pain, nausea and vomiting, a tingling sensation in the scalp, and, in a very few patients, a lichenoid rash. Trandate Tablets lOOmg PL 0045/0106, TrandateTablets 200mg PL 0045/0107, Trandate Tablets 400mg PL 0045/0109. Full prescribing information is available on request. Trandate is a trade mark of Allen & Hanburys Ltd London E2 6LA
86
Selecting appropriate tasks and procedures is a critical factor with regard to participation. You can also help by distributing participation. You can seek the views of quiet students, restrain dominant students and encourage students to comment on each other’s contributions. (d) Achieving closure by summarizing and foreshadowing issues. Medical students - being conditioned to expect concrete results -especially appreciate rounding-off and consolidation of each session. Emotional rounding-off should not be neglected either. When discussion is heated, opportunities to wind down should be provided by acknowledging and dealing with the feelings aroused. Examples of Learning Activities i n Small Groups
Case Problems Presentation of case problems serves to involve students in problem solving. A case can be presented in the form of a handout, by the use of a real or simulated patient and/or by audiovideo recording. Students are required to consider the case, generate hypotheses, pose questions, seek evidence and plan strategies for management. The teacher acts as a resource person and facilitator of the discussion, Examples of case problems are provided by Cobbs and Griffin (1975) and Simpson (1977, 1979). Textbooks, journals or real-life experiences provide interesting case material. This method is extensively used in innovative medical schools (for example, McMaster, Canada; Newcastle, Australia; and Michigan State University, USA) which have a problem-based curriculum.
Student Presentations Student presentations of critical reviews are often used in group learning. To avoid a mini-lecture by the student it is important to encourage discussion during or after the presentation. Lee (1978) suggested asking students to summarize the presentation and to pose some relevant questions to the speaker.
Role Play The role play technique has been used increasingly in medical schools (Lee 1978). Students can be requested to act out various parts, for example, a mother who is reluctant to have her child immunized. While some students act the scene, other students may watch and subsequently provide feedback.
Nominal Group Technique An adoption of the Nominal Group Technique developed by Delbecq and Van de Ven (1971) is an effective method of generating ideas in relation to specified problems. The students are asked to consider a problem (say, possible complications of urinary tract infections) and generate a list of points they wish to raise. At first the students think by themselves for maybe ten minutes. Then, the teacher Medical Teacher V o l 2 No 2 1980
requests them to bring up one issue at a time in roundrobin fashion until all students have a chance to exhaust their lists. The unique attribute of this approach is that all ideas are recorded before discussion commences. Hence, evaluation of ideas is deferred. This is an efficient way of considering a large number of possibilities, of reinforcing lateral thinking and of fostering objectivity.
Discussion in Pairs
Detection of dysfunction is often intuitive, rather than a result of careful analysis; sensitivity to ‘vibes’is essential. But knowledge of basic principles of group dynamics is a must. You should recognize the dimensions of group process and developmental stages of groups, and you should know how to conduct yourself in a manner that supports the group. This knowledge will aid you in diagnosis and treatment of problems. As in all human endeavour, experience and practice are vital. The skills of facilitation can be !earned by most teachers.
A small-group session might begin with students discussing in pairs issues raised by the teacher. This approach has the advantage of active involvement and it provides an excellent opportunity for warm-up before group discussion. Med Teach Downloaded from informahealthcare.com by McMaster University on 01/09/15 For personal use only.
References
Triggers The use of triggers, such as a recorded interview of a patient, is useful in conjunction with discussion in pairs or in small groups. The triggers may provide a real base for discussion and may encourage reference to specifics rather than abstractions.
Interventions You should avoid the temptation prematurely to offer solutions and suggest approaches. The authority role may have to be rejected several times. The mirror techniquereflecting requests for facts or direction back into the group - drives the message home. Temptation to intervene becomes hard to resist when the group wanders far from the track, when strong bids for leadership meet head-on, or when a member keeps trying to dominate. Anecdotal, humorous or confessional exchanges are often useful in putting out fires. The group should be given every chance to deal in its own way with conflict and dominance. Intervention, if necessary, should be low-profile and, if possible, disguised. At the same time, you have the right to express your own feelings as a member of the group. Presenting oneself as a ‘real person’ rather than a ‘super facilitator’ is usually well accepted. A ‘low profile’ should not entail insincerity. If you do not agree, say so. Moreover, you have a distinct duty to steer the learning situation towards specified objectives. You should not shy away from using your authority to establish order, eliminate confusion, and act for the good of all participants. Periods of silence can be productive. However, it is useful to have in mind a list of issues to be brought up, if they fail to surface naturally. All contributions must be taken seriously. An atmosphere wherein there is no such thing as a stupid question enables learning through mistakes and encourages risk -taking. Group dysfunctions are not unlikely. If noninvolvement, clique formation, personality clashes or excessive confusion persist, they block task performance and make intervention necessary. Medical Teacher V o l 2 No 2 1980
Berne, E., Group Treatment, Grove Press, NewYork. 1970. Cobbs, J. C. G. and Griffin, F. M., Infectious Diseases Case Studies, Medical Examination Publishing Corp, New York, 1975. Cox, R. and Jaques, D.. Small group discussion. In Improving Teaching in Higher Education, University Teaching Methods Unit, Institute of Education, London, 1976. Delbecq, A. L. and Van d e Ven, A., A group process model for problem identification and program planning, Journal of Applied Behavioral Sciences, 1971, 7,466-492. Elstein, A. S., Shulman, L. S. and Sprafka, S. A., Medical Problem Solznng: A n Analysis of Clinical Reasoning, Harvard University Press, Boston, 1978. Lee, A , , Small-group teaching in microbiology, Medical Journal of Australia, 1978, 1, 551 and 645. Lewin, K., Field Theory in Social Science, Harper Bros., New York, 1951. Neilsen, E. H., Applying a group development model to managing a class. In Group development, Ed. L. P. Bradford, 2nd ed.. University Associates of Canada, Toronto, 1978. Popper, K., Conjectures and Refutations, Routledge. London, 1972 Simpson, M. A , , Problem-based learning in medicine, General Practice International, 1977, 2, 63-66. Simpson, M. A . , Problem-based learning in medicine. In Medical Education and Primary Care, Ed. H . Noack. Croom-Helm, London, 1979. Walton, H. J., An experimental study of different methods for teaching medical students, Proceedings of the Royal Society of Medicine, 1968, 61, 109-112.
Further Reading Abercrombie, M. L. S., Aims and Techniques of Group Learning, 3rd ed. Society for Research into Higher Education, London, 1974. Bligh, D., Varieties of Discussion in University Teaching, Institute of Education, 1971. Bradford, L. P. (Ed.), Group Development, 2nd ed., University Associates of Canada, Toronto, 1978. Engel, C. E. and Clarke, R. M., Medical Education with a Difference. PLET, 1979, 16, 70-87. McLeish, J , , Matheson, W . and Park, J . , The Psychology ofthe Small Learning Group, Hutchinson, London, 1973. Walton, H. J.. Small Group Methods in Medical Teaching, Association for the Study of Medical Education, Dundee, 1973.
87
Use Small Groups in Medical Education ARIE ROTLM and PETER MANZIE
Med Teach Downloaded from informahealthcare.com by McMaster University on 01/09/15 For personal use only.
Arie Rotem, PH.D, is Lecturer in Medical Education and Peter Manzie, B A , MB.BS, FRACGP, is Senior Lecturer in Community Medicine at the Centre for Medical Education Research and Development, University of N e w South Wales, PO Box 1, Kensington, New South Wales, Australia
This is the first of a number of articles on the use of small-group methods i n medical education. T h e aim of this contribution is to introduce teachers to the underlying issues they must consider before embarking on a particular technique. T h e advantages of small-group learning are described and practical suggestions for facilitating effective small-group discussion are offered. Teachers are advised that the use of small groups for learning requires meticulous course planning. Specific examples of how small-group teaching methods can be used to advantage i n preclinical and clinical courses will be published i n future issues.
The study of small groups has blossomed into a distinct body of knowledge applicable to all spheres of human interaction. In educational settings some zealously advocate the use of small groups while others blame them for a variety of educational failures. This paper centres on the use of small-group learning in medical education. The emphasis is on practical considerations rather than theoretical foundations. In particular, we will consider learning groups which are created and maintained for specified educational aims. Such groups are typically led by teachers and differ from social and therapy groups. The dynamics of group development and interaction are not haphazard but predictable. As a teacher you may lack arbitrary control over the group; however, you can strongly influence its operation. By structuring activities and tasks you can create learning opportunities that are not otherwise available. The use of small groups for learning requires meticulous course planning. Small group learning should not be confused with open-ended, unintentional interactions. We believe that small-group learning can be, and for the medical curriculum must be, well-structured. This article indicates the advantages of small -group learning, reviews the primary attributes of small groups, and offers practical suggestions for group facilitators. 80
Why Use Education ?
Small-Group
Learning
in
Medical
Small-group learning enables students to become actively involved in the process of learning. Through interaction with each other and with teachers, they can explore, clarify and practise. Effective learning groups provide opportunities to ask questions, get feedback and share experiences, observations and insights. Assuming the role of active partners in the teaching and learning process, rather than that of passive absorbers of information, makes students more responsible for their own learning. In monitoring group discussion, teachers can provide educational inputs in accordance with students’ stage of development. Teachers observe and analyse learning difficulties, and identify areas of interest. On the basis of such observations teachers select problems and provide information which are meaningful to the students and which progressively expand students’ factual knowledge . and improve their reasoning capabilities. More specifically, it is claimed that appropriately structured small group activities are especially useful in the following areas: 1. Critical thinking and related cognitive skills. Because medical students cannot be taught everything they need to know, they must learn how to retrieve and apply information. Experienced clinicians make decisions by setting up early hypotheses and searching for evidence (Elstein et a1 1978). The process often begins with intuition-what Karl Popper (1972) termed ‘An act of imagination’. The process of generating hypotheses and eliminating alternative explanations for . a particular phenomenon can be learned effectively in small groups. The pooled experience and knowledge of group members enables a broader consideration of particular problems. Opportunities to pose questions, seek information, and get feedback enables students to exercise their ‘mental computers’ and to learn their strengths and weaknesses. 2. Ability to communicate. Medical practitioners need to
Medical Teacher V o l 2 No 2 1980
Med Teach Downloaded from informahealthcare.com by McMaster University on 01/09/15 For personal use only.
express themselves clearly and to understand accurately both patients and other health professionals. Discussion in a group setting cultivates communication skills. In effective groups students express ideas, seek and offer clarification, listen to others and help the less articulate members through feedback and encouragement. Teachers provide models of good listeners and effective presenters of information. 3 . Ability to perform as team members and leaders. Solution of problems confronting doctors often entails cooperation with colleagues and members of the allied health professions. The trend towards specialization increases interdependence, hence the need for team skills. Learning group experiences foster interactive skills. Students practise working together. They also get practice in negotiating goals and procedures, in resolving conflicts and in using each others’ contributions to promote the group goals. Such practice provides a good preparation for professional team work. Limitations of Small Groups There are five possible limitations to the use of small groups : 1. The use of small groups as a learning milieu does not guarantee the outcomes indicated above. Often, small groups are misused. The need for meticulous planning can be considered as a limiting factor in various learning settings. 2. Some of the major limitations of the learning group derive from logistics. Teaching is more costly in small
groups than in large lectures because it requires a higher ratio of staff to students. 3 , Group learning could be too slow for brilliant students (unless they are used as a resource for their peers) and inadequate for ‘loners’ and introverts whom the group might reject or harm in other ways. 4. Some educators find small-group teaching totally alien. Effective lecturers miss the opportunities to exhibit their special talents and become disenchanted with groups. Inexperienced teachers risk feeling intimidated by the unexpected directions in which groups might move. 5. Learning in small groups appears to be no more effective, when measured by traditional assessment procedures, than learning in lectures (Cox and Jaques 1976). However, research by Walton (1968) showed that students taught in small groups had more favourable attitudes towards psychiatry, judged their training as superior, felt more confident and were more interested in psychiatric patients. UnderlyingIssues Before offering guidelines for small-group teaching we should review the main attributes of small groups.
Group processes A group is made up of individuals who are interacting with one another. Interaction is thus a major attribute of groups. The dynamics of groups cannot be fully ex-
Figure 1: Processes of group formation.
Medical Teacher V o l 2 No 2 1980
81
appropriate. Berne (1970) has suggested that groups of over twelve divide into performers and audience.
tape/slides, film, video, etc. Such aids can provide an initial shared experience which serves to launch group activity.
2. Student Mix 4. Planning
Sometimes, it may be a good idea to mix more quick thinking students with those who are slower thinkers, particularly if the aim of the discussion is to solve a problem or to clarify issues which have already been learned more formally. In other cases, however, mixing extroverts with introverts may lead to the former dominating the discussion. Consultation with other members of staff may give you a better insight into students’ personalities and abilities (Cox 1979).
Med Teach Downloaded from informahealthcare.com by McMaster University on 01/09/15 For personal use only.
3. Physical Considerations You should decide what sort of room will best suit your discussion group: a classroom, tutor’s room, laboratory, etc. This, in turn, will depend on what sort of audiovisual aids you might wish to use: overhead projector,
You should find out what competencies students have acquired in previous courses so that you can introduce appropriate tasks (problems). Problems should be challenging but not overwhelming in relation to the group resources. Students’ previous experiences in learning groups should be considered in determining procedures for group work. You should also consider learning activities used in concurrent courses, in order to avoid overload or boredom. Even the most enthusiastic students might become disenchanted and bored in the absence of variety in format and style. Figure 3 illustrates a teaching plan that incorporates a variety of teaching approaches. Note that the plan includes, but is not limited to, small-group activities.
Figure 3: Teaching plan that incorporates a variety of teaching approaches.
Medical Teacher V o l 2 No 2 1980
Group activities are especially suitable when: (a) The learning task requires generation of ideas or recall of information. (b) It is possible for members to recognize and give feedback in relation to individual errors. (c) A division of labour is possible.
Med Teach Downloaded from informahealthcare.com by McMaster University on 01/09/15 For personal use only.
5 . The ‘ContTact’ initial group sessions are critical for establishing members’ commitment to group goals. It will be recalled that, at first, group members seek to establish relationships, bid for status, and formulate roles and norms. The group needs opportunities, and at times active facilitation, to form itself; members strive to know what is expected of them and explore what they want to do. Needless to say, you can strongly influence the formation of the group. You may well be advised initially to stress procedures, assignments and other expectations rather than content (Neilsen 1978). Starting a course with a loose structure can be cumbersomely ineffective, because it is hard to entice a straying group back to the path. If procedures and expectations are set at the beginning (say, during the first two sessions) and if goals of the course are clear, the need for teacher intervention and direction steadily decreases. Students are liberated to explore and discover within explicit boundaries. They depend less on the teacher’s telling them what to do. The learning group must achieve goals but also look after its own maintenance. You are responsible for the creation of meaningful tasks. You also have a role in the development of social and psychological support. The role should not be thought of as a fancy option but as an essential of group learning. Teachers who are reluctant to
facilitate the socio-emotional development of the group should perhaps steer clear of the small-group format. 6 . Varieties of Small-Group Activities
In deciding what type of small-group teaching you wish to use, you should consider how it is related to other learning activities in the course, where in the course it occurs, whether it is the best way of teaching a particular topic, what are the student’s expectations and needs, and what you perceive as your role in it. Figure 4 shows Bligh’s (1971) classification of smallgroup forms, between which there is considerable overlap. Some of these are considered briefly below, and we will return to them in future issues.
7. Facilitating learning You can facilitate learning by providing educational inputs and feedback. Specifically,you can do this by: (a) Focusing the activity so that the issues under consideration are clear and the aims of the activity are explicit, Irrelevant exchanges which sidetrack the discussion should be tactfully recognized and avoided. Opportunities for review and preview of material and activities are essential. (b) Clarifying ideas to ensure that they are understood by the group. You can help by providing analogies and examples and by rephrasing and simplifying complex statements. This may include probing the speaker to explain or elaborate. You can provide further information when necessary so that the group gains clearer understanding. (c) Promoting contributions by raising key questions, provoking, waiting quietly but expectantly and sup porting contributions by attentive listening and feedback.
Figure 4: Bligh’s (1 971) classzyication of small-group forms. After Varieties of Discussion in University Teaching, Institute ofEducation, 1971.
84
Thndata labetalol hydrochloride
Product information Presentation and Basic NHS Cost Trandate Tablets 100mg,Trandate Tablets 200mg and Trandate Tablets 400mg each contain 100mg, 200mg and 400mg labetalol hydrochloride, respectively In containers of 50 and 250 tablets. Basic NHS cost of 5 0 tablets of each strength is 23.78,26.10 and 29.70.
Med Teach Downloaded from informahealthcare.com by McMaster University on 01/09/15 For personal use only.
Indications Treatment of all grades of hypertension when oral antihypertensive therapy is indicated. Dosage and Administration The recommended starting dose is lOOmg three times daily. If necessary this may be increased gradually at intervals of one or two weeks. A daily dosage of 600mg is usually adequate but severe cases may require up to 2,400mg daily Once the optimum dosage is established a twicedaily dosage regimen can be used. Trandate Tablets should preferably be taken after food. For transfer of patients from other antihypertensive therapy see Data Sheet. Trandate therapy is not applicable to children. Contra-indications There are no known absolute contra.indications. Warning There have been reports of skin rashes and/or dry eyes associated with the use of beta-adrenoceptor blocking drugs.The reported incidence is small and in most cases the symptoms have cleared when the treatment was withdrawn. Discontinuation of the drug should be considered if any such reaction is not otherwise explicable. Cessation of therapy with a beta-adrenoceptor blocking drug should be gradual. Precautions Trandate should not be given to patients with uncompensated or digitalisresistant heart failure or with atrioventricular block. The presence of severe liver disease may necessitate reduced doses of Trandate. Care should be taken in asthmatic patients and others prone to bronchospasm. Unnecessaty administration of drugs during the first trimester of pregnancy is undesirable. Side effects If the recommended dosage instructions are followed side effects are infrequent and usually transient.Those that have been reported include: headache,tiredness, dizziness,-depressedmood and lethargy difficulty in micturition, epigastric pain, nausea and vomiting, a tingling sensation in the scalp, and, in a very few patients, a lichenoid rash. Trandate Tablets lOOmg PL 0045/0106, TrandateTablets 200mg PL 0045/0107, Trandate Tablets 400mg PL 0045/0109. Full prescribing information is available on request. Trandate is a trade mark of Allen & Hanburys Ltd London E2 6LA
86
Selecting appropriate tasks and procedures is a critical factor with regard to participation. You can also help by distributing participation. You can seek the views of quiet students, restrain dominant students and encourage students to comment on each other’s contributions. (d) Achieving closure by summarizing and foreshadowing issues. Medical students - being conditioned to expect concrete results -especially appreciate rounding-off and consolidation of each session. Emotional rounding-off should not be neglected either. When discussion is heated, opportunities to wind down should be provided by acknowledging and dealing with the feelings aroused. Examples of Learning Activities i n Small Groups
Case Problems Presentation of case problems serves to involve students in problem solving. A case can be presented in the form of a handout, by the use of a real or simulated patient and/or by audiovideo recording. Students are required to consider the case, generate hypotheses, pose questions, seek evidence and plan strategies for management. The teacher acts as a resource person and facilitator of the discussion, Examples of case problems are provided by Cobbs and Griffin (1975) and Simpson (1977, 1979). Textbooks, journals or real-life experiences provide interesting case material. This method is extensively used in innovative medical schools (for example, McMaster, Canada; Newcastle, Australia; and Michigan State University, USA) which have a problem-based curriculum.
Student Presentations Student presentations of critical reviews are often used in group learning. To avoid a mini-lecture by the student it is important to encourage discussion during or after the presentation. Lee (1978) suggested asking students to summarize the presentation and to pose some relevant questions to the speaker.
Role Play The role play technique has been used increasingly in medical schools (Lee 1978). Students can be requested to act out various parts, for example, a mother who is reluctant to have her child immunized. While some students act the scene, other students may watch and subsequently provide feedback.
Nominal Group Technique An adoption of the Nominal Group Technique developed by Delbecq and Van de Ven (1971) is an effective method of generating ideas in relation to specified problems. The students are asked to consider a problem (say, possible complications of urinary tract infections) and generate a list of points they wish to raise. At first the students think by themselves for maybe ten minutes. Then, the teacher Medical Teacher V o l 2 No 2 1980
requests them to bring up one issue at a time in roundrobin fashion until all students have a chance to exhaust their lists. The unique attribute of this approach is that all ideas are recorded before discussion commences. Hence, evaluation of ideas is deferred. This is an efficient way of considering a large number of possibilities, of reinforcing lateral thinking and of fostering objectivity.
Discussion in Pairs
Detection of dysfunction is often intuitive, rather than a result of careful analysis; sensitivity to ‘vibes’is essential. But knowledge of basic principles of group dynamics is a must. You should recognize the dimensions of group process and developmental stages of groups, and you should know how to conduct yourself in a manner that supports the group. This knowledge will aid you in diagnosis and treatment of problems. As in all human endeavour, experience and practice are vital. The skills of facilitation can be !earned by most teachers.
A small-group session might begin with students discussing in pairs issues raised by the teacher. This approach has the advantage of active involvement and it provides an excellent opportunity for warm-up before group discussion. Med Teach Downloaded from informahealthcare.com by McMaster University on 01/09/15 For personal use only.
References
Triggers The use of triggers, such as a recorded interview of a patient, is useful in conjunction with discussion in pairs or in small groups. The triggers may provide a real base for discussion and may encourage reference to specifics rather than abstractions.
Interventions You should avoid the temptation prematurely to offer solutions and suggest approaches. The authority role may have to be rejected several times. The mirror techniquereflecting requests for facts or direction back into the group - drives the message home. Temptation to intervene becomes hard to resist when the group wanders far from the track, when strong bids for leadership meet head-on, or when a member keeps trying to dominate. Anecdotal, humorous or confessional exchanges are often useful in putting out fires. The group should be given every chance to deal in its own way with conflict and dominance. Intervention, if necessary, should be low-profile and, if possible, disguised. At the same time, you have the right to express your own feelings as a member of the group. Presenting oneself as a ‘real person’ rather than a ‘super facilitator’ is usually well accepted. A ‘low profile’ should not entail insincerity. If you do not agree, say so. Moreover, you have a distinct duty to steer the learning situation towards specified objectives. You should not shy away from using your authority to establish order, eliminate confusion, and act for the good of all participants. Periods of silence can be productive. However, it is useful to have in mind a list of issues to be brought up, if they fail to surface naturally. All contributions must be taken seriously. An atmosphere wherein there is no such thing as a stupid question enables learning through mistakes and encourages risk -taking. Group dysfunctions are not unlikely. If noninvolvement, clique formation, personality clashes or excessive confusion persist, they block task performance and make intervention necessary. Medical Teacher V o l 2 No 2 1980
Berne, E., Group Treatment, Grove Press, NewYork. 1970. Cobbs, J. C. G. and Griffin, F. M., Infectious Diseases Case Studies, Medical Examination Publishing Corp, New York, 1975. Cox, R. and Jaques, D.. Small group discussion. In Improving Teaching in Higher Education, University Teaching Methods Unit, Institute of Education, London, 1976. Delbecq, A. L. and Van d e Ven, A., A group process model for problem identification and program planning, Journal of Applied Behavioral Sciences, 1971, 7,466-492. Elstein, A. S., Shulman, L. S. and Sprafka, S. A., Medical Problem Solznng: A n Analysis of Clinical Reasoning, Harvard University Press, Boston, 1978. Lee, A , , Small-group teaching in microbiology, Medical Journal of Australia, 1978, 1, 551 and 645. Lewin, K., Field Theory in Social Science, Harper Bros., New York, 1951. Neilsen, E. H., Applying a group development model to managing a class. In Group development, Ed. L. P. Bradford, 2nd ed.. University Associates of Canada, Toronto, 1978. Popper, K., Conjectures and Refutations, Routledge. London, 1972 Simpson, M. A , , Problem-based learning in medicine, General Practice International, 1977, 2, 63-66. Simpson, M. A . , Problem-based learning in medicine. In Medical Education and Primary Care, Ed. H . Noack. Croom-Helm, London, 1979. Walton, H. J., An experimental study of different methods for teaching medical students, Proceedings of the Royal Society of Medicine, 1968, 61, 109-112.
Further Reading Abercrombie, M. L. S., Aims and Techniques of Group Learning, 3rd ed. Society for Research into Higher Education, London, 1974. Bligh, D., Varieties of Discussion in University Teaching, Institute of Education, 1971. Bradford, L. P. (Ed.), Group Development, 2nd ed., University Associates of Canada, Toronto, 1978. Engel, C. E. and Clarke, R. M., Medical Education with a Difference. PLET, 1979, 16, 70-87. McLeish, J , , Matheson, W . and Park, J . , The Psychology ofthe Small Learning Group, Hutchinson, London, 1973. Walton, H. J.. Small Group Methods in Medical Teaching, Association for the Study of Medical Education, Dundee, 1973.
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