Opportunities for Use of Small Groups

In emergency medicine, small groups are beneficial for almost any educational objective. To be successful, enough time and space must be allotted for a small-group session to proceed naturally. A large contingent of faculty members might be required to assist with each session. Some of the most effective scenarios are listed in the following sections.

Approach to A Clinical Problem

A systematic approach to and pattern recognition of a patient complaint is the essence of the practice of emergency medicine and must be taught to our trainees. A large-group lecture or textbook readings can give the basic facts about a disease, but a small-group discussion works much better for describing the cognitive process that an expert uses to identify a differential diagnosis and direct the ED evaluation of a patient. For a patient with dyspnea, for example, an effective facilitator can lead the group through a review of the laboratory and radiologic testing that is necessary to narrow down the possible causes.

Developing A Skill Set

A small-group discussion is an excellent way to reinforce information provided in an initial overview given by lecture or assigned reading. One example is the development of the skills needed to read electrocardiograms. After basic knowledge has been provided, interaction time with an instructor can be spent in discussion and answering questions rather than passing on rote facts.

Teaching Procedures

The best way to teach a procedure is usually in a small-group setting. An important aspect of demonstrating a procedure is allowing each learner to see the appropriate anatomic landmarks and each piece of equipment while its use is explained. For instance, in learning how to place a central line, a small group of trainees can observe and discuss each step around a model more effectively than during a lecture with slides. Having a senior house officer as the group leader who teaches the procedure and leads the discussion will reinforce the procedural skills also for this more experienced trainee.

Literature Review

Breakout sessions can be used at a journal club or literature review session and can be organized according to the level of understanding of each group. The entire training program can discuss articles as a large group, noting global strengths and weaknesses. Then the house officers can be divided into smaller groups based on the education level to concentrate on specific skills (e.g., basic statistics). The involvement of every member of the group creates a more meaningful and active learning environment.

Types of Small Groups

Learners around the globe use many types of small groups. Some are described in other chapters in this book, including those outside the typical classroom such as simulation and bedside teaching. Even a lecture for a large group can be turned into a small-group discussion by having paired discussions (learners turning to each other to briefly discuss one topic). Other types of small groups are described in the following sections.

Case-Based Learning

Individual cases can be used to practice the concept of small-group discussion. The description of a case or cases, with associated questions, can be distributed in advance of the discussion. All the learners develop their own answers before meeting, allowing time for those having less background knowledge of the topic to preview the subject matter. Then the case is discussed in the small group. This is particularly appropriate for students and junior house officers.

Role-Playing

Role-playing is useful in evaluating a trainee’s ability to communicate effectively in difficult cases. Typically, a case is presented to a group of learners and one member of the group acts as the patient. This is most effective when the story has been developed in advance and the person acting as the patient understands his or her role before starting. Frequently practiced scenarios are giving bad news, dealing with an angry parent, or calming an agitated psychiatric patient. The role-playing and subsequent small-group discussion give trainees opportunities to work through critical and stressful situations in their minds before being overwhelmed in the emergency department. This can be a powerful tool for determining competency in areas that have less objective evaluation techniques (e.g., communication skills).

Problem-Based Learning

Problem-based learning is used frequently in the US medical school education. It is different from simple small-group discussions in that participants are encouraged to use self-directed learning skills [7]. The student is responsible for deciding what needs to be learned and then learning it [5]. This is performed in a group setting, where an open-ended clinical scenario is proposed. The students analyze it, formulating and prioritizing key learning objectives. They then disband to collect the needed information and regroup several days later to discuss the findings [7]. This interaction gives the learners a sense of ownership of the new knowledge.

Team-Based Learning

Team-based learning (TBL) is another variation of small-group discussions that is becoming popular in medical education throughout the world [8–11]. TBL encompasses three components: preparation, assessment, and problem solving. One large class is divided into smaller diverse groups of five to seven students. Each participant is expected to prepare by completing readings before class. Next, a 10-item multiple-choice readiness assessment test (RAT) is given to each person individually and then to the group. The grade for the project should include the individual’s RAT score to ensure that he or she prepared for the group discussion. Groups can appeal wrong answers and the instructor can educate where clarification is needed. Finally, each group works on the same problems simultaneously, posting the answers at the same time for the other groups to discuss. The most difficult, yet important, part of TBL for the instructor is preparing questions that are difficult and vague enough to generate discussion but that still have a discrete answer. This methodology enjoys all the benefits of a small-group discussion yet is faculty sparing. Learners tend to express genuine excitement and become actively engaged, thereby advancing in their problem-solving skills as a team.

Characteristics and Techniques of A Good Facilitator

Facilitator Characteristics

A skilled facilitator is necessary to achieve the discussion objectives and maintain cohesion of the small group during the task (Table 22.1) [5]. Discussions, by nature, are unpredictable, so a good facilitator must be spontaneous and creative [3]. Being comfortable with ambiguity and differing opinions helps, along with having a good sense of humor.

Table 22.1 Characteristics of a good small-group facilitator.

Spontaneous and creative

Comfortable with ambiguity

Good sense of humor

Enthusiasm for learning

Approachable

Possesses solid clinical knowledge

Can acknowledge limitations

Enthusiasm for learning and respect for the learner are also necessary traits for a facilitator. Learners clearly respond better to faculty members who are approachable and appear interested. Trainees look up to someone who is knowledgeable, a good clinician, and confident in his or her clinical skills. At the same time, students clearly appreciate faculty who can acknowledge when they do not know the answer [12, 13]. This facilitates discussion, as the group looks up the information together.

Techniques

Preparation

Some successful lecturers perform poorly as discussion facilitators because they do not understand the unique preparation and techniques required in this learning environment [3]. The faculty leader must first believe that the small-group discussion is a valid and powerful teaching method. Preparation time is similar to organizing a lecture. Along with gathering necessary material, the learners’ knowledge base must be assessed and specific goals for the session need to be defined clearly. It is important for the facilitator to remember that not as much detail can be covered in a group discussion as in lecture. Without planning for a discussion, an urgency to cover all the material develops and, instead of allowing the free exchange of ideas and deeper learning, many teachers revert to the classic lecture format [14].

Restraint

The facilitator will likely have the answer that the group is looking for, but providing this knowledge defeats the purpose of the group discussion. In fact, an effective facilitator need not be a content expert, as an energetic leader with an understanding of the group interactions is more valuable than a less dynamic leader with medical proficiency in the subject [7]. Having expertise in the particular topic may even be disadvantageous to the group, as one might have a tendency to return to lecture mode. Still, the faculty member may want to interject an occasional, thoughtful personal experience for everyone’s learning and to generate further discussion.

Questioning

A facilitator uses questions for three reasons: to initiate discussion, to encourage participation, and to keep the discussion on track [3]. Questions can be open or closed, but they always need to be specific. Open questions will broaden a topic, while closed questions are used to drill down on a specific idea. Showing enthusiasm for all answers, not just the correct ones, will increase participation. The leader must be comfortable with silence and not pass a question onto another student until there has been plenty of time to ponder the answer. Questions from group members directed to the leader should be put back out to the group.

Summarizing

Summarization is used to emphasize every major topic and regain the group’s focus. The summary is a brief statement that includes comments made by multiple group members. By creating a rhythm of questions and answers, with frequent summarization, the facilitator can lead the group to achieve “moments of greater understanding” [3].

Brainstorming

The key to brainstorming is to hold judgment until after all ideas are generated. Encourage the learners to improve on their ideas by combining and building on them. Time is allotted afterward for evaluation. In emergency medicine, this is commonly used to develop a differential diagnosis in a case-based learning scenario.

Adjusting Tension Level

All verbal interactions are associated with a certain tone, level of tension, or ambience [3]. The moderator’s goal is to keep the group at a moderate tone. If the atmosphere is too stressful, then group members will feel inhibited and might be reluctant to contribute. If the mood is too lenient, then the discussion can become too casual and unproductive. The tenor in professional settings is usually too high, so the moderator should approach the discussion with a comfortable, conversational tone [3]. Preparation is paramount to being able to actively adjust the tone of a group.

Starting A Small-Group Discussion

Establish Goals

Before organizing small-group discussions, define goals for the educational exercises (Table 22.2). This will likely include learning objectives with specific key points of knowledge, for example, the treatment protocols for acute asthma. The group members must understand that active participation of all members is required.

Table 22.2 Techniques for success.

1. Determine the type of small group

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