Increasing the Value of Small-group Learning

Objective: To promote more active learning, small groups are replacing lectures in medical education. However, common problems often arise, such as inconsistent quality, diverse approaches, and varying levels of facilitator skills. To address these problems, we created a small-group teaching model with five components: two-year continuity groups, cofacilitation of groups, required faculty development sessions, articulation of course goals and methods, and faculty attendance at course lectures. Description: In the Foundations of Patient Care course at the University of California, San Francisco (UCSF), first- and second-year medical students spend one-half day per week throughout the first two years in primary care preceptorships and on-campus discussion groups after scheduled lectures. In small groups, students learn doctor—patient communication skills, discuss their preceptorship experiences and course content, address difficult topics such as death and dying, and reflect on their own professional development. The group sessions are based on an experiential, self-directed approach to learning, where students take responsibility for their own learning. The course has 48 small groups, with six students and one or two facilitators for each group. Two thirds of the groups have co-facilitators, typically a physician and a non-physician (e.g., a behavioral or social scientist). Of 79 facilitators, 52 are physicians and 27 are non-physicians. When we started small-group teaching, the groups were uneven in quality and disconnected from the rest of the course. Many groups lasted only a year and were led by a single physician facilitator, thereby lacking the richness provided by having co-facilitators. Facilitators were unaware of other course components and often needed training in group-facilitation skills. Faculty and students lacked a clear understanding of small-group goals or of the self-directed, experiential model of learning. To address these issues, we changed our small-group model two years ago: (1) students were placed in the same group for two years, (2) facilitators were asked to remain with the same group for two years, (3) co-facilitation of small groups was encouraged, (4) facilitators were required to attend faculty development sessions on small groups, (5) facilitators were requested to attend the lectures that preceded the small-group meetings, and (6) course goals and pedagogic approaches were explained to students and faculty. Discussion: Implementing the two-year continuity, co-facilitation model has allowed groups to become more cohesive, to build trust essential to discussing challenging topics, and to benefit from the skills and perspectives of two facilitators. Similarly, requesting faculty to attend lectures and faculty development sessions has increased their understanding of the overall course and provided the opportunity to learn and practice facilitation skills. Students' evaluations of the course show satisfaction with small groups; the item “this component of the course was excellent” received a mean rating across the last two years of 3.7 on a five-point scale (5 = strongly agree). The challenges of this teaching model include recruiting and maintaining faculty for two years, achieving consistency across facilitators, and spending the time required for problem solving when groups do not go well. In spite of these challenges, the small-group teaching model has provided a successful learning/teaching experience for our students and faculty.