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Thinking Small

December 30, 2021
Leslie R. Ellis, MD
Associate professor of hematology and oncology at Wake Forest Baptist Medical Center in Winston-Salem, North Carolina

Anyone in medical education is familiar with Bloom's Taxonomy, a pyramid-shaped model representing different types of learning objectives, from lower- to higher-order thinking (Figure 1). Basic knowledge – recalling simple concepts and facts – serves as the foundation of the period, while creating – developing original ideas using learned facts – is at the top of the pyramid.

As medical educators, our goal is to move students through that taxonomy. We can use many teaching methods and learning environments to help students reach the top of that pyramid. The large-group, didactic lecture, for instance, with a teacher unilaterally transmitting knowledge to the learner, may be great for the learning objectives that are lower on Bloom's Taxonomy.

Small-group instruction, with the teacher acting as a facilitator for smaller groups of students, is another one of these pathways. It offers critical advantages over other types of instruction, including fostering interaction among the students and the opportunity to cultivate higher-order, critical thinking skills. Student learning can be maximized by having students explain ideas and concepts, apply the information, and analyze their results. That is something that, traditionally, can be very difficult to do in a large-group lecture.
As with all instruction, and specifically within a small group, the instructor can educate him- or herself on how to be a good small-group facilitator. To best apply small group learning in our classrooms, we need to know what makes it effective – from both the perspectives of the student and the teacher.

Small-Group Instruction in Action

I've used a combination of different instruction formats when teaching a specific topic. For instance, when students learn about hematopoiesis, they first need to understand what normal hematopoiesis is before learning about abnormal hematopoiesis. So, during the first week, we cover the basic knowledge about normal hematopoiesis in a large group lecture. Once they understand that foundation, then we can move to higher-order thinking in which students are asked to look at patient scenarios of abnormal hematopoiesis. That's where small-group instruction is the most effective.

I incorporate small-group instruction in my classroom with teaching sessions called case-centered learning (CCL).

For the first two weeks of each CCL unit, students learn new content that they have not learned in a formal, large-group lecture. For example, during the first two weeks of a unit on sickle cell disease (SCD), the content will focus on a patient. Everything the students learn about SCD ultimately will be information they have taught themselves. Before each CCL unit, I also review the standard set of learning objectives and the core information I expect students to learn, which they will eventually be quizzed on.

Each CCL session is set up like a real-world patient encounter in the clinic (See Figure 2 for some examples of the slides I use during the first week of a CCL). First, students are presented with a patient's chart and past medical history and are asked to accomplish a set of specific tasks related to that information. To complete those tasks, students work among themselves in small groups for a 10- to 15-minute period to decide what resources they are going to use. After that, the class regroups, and I ask the students to explain how they reached their answers.

Then, they examine the patient and receive another set of tasks related to the physical examination findings, such as deciding which lab or imaging test to order. Again, they work together in small groups, before we regroup as a class to discuss their responses to those tasks. Finally, I give them the results of the labs they ordered, and they have to develop their own learning objectives before the next CCL session.

Strategies for Small-Group Success

I am a proponent of small-group instruction, but not everything needs to be taught in this format. Think about your goals for the learning session: If your goal is primarily to transmit information, then large group lectures are perfectly appropriate. Personally, I feel that large group lectures get a bad rap; people have designed interactive, large group lectures that help students advance through Bloom's Taxonomy. The key with any type of instruction is to be mindful of how a teaching strategy is being used. So, if your goal is to have students understand concepts and start to apply those concepts to different situations, then small-group instruction may be the best way to accomplish that goal.

Like everything, small-group instruction is a tool, and a tool is only as good as the person using it. Just because you're using small-group discussion doesn't mean you're doing it well.
One of the pitfalls of small-group instruction, and of any type of self-directed learning, is the risk that students don't yet know what is relevant and what is not, meaning they could be missing the learning objectives of the session. To help keep them on track, I provide a set of short, focused tasks. It is a controlled situation, even though they are doing all of the learning among themselves.

Making Every Voice Heard

Introducing a small-group format means taking some risk – both for the teacher and the students. Opening up the classroom to that type of discussion means taking the chance that students will deviate from the learning objective topics. So, as instructors, we have to be ready to step outside of our narrow content areas when students come to us with those questions.

On the other hand, students may feel uncomfortable that, in a small-group learning environment, they are going to do most of the talking, and I am going to do the least. Another one of my responsibilities as an instructor is to make sure the classroom is a safe learning environment. That includes making sure every student has the chance to be heard.

I can best help students learn by listening to them. Some students are naturally quieter or more hesitant to speak up than others; some students will be chomping at the bit to answer my questions. In the latter group, students tend to have all the right answers to my questions, but they forget that that's not the point of small-group instruction. It's not about having the answers; it's about understanding how to get to those answers.

I make sure that all of my students know that it is important for me to hear from every student. There may be times when I'm looking for more input from certain people and less input from others. It does not mean that I value some people's input over others; it just means that I need to make sure everyone is on track.

There are a multitude of ways that teachers can encourage quieter students to speak up, and this does not have to happen in a confrontational way. I have found that encouragement through eye contact, or acknowledging with humor that one particular student is monopolizing the conversation, can help make students comfortable.

Hearing from every student is the only way I can be an effective teacher. I need to see what path students are taking, where they are deviating, and how I can get them back on track.

That's not something that can happen in one hour with 120 students. If a student offers a wrong answer in that setting, we don't have the opportunity to go through and figure out how they got to that answer and how to get them to the right answer. In a small-group setting, we have a better chance of figuring that out.

Working Past Word Association

The most important distinction between small group and other types of instruction is the role of the teacher. Small-group instruction asks students to work among themselves, while the teacher facilitates discussion. Because the instructor rarely interjects in the students' conversations, we have to be mindful of when and how we choose to do so.

It's not just a matter of dividing the larger body of students into small groups and letting them run with it. As the facilitator, I wander around the classroom to listen in on the conversations the students are having in the small groups. If I hear a group getting off base, I try to redirect them; if I hear a group working toward the right answer, I try to push them a little to make sure they are truly understanding what they are learning as it relates to a given patient scenario.

My responsibility as a medical educator is to help students progress along Bloom's Taxonomy – from memorizing facts to developing novel ideas. In one of my classes a couple of years ago, I noticed that the students were very good at giving me answers that were nouns, but they would never give me verbs. It made me realize that much of what the students were learning was word-association. While learning that knowledge is important, they also need to understand how those words relate to each other. That's where the verb comes in.

That ended up being the question I asked that class that year: "Okay, you gave me a noun. Now, give me the verb." That forced them to think about the connections between the new pieces of knowledge they received and how that fits into the pathophysiology of the disease they already knew.

Continuing Learning

Self-directed learning is a skill that carries on throughout real-world clinical practice, where new things are constantly being discovered. Personally, though I have finished my training, I still have to educate myself on all of the new drugs that have been approved and all of the new information we learn about diseases since I was in medical school.

Because small-group instruction allows for more input from students than the traditional large group lecture setting, I also find that I learn something every year because of the great questions that my students ask me. These young students are coming at challenging patient scenarios from a different perspective than I am, and, even though I've "known" these concepts for 20 years, I always have to look something up in the medical literature.

Admitting that I don't have all the answers is also modeling for students that learning and acquiring new information is a lifelong pursuit. In a more practical sense, the last thing we want trainees to do when they start practicing and caring for patients is make up an answer when they don't know something.

The ability to interact and learn with peers continues throughout your career, as well. In the field of hematology, this skill is of great importance. Hematology is an inter-professional field; a physician is one member of a team that includes nurses, social workers, physical therapists, pharmacists, and other health-care providers. Being able to learn from our peers can only help trainees when they start practicing in the real world.

Editor's note: Dr. Ellis served as a faculty member for the inaugural ASH Medical Educators Institute that took place at ASH Headquarters in late September. The ASH Medical Educators Institute (ASH MEI) is designed to develop future leaders in hematology education by providing a "boot camp" in teaching techniques, medical education scholarship, and trainee and program evaluation for hematologists who are new to medical education careers.


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