The small group experience is the centerpiece of the PCC curriculum.  Small groups are specifically useful for developing higher order cognitive skills such as evaluation, problem-solving, interpretation of complex concepts, and application of principles and basic information to practical problems.  In addition, small group activities are much more conducive to promoting collaboration, development of interpersonal skills, and affective changes than the traditional classroom lecture. These characteristics of small groups are essential to medical education wherein the development of competent professionals with the ability to care humanely and sensitively for individuals and families is one of its major goals.
 

Small group process

The PCC curriculum at OU-COM will start with three small groups each with six to eight students.  All small groups will have one to two facilitators: usually a basic scientist and a clinician.  The groups will be the setting for discussion geared toward exploring issues pertinent to the basic science disciplines in the context of a clinical case.  Each group member is encouraged to participate freely through brainstorming, challenging ideas and hypotheses, opening himself/herself to critical questions as he/she looks for learning issues raised during the discussion.  The PCC group composition will change at the end of each quarter in order to allow for interaction among all PCC students.

For the small group process to work effectively, students are required to attend and participate fully.  True participation will occur when students feel safe to take risks in the discussions in the form of expressing ideas, offering and receiving feedback, challenging assumptions, recognizing deficiencies, etc.  However, the facilitators are not just passive observers.  The most significant role of the facilitators is to make sure the group participants are actively involved in the discussion and that the group addresses the objectives of the session.  Students are also responsible for coming prepared for the discussions.  Preparation entails studying the learning issues during the independent study periods and actively contributing to the understanding of the case.  The success of the program depends on student involvement. 

The cases are based on actual patients

 The cases are based on actual patients, with the patient information distributed over several pages.  The facilitators will present the information progressively during the group discussion, in a sequence similar to that available to the physician.  The first page, for instance, contains only the information available to the physician at the beginning of the visit:  name, sex, age, and chief complaint.  The subsequent pages provide data that will answer the probable questions concerning patient history, physical exam, results of laboratory tests, and ultimately, diagnosis and treatment.  The process attempts to emulate the interaction between physician and patient in the course of exploring the problem presented by the patient.  Students are stimulated to generate questions, ideas, and hypotheses which will help them address specific clinical situations.  Facilitators provide the information students request without attempting to “correct” students’ direction of inquiry, but allowing for a free exploration of alternatives in the process of solving the patient problem.  The ultimate goal of the discussion is not the solution of the problem per se, but to identify learning issues students need to address in order to arrive at that solution. 

The beginning: Tutorial

The group tutorial process starts with introductions of students and facilitators.  Each group member “tells his/her background so that levels of existing expertise are known.” The facilitators then circulate the first page of the case for discussion.  A case may require several group sessions to complete.

The tutorial process may be divided into three phases.  In the first phase the group is presented with the case and starts to identify learning issues needed to understand the presented problem.  One student reads the case, while another--the “scribe”--writes information on a blackboard.  In order to facilitate the discussion, the information is organized as facts, questions, ideas, and hypotheses, and learning issues.  The group evaluates the information regarding its relevance to the case and attempts to provide explanations for the clinical picture presented.  Students are encouraged to participate freely in the generation of ideas and hypotheses regarding the case as well as to question, challenge, and probe into each other’s ideas and hypotheses.  The basic assumption is that the collective thinking process is beneficial to the solution of the problem and to the identification of areas of inquiry students need to explore.  As students raise and test hypotheses, they identify learning issues they need to pursue.  These learning issues are topics for which their current level of knowledge is insufficient to understand the clinical picture or to test the hypotheses.  At the end of the session, students prioritize and select the learning issues they will pursue and decide which resources they will utilize in order to obtain the information.  Although the discussion is based on a clinical case, students do not need to be concerned with making a diagnosis or selecting the treatment for the patient.  The ultimate goal is to help students understand the basic mechanisms responsible for clinical signs and symptoms.  The final activity of each session is for the group to evaluate its efforts in this regard and to make recommendations for improvement of the group’s performance.

The second phase is for independent study of the issues identified during the group session.  Students are encouraged to utilize any resources available (textbooks, journals, x-rays, audio-visual materials, resource faculty, etc.) in order to obtain the information they need to understand the clinical case.  Students may meet outside the group, work individually, communicate with members of other groups or take any steps that may assist them during this phase.

Role of Discussion in the Group

During the third phase, the students reconvene to discuss the results of their independent study on their understanding of the clinical case.  They repeat the process of the first phase, now applying their new knowledge in order to formulate new hypotheses and identify additional learning issues.  At the end of the session, they evaluate the group performance and launch another period of independent study.  The process may have several iterations until the students are satisfied with the knowledge they gained in order to understand the basic mechanisms underlying the clinical picture of the case.  At this time, a final self-evaluation occurs and the group summarizes what it has learned.  

Each group will have two facilitators, usually a basic scientist and a clinician.  Their role is to provide the case information progressively as needed during the discussion.  They will hand out one page of the case at a time as the students request information on the case.  The most significant role of the facilitators is to make sure that the group participants are actively involved in the discussion and that the group addresses the objectives of the session.  These discussions are critical components in the case study for two reasons: 1) each student has a responsibility to contribute to the group discussion; 2) the student’s grasp of material might not be as solid as the student believes, and one of the purposes of discussion is to explore and elaborate on their knowledge.  An important part of medical education is knowing when you do NOT know something!  Subsequent session discussions involve sharing information learned through independent study, continued development of learning issues, and continued work on resolving the problems presented in the case.

The facilitators are also involved in the evaluation process as they evaluate group members in their participation in and contributions to the discussions.  They also contribute to the construction of the examinations used in the program by monitoring the learning issues covered.

The facilitator's role           

The chief danger that any facilitator presents to the group is being overly directive and the role of “omniscient tutor” must be avoided.  Students are responsible for participating in the discussion.  For a variety of reasons, it is easy for students to look to faculty for answers.  For the small group process to work and be effective, facilitators must avoid this role. True participation will occur when students feel safe to take risks in the discussions in the form of expressing ideas, offering and receiving feedback, challenging assumptions, recognizing deficiencies, etc.  They are also responsible for coming prepared for the discussions.  Preparation entails studying the learning issues during the independent study periods and actively contributing to the understanding of the case.  The success of the program depends on student involvement.