curriculum learning students teaching

Small group teaching

This is the first draft of an articles that published in my Clinical Teacher mobile app.


Small group learning is one of several educational strategies used to promote student learning, as it promotes a student-centred approach in the educational context (as opposed to a teacher-centred approach, in which the teacher determines the objectives, content to be covered and assessment tasks). There are a variety of benefits associated with learning in small groups, which is why they are often integrated into different learning approaches. For example, working in small group is usually an integral component of problem-based learning (Dent & Harden, 2005).

The learning objectives are what should determine the teaching strategy and as such, small group learning should not be seen as universally appropriate for all educational contexts. In addition, the success of small group learning will be influenced by the availability of resources, including physical space, facilitators and materials. In addition, the relative experience of the facilitators can play a major role in the outcomes of the learning experience.

There are four important group characteristics for small group learning to be effective:

  • There should be active participation and interaction among all group members
  • There should be a clearly defined, specific task or objective/s, that the group is working towards
  • The group should reflect on learning experiences and modify their behaviour accordingly
  • There is no defined number of students that should be in a small group, and in fact, the size is often dictated by the availability of facilitators and other resources

Advantages of small group teaching

Students have opportunities to develop important skills for working in multidisciplinary teams. They learn how to communicate effectively, as they are encouraged to discuss new concepts that arise. They learn how to prioritise tasks, which is usually a component of the PBL process (Kitchen, 2012; Dent & Harden, 2005; Crosby, 1997; Entwhistle, Thompson & Tait, 1992; Walton, 1997).

  1. Promotes ‘deep’ learning: Encourages deep learning and higher order cognitive activities, such as analysis, evaluation and synthesis. Engage by being active participants in the learning process, as opposed to passively “absorbing” information.
  2. Develops critical thinking skills: Allows students to develop critical thinking by exploring issues together and testing hypotheses that are difficult to do well in a lecture. This practice develops problem-solving skills.
  3. Promotes discussion and communication skills: Environment is conducive to discussion. Students do not feel exposed or hidden, but are comfortable. Each student is encouraged to actively participate.
  4. Active and adult learning: Help identify what a student does not understand, and discussion aids understanding by activating previously acquired knowledge. Students are encouraged to reflect on their experiences and develop self-regulatory skills.
  5. Self motivation: Encourages involvement in the learning process, increasing motivation and learning. By taking responsibility for their learning they become self-motivated rather than being motivated by external factors e.g. the lecturer (teacher-centred approaches usually do not facilitate self-directed learning).
  6. Develops transferable skills: Helps develop skills necessary for clinical practice, e.g. leadership, teamwork, organisation, prioritisation, providing support and encouragement for colleagues, problem solving and time management.
  7. Application and development of ideas: Yields opportunities to apply ideas and consider potential outcomes. Making connections during group discussion enhances student understanding.
  8. Tutor as a role model: A logical and systematic tutor approach demonstrating ‘transferable’ skills motivates student learning and development.
  9. Recognises prior learning: Students are encouraged to surface their own prior knowledge, including their own perceptions (and misconceptions) of material previously covered.
  10. Social aspects of learning: Participation and social aspects of small group learning means that learning is more enjoyable than solitary approaches.
  11. Encourages alternative viewpoints: Encourages an awareness of different perspectives on various topics and can therefore help develop an attitude of tolerance.

Small group processes

“Appropriate ground rules make students feel ‘safer’ in sharing and expressing their views” – Kitchen (2010)

Students often find that working in small groups is a greater challenge than expected, probably because they are used to situations in which they work as individuals within a group. However, when individual success is dependent on the group cohesion and collaboration, and the group struggles to perform effectively, students may resist the process. It is therefore important to make them aware of the normal progression of group development (Tuckman & Jensen, 1977).

  1. Forming – a collection of individuals attempting to establish their identity within the group
  2. Storming – characterised by conflict and dissatisfaction that may lead to the development of trust
  3. Norming – attempts to function effectively by developing a sense of group identity and norms
  4. Performing – group performs at an optimal level by being focused on the task, and manages disagreement appropriately

The role of the facilitator

“Small group productivity depends on good facilitation, rather than on topic knowledge” BUT “Less than one third (of clinicians) have received formal training in small group teaching” – Kitchen (2010)

The facilitator plays an essential role in small group, and traditionally would design the module. This would include the development or preparation of stimulus material, which can be in the form of questions, scenarios, images, video, research papers or case studies (Kitchen, 2012). In addition, the facilitator would present the objectives of the session, initiate the process, encourage participation, promote discussion and close the session. In these cases, the facilitator is very clearly leading the process and is in control. This approach is probably the one that most clinical educators are familiar with, and derives from a combination of ability, expertise, experience and enthusiasm. However, when the facilitator clearly dominates the process, self-directed learning and interaction between learners can be limited. Increasingly, small group learning is looking to students to provide more initiative, explore learning options, test hypotheses, develop solutions and review outcomes. In these situations the role of the tutor is less clear and will vary depending on the type of learners making up the groups.

The facilitator/s (often, small groups have multiple facilitators) must all be informed of the objectives of the session. If not, there is the possibility of different groups moving in different directions. This is not as much of a problem if exploration of a concept is the goal. However, if all groups are meant to achieve the same objective, consistency among facilitators is important. For this reason, staff training is vital whenever small groups are being considered as a teaching strategy. It is important to understand that, while content-specific expertise is useful, facilitation skills are essential.

“A fundamental feature of effective facilitation is to make participants feel that they are valued as separate, unique individuals deserving of respect” – Brookfield (1986)

One of the most important roles of the facilitator is to ensure that an atmosphere of trust and collaborative enquiry is created in the small group. This can be achieved by the group setting their own norms and objectives for the session, or if they are inexperienced in groupwork, for the facilitator to guide them through this process. It would also be useful to have the students express their own expectations for the session, especially of their role and responsibilities in the group. As the group members grow in experience, they should take over more and more of the facilitators role, until it may be difficult to tell them apart. As the learners take more control of the group session, more traditional teachers and facilitators may have a challenge adjusting to the new dynamic.

Finally, it is the responsibility of the facilitator to arrive early in order to check that the venue is appropriately prepared for the session. Arriving early is not only useful in order to ensure that the session runs smoothly, but also to set an example for students.

Assessment of small groups

“With undergraduate medical education currently carrying a health warning because of the stress and anxiety exhibited by students and young graduates, any educational process that promotes enjoyment of learning without loss of basic knowledge must be a good thing” – Bligh (1995)

As with all assessment, it is important for students to be aware of the assessment process and outcomes. Teachers and facilitators must decide beforehand on the nature of the assessment task, as well as whether it will be formative or summative, and who will be responsible for conducting it. If the person responsible for assessing the students is also involved with facilitating the groups, it is especially important for students to feel that the environment is a safe space. If not, they may be reluctant to fully participate in the process, as in doing so, they may reveal their ignorance and therefore be vulnerable. This may be addressed by the facilitator being open and discussing their role in assessment as part of the process. If students will be evaluating the facilitators, there may also be a sense of shared responsibility for assessment, thereby “equalising” the balance of power in the relationship.

Assessing the group outcomes is reasonably straightforward and can relate to either the achievement of objectives, or the process of working in a group. Determining the achievement of objectives can be be through student self-report, facilitator observations, or observation by an external assessor. While the assessment of individuals within the group is more challenging it is nonetheless possible, especially when students are able to assist in the process by evaluating their peers. Individual performance can be measured through attendance, contribution or participation, conducting research for the group, and by supporting or encouraging others.

Challenges when working in small groups

“The size of a small group is less important than the characteristics of the group” – Dent & Harden (2005)

When considering implementing small group learning in your course, bear in mind that a change in teaching approach should complement the overall programme strategy and objectives, as well as actually enhance the learning experience. Small group learning should be seen as an integrated component of the curriculum and should be related to other components. In other words, small group learning should be seen as a simple addition.

Often, busy clinical teachers struggle to find the time to implement small group learning strategies, especially when you take continuity of the teaching experience into account. However, this has an impact on scheduling of other teaching activities, which can be challenging to arrange. Careful planning is therefore an important aspect of integrating small groups into the curriculum.

There is a perception that students do not enjoy working in small groups. However, this is possibly based on situations in which students either were not able achieve the objectives, or their learning experience was poor. Careful planning and design are essential in order for the group to successfully achieve the outcomes that are set. Too often, teachers think that group work is about a group of individuals working in a team. It is essential for the groups’ success to be based on cooperative behaviour. In other words, the individuals must work together in order to achieve shared goals that are difficult to achieve as individuals.

Practice points

  • Working in small groups is characterised by student participation and interaction, in order to promote student learning.
  • The size of the group is dependent on the learning activity, although 3-6 students is usually recommended. The size of the group is less important than the group characteristics.
  • Facilitator training is an essential factor for small group success, although most small group facilitators have received no formal training.
  • Integrating small group learning into a curriculum should be carefully considered as part of an overall teaching and learning strategy, rather than as an addition.


Small group work can be an exciting and engaging approach to teaching and learning practice, especially if it is implemented with careful thought and consideration as part of an integrated curricular strategy. The reasons for making the choice should be pedagogical and as such, have educational advantages as the primary motivating factor for the move. Small group teaching has been shown to be beneficial in terms of developing self-directed approaches to learning, critical thinking and reasoning, tolerance of the views and perspectives of others, and the development of interpersonal skills. While there are challenges in its implementation, they can be addressed with thoughtful design and regular feedback from all stakeholders.

References and other sources

curriculum ethics

Developing empathy in clinical education

This post was originally written for the Clinical Teacher iPad app, and can be downloaded there as well.


Empathy is the ability to understand the emotional context of other people and respond to them appropriately. It has been identified as the cornerstone of the clinician-patient relationship and is recognised as one of the most important characteristics of health care professionals that influence the patient’s outcomes and levels of satisfaction. However, even though it is clear that empathy is an essential aspect of clinical practice, there is evidence that empathy actually decreases as a result of medical education and clinical training. In fact, the greatest decrease in empathy seems to coincide with introduction of patient contact into the curriculum. If empathy really is valued in health care professionals, what changes need to take place in the health care curriculum in order to maintain the caring attitudes that students bring with them into their undergraduate training? How should clinical educators respond to the decline in empathy that seems to be a direct result of the clinical education process? This article explores the role of empathy in health care professional practice, as well as briefly identifies some strategies to further develop and maintain a caring attitude towards patients.

What is empathy?

Empathy is the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts and experiences of another human being, without having those feelings, thoughts and experiences communicated in an explicit manner. It is the capacity to share and understand another’s emotional state of mind and is often described as the ability to “put yourself into another’s shoes” (Ioannidou & Konstantikaki, 2008). In essence, empathy is the ability to understand the emotional makeup of other people and respond to them appropriately.

There are three types of empathy (Goleman, 2007):

  • Cognitive: knowing how another person feels and what they might be thinking
  • Emotional: physically feeling what another person is feeling
  • Compassionate: not only understanding a person’s situation and feeling with them, but being moved to help them

We can’t begin being empathetic when another person arrives. We have to already have made a space in our lives where empathy can thrive. And that means being open—truly open—to feeling emotions we may not want to feel. It means allowing another’s experiences to gut us. It means ceding control. Empathy begins with vulnerability. And being vulnerable, especially in our work, is terrifying. – Sara Watchter Boehner

See the video below for a presentation by Joan Halifax, a Buddhist who works with the terminally ill and those on death row, on the link between compassion and empathy.

Development of empathy in children

By the time that children are two years old they normally begin demonstrating empathy by responding emotionally to someone else’s emotional state. At this stage, toddlers will sometimes try to comfort others or show concern for them. Children between the ages of 7 and 12 appear to be naturally inclined to feel empathy for others in pain, a finding that is consistent with functional MRI studies of pain empathy among adults. Researchers have also determined that other areas of the brain were activated when young children saw another person intentionally hurt by another individual, including regions involved in moral reasoning (Goleman, 1995). The evidence seems to be that from a very young age, children are predisposed towards feeling an emotional response when confronted with another person’s suffering. This would seem to suggest that the emergence of empathy is an inherent characteristic of human development and which occurs spontaneously.

Empathy in clinical practice

Empathy, in the context of health care, is the “…ability to communicate an understanding of a client’s world” and is a crucial aspect of all interactions between clinicians and patients (Reynolds, Scott & Jessiman, 1999). It is the clinicians way of saying (Egan, 1986, pg. 99):

I’m with you, I’ve been listening carefully to what you’ve been saying and expressing, and I’m checking if my understanding is accurate.

It is considered to be an appreciation of the patient’s emotions and associated expression of that awareness to the patient. Empathy is also believed to significantly influence patient satisfaction, adherence to medical recommendations, clinical outcomes, and professional satisfaction. In the clinical setting, the common definition of empathy has been expanded to include emotive, moral, cognitive and behavioral dimensions (Stepien & Baernstein, 2006):

  • Emotive: the ability to imagine patients’ emotions and perspectives
  • Moral: the physician’s internal motivation to empathise
  • Cognitive: the intellectual ability to identify and understand patients’ emotions and perspectives
  • Behavioral: the ability to convey an understanding of those emotions and perspectives back to the patient

These additional features of empathy highlight that emotional engagement and not just intellectual understanding is an important aspect of effective empathy. However, some have suggested that the emotional aspect of empathy brings it closer to sympathy. Confusing the two is a conceptual challenge whereby the clinician actually experiences the other person’s emotions, as opposed to simply appreciating that they exist. This is problematic because when clinicians sympathise with patients and share their suffering, it may lead to decreased objectivity, emotional fatigue and subsequent burnout.

During medical education, we first teach the students science, and then we teach them detachment. To these barriers to human understanding, they later add the armor of pride and the fortress of a desk between themselves and their patients. – Howard Spiro

Decline in empathy during medical training

Empathy has been identified as one of the most important characteristics of medical professionals and is routinely screened for among students. However, while the development of empathy seems to be an essential aspect of positive health care relationships, there is some evidence that as medical students move through the curriculum, their scores on tests of empathy drop, with the largest decrease occurring at about the same time that they begin to see patients. Studies show that the empathy scores of students in their preclinical years were higher than in their clinical years. In addition, gender was a significant predictor of empathy, with women having higher scores on tests of empathy than men. Students with high baseline empathy showed a smaller decrease in empathy scores than students with low baseline empathy during medical education. Self-reported empathy for patients, which is potentially a critical factor in good patient-centered care, seems to wane as students progress in their clinical training, particularly among those entering technology-oriented specialties (Chen et al., 2012).

What we need in medical schools is not to teach empathy, as much as to preserve it – the process of learning huge volumes of information about disease, of learning a specialised language, can ironically make one lose sight of the patient one came to serve; empathy can be replaced by cynicism – Abraham Verghese

There are good reasons for the decrease in empathy, including the fact that students work in high-stress environments that place significant pressure on them with heavy workloads, intense time pressures and a diminished sense of autonomy in the healthcare system. In many health systems productivity is valued and rewarded financially and doctors who don’t see as many patients as their peers are sometimes seen as slow and inefficient.The stress of studying and working in the clinical environment may eventually take its toll on students and clinicians in terms of their time, and physical and emotional well-being, all of which make it difficult for them to be empathic. The focus on science and rationality during medical training tends to emphasise detachment and objective clinical neutrality, and prioritises the technologic over the humanistic. Trying to find the right balance can be tricky (Lim, 2013).

In addition, the focus of medical education seems to devalue the patient as a human being. We often talk about the “case” rather than the person. The style of writing is “objective” and impersonal, where that which can be seen is given more importance than that which can be heard. Often the patient is seen as a model, a body to be treated, or a good “teaching case” that illustrates a point (Shapiro, 1992). If we accept that decreased empathy as a direct result of participation in the medical curriculum is undesirable, we need to ask how we can address the problem.

We start with students who are very caring but have no diagnostic skills, and end up with physicians with great diagnostics skill but who don’t care. – Richard Frankel

Developing empathy in clinical education

It seems that empathy can be developed and it should therefore be possible to design a curriculum aimed at maintaining empathy during the third year of medical school. A curriculum where students are encouraged to discuss their patient reactions and emotional response in a safe environment during their clerkships may contribute to the preservation of empathy. Students can also be introduced to the idea that doctors can be taught that empathy is a skill that can be developed and maintained, as opposed to an inherent, unchangeable personality trait. Another strategy that can affect the development of empathy in students is the introduction of the Longitudinal Integrated Clerkship, which has been shown to have a positive impact on the patient-doctor relationship (Ogur et al., 2007).

An interesting perspective on developing empathy in medical education has also been to introduce modules that incorporate literature, movies, drama and poetry into the medical education curriculum. Some medical schools have gone so far as to integrate studies of the Humanities into their curricula, suggesting that the study of literature can help to achieve the following objectives (Shapiro & Rucker, 2003):

  • Stimulate skills of close observation and careful interpretation of patients’ language and behavior
  • Develop imagination and curiosity about patients’ experiences
  • Enhance empathy for patients’ and family members’ perspectives
  • Encourage relationships and emotional connections with patients
  • Emphasise a whole-person understanding of patients
  • Promote reflection on experience and its meaning

There is evidence that empathy and attitudes toward the Humanities in general improved significantly after participation in a literature-based module. In addition, students’ understanding of the patient’s perspective became more detailed and complex after the intervention. They were also more likely to note the ways in which reading literature might help them to cope with study-related stress (Shapiro et al., 2004).

Other strategies include interventions like role-playing and video analysis to try and preserve empathy during the challenging medical education process. Studies of these interventions, particularly the use of communication skill workshops, indicate that the behavioral dimension of empathy can be influenced through curriculum change (Stepien & Baernstein, 2006). In addition, programmes that aim to validate humanism in medicine (such as the Gold Humanism Honor Society) may reverse the decline in empathy (Rosenthal et al., 2011).

Studying the humanities may also be used to combat a perceived loss of empathy that may occur over the course of medical training. – Schwartz et al., 2009

It should be noted however, that current studies on empathy in medical students are challenged by varying definitions of empathy, small sample sizes, lack of adequate control groups, and variation among existing empathy measurement instruments (Stepien, 2006). Some of the empathy measures available have been assessed for research use among medical students and practising medical doctors. These studies have shown that empathy measures can be used as tools for investigating the role of empathy in medical education and clinical training. However, no empathy measures have been found with sufficient evidence of predictive validity for use as selection tools for entry into medical school (Hemmerdinger, 2007).

In the era of new health care policy and primary care shortages, research on empathy in medical students may have implications for the medical education system and admission policy for training institutions (Chen et al., 2012).

What we know matters, but who we are matters more. Being rather than knowing requires showing up and letting ourselves be seen. It requires us to dare greatly, to be vulnerable…Vulnerability is the birthplace of love, belonging, joy, courage, empathy, accountability, and authenticity. If we want greater clarity in our purpose or deeper and more meaningful spiritual lives, vulnerability is the path. – Brene Brown


There is clear evidence that empathy is an essential aspect of developing and maintaining effective clinician-patient relationships. However, there is also evidence to suggest that the process of clinical and medical education may actually lead to a decrease in empathy as a direct result of the way that clinical training is structured. Incorporating a range of strategies from the Humanities may help to maintain empathy in health care professional students, including using literature, poetry, art and music as ways for students to explore various aspects of empathic engagement. While it seems that the ability to measure empathy would have a significant influence on curriculum design, current studies of empathy have been criticised for a variety of reasons, indicating that stronger evidence is needed if we are to integrate the teaching and assessment of empathy in clinical education.


Chen, D.C., Kirshenbaum, D.S., Yan, J., Kirshenbaum, E. & Aseltine, R.H. (2012). Characterizing changes in student empathy throughout medical school. Medical Teacher, 34(4): 305-11. doi: 10.3109/0142159X.2012.644600.

Chen, D., Lew, R., Hershman, W. & Orlander. J. (2007). A cross-sectional measurement of medical student empathy. Journal of General Internal Medicine, October, 22(10): 1434-1438.

Ducharnme, J. (2013). Medical students diagnosed with low empathy. Boston Magazine.

Egan, G (1986). The skilled helper. Brooks-Cole, Monterey, CA.

Goleman, D. (1995). Emotional intelligence: Why it can matter more than IQ. Bantam Books. ISBN: 055338371X.

Hemmerdinger, J.M., Stoddart, S. & Lilford, R.J. (2007). A systematic review of tests of empathy in medicine. BMC Medical Education, 7:24, doi:10.1186/1472-6920-7-24.

Ioannidou, F., & Konstantikaki, V. (2008). Empathy and emotional intelligence: What is it really about? International Journal of Caring Sciences, 1(3), 118–123.

Lim, J. (2013). Empathy, the real measure of a doctor. Today Magazine.

Ogur, B., Hirsh, D., Krupat, E. & Bor, D. (2007). The Harvard Medical School-Cambridge integrated clerkship: an innovative model of clinical education. Academic Medicine, April, 82(4): 397-404.

Poncelet, A., Bokser, S., Calton, B., Hauer, K.E., Kirsch, H., Jones, T., Lai, C.J., Mazotti, L., Shore, W., Teherani, A., Tong, L., Wamsley, M. & Robertson, P. (2011). Development of a longitudinal integrated clerkship at an academic medical center. Medical Education Online, 16:10. Published online 2011 April 4. doi: 10.3402/meo.v16i0.5939.

Reynolds, W. J., Scott, B., & Jessiman, W. C. (1999). Empathy has not been measured in clients’ terms or effectively taught: A review of the literature. Journal of advanced nursing, 30(5): 1177–85.

Rosenthal, S., Howard, B., Schlussel, Y.R., Herrigel, D., Smolarz, G., Gable, B., Vasquez, J., Grigo, H. & Kaufman, M. (2011). Preserving empathy in third-year medical students. Academic Medicine, 86(3): 350-358.

Schwartz, A. W., Abramson, J. S., Wojnowich, I., Accordino, R., Ronan, E. J., & Rifkin, M. R. (2009). Evaluating the impact of the humanities in Medical Education. Mount Sinai Journal of Medicine, 76, 372–380. doi:10.1002/MSJ

Spiro, H. (1992). What is empathy and can it be taught? Annals of Internal Medicine, 116(10): 843–6.

Shapiro, J., Duke, A., Boker, J., & Ahearn, C. S. (2005). Just a spoonful of humanities makes the medicine go down: Introducing literature into a family medicine clerkship. Medical Education, 39(6): 605–12. doi:10.1111/j.1365-2929.2005.02178.x

Shapiro, J., Morrison, E., & Boker, J. (2004). Teaching empathy to first year medical students: evaluation of an elective literature and medicine course. Education for Health, 17(1): 73–84. doi:10.1080/13576280310001656196

Shapiro, J., & Rucker, L. (2003). Can poetry make better doctors? Teaching the humanities and arts to medical students and residents at the University of California, Irvine, College of Medicine. Academic medicine. Journal of the Association of American Medical Colleges, 78(10): 953–7.

Stepien, K.A. & Baernstein, A. (2006). Educating for empathy: A review. Journal of General Internal Medicine, 21(5): 524–530. doi: 10.1111/j.1525-1497.2006.00443.x

assessment curriculum

David Hirsh seminar – Longitudinal integrated clerkships

How to build longitudinal Integrated Clerkships to fit context: Practical tools for modern pedagogy (Prof. David Hirsh, Harvard Medical School)

Prof. David Hirsh
Prof. David Hirsh

Last week I attended a seminar by Prof. David Hirsh from Harvard Medical School, where he discussed the implementation of the Longitudinal Integrated Clerkship (LIC) in their programme. Here are my notes from the seminar.

We hold close the ideas we have of what education should be but don’t question where we get those ideas from. Sometimes, it’s worth questioning.

How does longitudinal clerkship impact on educational design? The case for change was premised on three main ideas: Flexner, ethical erosion, science of learning.

Flexner: Flexner suggested that continuity of teachers and the “closeness” of students as they follow their patients, that students should be “close” to reality. However, the context of care has changed since 1910. Now, patients and students rotate through placements too quickly to be close to anything.

Ethical erosion: There is a decline in students’ professionalism / humanism as a consequence of current approaches to medical education. Students decline in patient-centredness seems to occur as a consequence of their clinical year and exposure to teachers. Their empathy declined significantly in medical school. Medical students seem to show blunted moral development as a direct consequence of medical education during their clinical years. Unprofessional behaviour among medical students predict subsequent unprofessional behaviour.

Learning science: There is no learning theory to suggest that random, dissociated clinical placements, where students are directed by junior clinicians with no pedagogical training (the current model), is a good learning environment for students. There is therefore very little evidence that supports the current model of medical education.

If there’s a gap between where you are and where you believe you should be, that’s reason for change.

Continuity of care: students and patients and students need to matter to each other i.e. it is relationship-based (“my student” not “the student” / “my patient”, not “a patient”)

We need to see:

  • Continuity of curriculum: assessment matches learning
  • Continuity of supervision
  • Continuity of idealism

Need to move away from clinical blocks to streams with “perforations” between the streams to allow movement of concepts and interactions between them. Students follow cohorts of patients throughout the whole year, which allows them to see patients in multiple venues of care. The patient is the organising principle, not the venue or their condition.

We have a tendency to want to match time to the old model of traditional blocks e.g. 4 weeks in an orthopaedic rotation. However, we should rather match time according to the educational and patient needs e.g. spend more time in areas where the patient or student needs it.

In studies of efficacy, we commonly see no significant difference between and within groups who did either the LIC or “block” curriculum. However, tests did show that the LIC group trended towards being slightly better on all tests.

Longitudinal: Students should be present throughout the patient’s time under treatment, including diagnosis and initial presentation (“whole illness episode”). Students were entering the interaction too late, without being exposed to the human being. They were seeing “conditions with human beings attached”.

How often do students establish meaningful relationships with patients?

Even though LIC students found their course to be more stressful and hectic, they also found it to be more rewarding, satisfying, transformational, humanising, etc. LIC students’ scientific rigor and spirit of inquiry is driven by a desire to help their patients. These feelings held true 4-6 years after graduation.

Students are more patient-centred but are still “grouchy” about their overall educational experience. In other words, the LIC students are not made to feel special or given special consideration.

Medical education is not an end in itself and should be directed towards some purpose. Processes should be aimed towards having students “flow” towards that purpose.

The curriculum has “many moving parts”, which feels modern…and scary. From educational change comes systems change. Disruption is powerful. We need to be more intentional about how we design this medical education machine if we really believe that education can be used for transformational change.

“Run toward the gaps” in the curriculum.

The presentation below is not the one I attended, but the content is similar.


Finding the time

People do not fail in life because they aim too high and miss… (The Principal of Change)

“People do not fail in life because they aim too high and miss. They fail in life, because they aim too low and hit.”

We often can’t imagine how we’ll ever find the time to make the changes we know are important to improve learning. But it’s not about finding the time. If you try finding the time in an already packed curriculum, you won’t. It’s about recognizing that if the change is important, then you must make the time to do it.

Note: This was originally posted at Unteaching.


Posted to Diigo 04/12/2011

    • humans are incapable of imagining something they have never actually experienced
    • this is one of the most important reasons that it is so hard for the teaching of thinking skills to take hold in education
    • Teachers and curriculum designers who were never asked to think in their own educations cannot imagine how to include it in their own teaching. More importantly, they have no idea how to assess it.
    • Differing ideas bring different levels of value, but they all bring value. Even an observation that leads to a dead end is not wrong — it is just an observation that turns out not to be productive, and the process of finding the dead end is helpful in itself. Students are not only learning to think, they are learning the collaborative process by which modern work teams complete their projects.
    • To use this technique, the teacher must be comfortable facilitating a process that may go in a totally unpredictable direction. Students may notice things the teacher hadn’t already known. Students might be puzzled by and ask questions about something the teacher doesn’t know. The skilled teacher will not be bothered by this because the act of working this out with the students is an excellent lesson in itself. A teacher who cannot say “Hmmm. I have never thought of this before. Let’s think about it” will not be happy with such an approach.
    • A course that focuses instruction on thinking skills needs to focus assessment on thinking skills as well
    • Assessment is actually the key. If students are assessed by how they use thinking skills to analyze a new work of literature, devise a scientific experiment, draw a conclusion about historical data, or apply appropriate mathematical processes to solve a problem, then they will need to be taught how to do it in the first place
    • We talk hard about life-long learning, but I do not believe that it is figuring in to the procedures, policies, and pedagogies of formal education nearly as much as it should
    • Today, with everything changing so fast, the ability and proclivity to learn is as critical as the basic literacies were in my time
    • Imagine education focusing less on what’s been taught, and much much more on skilled, curious, resourceful, and habitual learning