Using the group effectively is a skill that is employed most frequently during the Middle of a teaching session, but it is also relevant in the Opening and Closing. This module will highlight strategies to use throughout a teaching session, but will focus primarily on the Middle.

RATIONALE:

Skill-development teaching sessions rely heavily on individualized teaching, in which the faculty works 1-1 with the learner. In a small group, or on teaching rounds, this individual focus can leave the rest of the group or team members unengaged. Using the group becomes important for a number of reasons, including:

• If an expectation has been set that group members will be turned to during the teaching encounter, group members are more likely to stay alert and attentive.
• As a teacher, you can take advantage of having multiple observers watching the communication encounter. They will notice and articulate skills or behaviors that you might not have included in your observations.
• It can help the learner to hear from peers. Not all the teaching points need to come from you.
• Many of us learn by observing others, so you can set expectations that the observers will learn during the encounter as well, if they attend to specific things the learner is doing well, or considering things they might do differently if they were interacting with the patient.

PITFALLS

• Using the group requires trusting the group. There are always uncertainties about how the group will respond or what kind of feedback they will give. You will need to be ready to do some recasting, reframing, or redirecting, if comments are off-base.
• Using the group takes time. Once assignments or expectations have been set, the participatory behavior must be reinforced by including time for observer comments.

SUGGESTED PROCEDURE:

Group members can be enlisted to participate in most aspects of the teaching session: agenda setting, observations, problem-solving, giving feedback, and summarizing.

Agenda Setting: When Opening a skill practice session, it is important to assess learners assumptions and fears, all the while creating buy-in for the process. During this discussion, you are engaging the group and reinforcing expectations that you may have set at the outset regarding group participation. These are general, open-ended questions that get the group reflecting on the task at hand. Some questions you might use include: "What is challenging about doing role plays to learn communication skills?" "Given the range of skills and strategies we have discussed so far, what stands out to you as important or useful to your practice?" or "What do you think makes breaking bad news so hard?"

You can facilitate the discussion, which need only take a few minutes, and use a flip chart to capture their ideas. Using a flip chart creates the expectation that you will get responses from the group (you have to record something, you are poised), allows the group to review what has been said so far so they can add or extend comments, and also gives you some control over how the comment gets framed in summary. Restating the comment on the flip chart, with permission of the participant, can frame the suggestion in either a more generalizable or cogent way that ties to your own teaching goals while still having a foundation in the participant's suggestion.

Observations: When working with role plays or at the bedside, generally one learner is in the 'hot seat'. If you have begun by goal setting with the learner, eliciting skills that they particularly want to work on during this session, you can ask the rest of the group to help you watch for those skills.

Assigning Tasks: Some faculty prefer to make assignments, breaking up the skills of interest into very specific, discrete skills, so that each group member can stay focused. It is difficult to track the range of things that are going on in an encounter, between nonverbals, patient reactions, and specific, varied communication skills. Having only one thing to watch for can help a novice observer give focused feedback. However, making specific assignments takes time and can seem forced. Read your group and consider using the assignment strategy if some group members are not participating, or give non-specific feedback. Important for either method of using the group for observations is reinforcing their behavior by asking for their observations, even if only in the last few minutes of an encounter.

Problem-solving: If a learner gets stuck at a certain place in the patient encounter and a timeout has been called, by either the faculty or the learner, after the initial debriefing with the learner, the faculty can ask the group for suggestions. Tone is important here as there is a risk of 'de-skilling' the learner if other group members try to fix the encounter. However, many learners find it helpful to hear a range of ways others might respond in a patient encounter, allowing them to choose one of the suggestions to try when moving forward. The message here is that there is more than one 'right' way to respond in the encounter. For example:

FACULTY: Okay, How could Jules make an empathic response? What could he say?

LEARNER: 'I can see how difficult this treatment is for you.'

GROUP MEMBER 1: 'I'm sorry you feel this way.'

GROUP MEMBER 2: I would have probably said to my patient, 'man this sucks,' and the patient would have said, 'you're darn right'.

FACULTY: So maybe you could pick one of those suggestions and we can kind of roll back the interview. So why don't you ask her again how she's doing, and see what happens.

In another encounter, the faculty member stopped the standardized patient interview right when a difficult question was asked.

FACULTY: I stopped there because she just said the most difficult thing. So now we're going to have to respond to that. What I think we should do is come up with some possible responses to that, okay? So, let's hear some ideas, how he should respond to that when she says, "We're going to beat this thing."

This strategy can be used as a way to offer support to the learner. In this case, the faculty had advance knowledge that the question that was asked would be a hard one for him.

Feedback: An important way to close the loop after asking group members to be observing the encounter is to ask them for feedback. The work for the faculty here is priming the group members to be specific with their feedback, so that the learner has some data to work with next time. For example:

FACULTY: Other things people noticed?

GROUP MEMBER: I thought she did a great job.

FACULTY: I thought she did great too. What did you notice that she was doing that helped to make this encounter go so well?

If expectations have been set and the group is working well together, often short-hand can elicit the feedback from the observers:

FACULTY: Timeout. You did 2 things so well, I'm timing out even though it's short. What are the 2 things? Can people..?

Another challenge for faculty here is helping the group members give balanced feedback, and not just focus on the positive or just the negative aspects of the encounter. Framing your elicitation of feedback specifically can help. For example, "What are other things that people noticed that she did well?" or "What are some things that you might have done differently?"

The group can be used to provide another perspective for learners who may struggle with a perception of themselves. For example, if the learner is worried that she is talking too much in an encounter, or is being too controlling of the interview, you can just ask the group to give feedback on that particular concern. Since physicians and medical trainees rarely have peers observe them in patient encounters, just having outside observers can be very useful to calibrate the learner's own self-assessment.

Strategies to Engage the Group: Several strategies can be used to engage the group. For example, the faculty can set expectations early on, being explicit about the role he or she expects group members to take during the communication skill practice session. For example, when the faculty is describing how the practice session will go she can say:

FACULTY: "What will happen is that the learner will talk with the patient for about 5 minutes or so, and we'll all watch, being ready to give feedback."

If a group member remains disengaged, a number of further strategies could be used to explore with the member what might be going on. At this stage, thinking about parallel skills that are employed in patient interviews can help you. If you are talking with a patient and notice affect change, you might try exploring with the patient or inviting her to talk about what is going on. Another strategy might be to test a hypothesis with the patient, for example, "You seem a little sad to me, is there something going on that you would like to talk about?" or "As we've been talking I noticed that you seem to be getting tense, is that right?" Just as you use these skills with patients, you can use them with your group members:

• Setting Expectations: "It can help to take a few notes while you are watch the encounter, so when you give feedback at the end, it is really specific and tied to particular words or phrases that you observed."
• Naming and Exploring: "We haven't heard from you yet John, what are you thinking about?"
• Inviting: "John, we haven't heard from you yet, what did you notice that Sue did during this encounter that helped the patient open up to her?"
• Hypothesis testing: "It seems like this part might be hard for you, I was wondering, and tell me if I'm right or not, if this particular scenario is striking a chord of some kind."

Group Process Expectations. An educator several years ago noted that groups go through predictable stages when working together. He described them as: forming, storming, norming, performing. You should expect that a group will take some time to form and develop a style of working together. Even a group that is working well will reach a point where something shifts and the group will need some attention (the storming phase). It can be useful to return to some of the strategies used during the Opening of a session to refocus and explore what issues have emerged for the learners as important now that they are part way through an experience.

PEARLS

• If learners are participating with you in the group, they will feel some responsibility for what is happening in the group which will heighten their involvement and engagement.
• The small group environment can become quite dynamic and energizing for everyone, when all members are engaged and participating.

REFERENCES

• Schwartz R. The Skilled Facilitator. Jossey-Bass, 1994.
• Tuckman, B.W. "Developmental Sequence in Small Groups," Psychological Bulletin, vol. 63, 1965, pp. 384-399.