Fostering critical thinking in small groups
Barbara Cockrill, M.D. & Pieter Cohen, M.D.
HMS Medical Education Day Workshop, October, 2011
Warning: Below we have provided advice that we have found (sometimes) useful in
enhancing critical thinking in small group settings. Do not try everything at once – it’s
too much! Depending on the specific teaching assignment, we suggest you select from
among the tips and options below. We hope that, over time, you’ll have a chance to
experiment and find those approaches that work for you.
Prior to the small group session:
 Prepare for group discussions as much as, or more than, you would for a lecture.
o Prepare content (but recognize you will actually share very little of the
material yourself)
o Understand students’ content knowledge level and clinical experiences
o Learn the students’ names or use name cards
o Learn how prior sessions have been taught & students’ expectations
o If there is a student leader (or other faculty member), work closely with them
in planning the session.
o Understand how students are being evaluated and try to avoid conflict with
your teaching approach (e.g., if students are being evaluated as individuals
might be difficult to have them work through problems as a highly
functioning group)
 Define your objectives with student and faculty input. Focus on application of
knowledge, analysis and synthesis rather than content (which is best learned in
other settings or during preparatory work). Sacrifice content for understanding:
recognize (and accept!) that you cannot cover all the material.
 Design the session to meet your objectives – everything you plan should be designed
to reinforce the sessions objectives:
o Preparatory work for students –communicate ahead of time required
readings/web-based activities/exercises to be completed prior to session
o Placement/seating of students/teacher
o Appropriate room/visual aids—chalk board, wipe board, anatomic models
o Decide what parts of the session will be teacher led vs. student led
o Prepare a few “thought questions” to use to advance your objectives.
o Create agenda for the time including activities (e.g., break-out groups,
teacher leaving the room, role plays) to enhance active engagement
When introducing/beginning the small group session:
 Introduce yourself (a little personal story is helpful) and explain your role
 Explain that you (and fellow students) will be trying to understands the group’s
thinking -- there are no “right” or “wrong” conceptions as often ideas that seem
most off-base are the ideas that can lead to deeper understanding of the problem.
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Reassure students that you will attempt to clarify misconceptions at the end of the
session. Given the freedom to think and question, the group will usually correct
misconceptions along the way (but sometimes they might not know they did). Let
students know there will likely be questions you also can’t answer and will follow-up
after the session and/or help them develop a strategy to obtain those answers.
Explain that it is important not to be thinking about a brilliant thing to say as this
means that you are not listening to the group. Everyone has a responsibility to
follow where the group discussion is going.
Explain that you may decide to move the discussion along in the interest of time and
meeting the learning objectives.
Emphasize the value of working as a team to think through the problems and
carefully listening to one another.
Encourage students to use the board or other media, when appropriate, to facilitate
group focus and engage the visual learner
Clarify your expectations for use of personal devices (e.g., iPhones, responding to
phone calls, text messages, etc.) during the session.
Ensure that the students understand the expectations/task to be carried out
When facilitating/teaching the small group session:
 Push for understanding without giving answers, and then be quiet!
o “How does that work?”
o “I am not sure we’ve fully explored this concept.”
o “How can we explain this differently?”
o “Can anyone make the counter argument? …play the devil’s advocate?”
 If asked a question by a student, rather than answering it yourself turn the question
to the group, e.g., “Interesting question, what do people think?”
 Look around the group both when you are speaking and when a student is speaking.
Students will realize they are addressing the group – not you.
 Wait (if necessary 10 seconds) after asking a question before reformulating it or
answering it.
 When you have something you could say (which is likely to be most of the time)
count to 10 (silently!) before saying anything.
 Avoid “rapid reward” for a correct statement – rapid positive feedback such as
writing the answer on the board or saying “great answer” may:
o Lead to immediate “shut-down” of thinking by others since the “right”
answer has been found
o Imply that other responses were not great or worthy.
 Be aware of participation level of individual students and help decrease participation
from garrulous students and encourage participation from reticent students. Your
body language is usually sufficient and directed questions or ‘cold calls’ are often not
necessary.
 Be aware of tension level in the group: Tension is not per se a problem and likely an
important component of an effective learning experience – but the level of tension
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should ideally vary and sometimes you may need to interject more tension (e.g., by
challenging the group’s assumptions or ‘cold calls’) while other times you might
need to defuse tension (e.g., by supportive comments, mediating between differing
views, interjecting humor, etc.)
Be yourself, don’t be afraid to share your own personality – humor, personal stories,
etc. as appropriate. Our students love to hear about personal clinical encounters
that provide context to what they are learning.
Create a mechanism for students to provide anonymous feedback to you about your
teaching.
After the small group session:
 Block your schedule so that you can linger and talk with students. Consider asking,
“What is one thing that I could do to improve this session the next time I have the
opportunity to come?” (avoid: “Did you like it?” or “How did it go?”)
 Reflect and take personal notes on what to try next time to enhance the learning.
 Debrief with a thoughtful educator-colleague. Consider inviting your colleague to a
future session to observe your teaching (see Atul Gwande’s Oct 3, 2011 New Yorker
essay: “Personal best: top athletes and singers have coaches. Should you?”).
Please share your ideas & tips with us:
Pieter can be reached at pcohen@challiance.org
Barbara at bcockrill@partners.org
Recommended reading
Azer, SA. Challenges facing PBL tutors: 12 tips for successful group facilitation. Med
Teacher 2005; 27:676-681.
Specifically written for PBL tutorial teaching, this article provides practical
recommendations for successful teaching in any small group setting.
DiCarlo, SF. Too much content, not enough thinking, and too little FUN!. Adv. Physiol
Educ 2009; 33: 257-264.
Short ,easy to read and well-referenced essay which explores the difficulties
teaching medical students effectively in a world where medical knowledge is exploding.
Dr. DiCarlo is a noted authority on active learning. The title says it all.
Jaques, David. Learning in Groups: a Handbook for Improving Group Work. 3rd Ed.
2000 Bell & Bain Ltd, Glasgow, UK.
This book reviews the literature on teaching and communication in groups. It is
designed with an undergraduate or graduate liberal-arts tutorial in mind but provides
many practical tips for medical educators teaching in small group setting. A new edition
(which we’ve not yet read) also covers online learning, subtitled “A Handbook for Faceto-Face and Online Environments,” is now available.
McCormick D, Kahn M. Barn Raising: Collabortative group process in seminars.
EXCHANGE: The Organizational Behavior Teaching Journal. 1982; 7:16-20.
This thought-provoking article considers four models for small group discussion.
The authors argue for a collaborative approach they term ‘barn raising’ in that the group
comes together to tackle the problem as a community and individual members are not
responsible to defend their own ideas or concepts (that responsibility is jointly shared
by the group).
Napell, SM. Six Common Non-Facilitating Teaching Behaviors. Contemporary
Education 1976; 47:79-82.
Although written in the negative (i.e., what mistakes to avoid), this is a classic
and very helpful discussion of the pitfalls that teachers can fall into when trying to
facilitate small group learning.
Christensen CR, Garvin DA, Sweet A. Education for Judgement: The Artistry of
Discussion Leadership. Harvard Business School Press 1991, Boston, MA.
Written by experts in small group discussions using the Harvard Business School
case-based model, this book has several excellent chapters that are readily applicable to
medical education including: “Premises and practices of discussion teaching,” “Every
student teaches and every teacher learns: the reciprocal gift of discussion teaching,”
and “With open ears: listening and the art of discussion leading.”