Clinical review

ABC of learning and teaching in medicine

Teaching small groups
David Jaques

Group discussion plays a valuable role in the all-round

“By separating teaching from learning, we have teachers
education of students, whether in problem based learning and
who do not listen and students who do not talk”
team projects or in the more traditional academic scenario of
the tutorial or seminar. When it works well, discussion can allow Based on Palmer P (The Courage to Teach. Jossey Bass,
1998)
students to negotiate meanings, express themselves in the
language of the subject, and establish closer contact with
academic staff than more formal methods permit. Discussion
can also develop the more instrumental skills of listening,
presenting ideas, persuading, and working as part of a team. But Problems associated with leading effective small groups
perhaps most importantly, discussion in small groups can or x The teacher gives a lecture rather than conducting a dialogue
should give students the chance to monitor their own learning x The teacher talks too much
and thus gain a degree of self direction and independence in x Students cannot be encouraged to talk except with difficulty; they
their studies. will not talk to each other, but will only respond to questions from
All these worthy aims require active participation and the the tutor
ready expression of ideas. Yet it frequently doesn’t work out this x Students do not prepare for the sessions
x One student dominates or blocks the discussion
way. Indeed many tutors too readily fall back on their reserve
x The students want to be given the solutions to problems rather than
positions of authority, expert, and prime talker. Many of the discuss them
problems associated with leading small groups effectively are
likely to be exacerbated with larger groups. So how can we
avoid the common traps?
If you are leading a group discussion you will need to
Your own behaviour can have an
consider both the configuration of the group and your own enormous effect on how the group
behaviour. Groups often communicate poorly because the functions
physical conditions make it difficult to communicate. For
example, in a group of 10 students seated round a rectangular
table, at least four students on either side of the table have no
eye contact with each other, thus reducing participation. If you
Techniques for effective facilitation in group discussion
ask and answer questions all the time, even less interaction is
x Ensure that group members have an agreed set of ground
likely.
rules—for example, not talking at the same time as another group
If a group sits in a circle without a table, communication is member
likely to be easier. When the discussion has started, it is your x Ensure that the students are clear about the tasks to be carried out
responsibility as discussion leader to listen to and respond to x When you present a question don’t answer it yourself or try to
the whole group. Listening becomes a problem when the reformulate it—count to 10 silently before speaking again
students regard you as an expert or you engage with one or two x When you have something you could say (which could be most of
of the more vocal students rather than the whole group. the time), count to 10 again
x Look round the group both when you are speaking and when a
student is speaking. That way the students will quickly recognise
that they are addressing the group rather than just you. It will allow
More structure, less intervention you to pick up cues from those who want to speak but are either a
bit slow or inhibited
Being a democratic discussion leader involves making the right
sort of nudges and interventions. The role can be made a lot
less demanding by using more structure and less intervention in
the group process. The rest of this article shows how clear and
purposeful group structures can help to bypass many of the
Step 1
problems outlined above, by delegating responsibility for group Consider what you want the students to learn or achieve - in other words, what the
interaction (and therefore for learning) to the students. learning outcomes should be (for example, students will be able to identify and
competently use three different general strategies for solving patients' problems)

Group structures and processes Step 2

Choose a suitable set of group tasks to deliver the desired outcomes. For example:
You can minimise your internal involvement in the group • The group is given a problem to solve
process by organising or structuring groups into smaller units, • The students have to monitor the problem solving strategies that they are to use
• They then share their findings and compare them with research evidence
especially when the group process is likely to be problematical. • They draw up a classification of the findings
This is particularly so when you wish to mobilise a sense of
coherence and full participation among a largish group of
students. A sequence of tasks might then be set. For example: Step 3
Decide how to organise the small group. Your tasks
x Students work individually for five minutes drawing up a list are to prepare any materials, explain and check agreement on the
x They share their ideas in pairs for 10 minutes tasks, monitor the development of the tasks, and control time boundaries
x In groups of four to six, students write up categories on a
large sheet of paper Planning the structure of a small discussion group

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x This is followed by 25 minutes of open discussion among the

To encourage group interaction consider
groups.
breaking a larger group into smaller
Your role in this kind of situation may be to move round groups of five or six students; organise
checking that everyone understands and accepts the task and is membership on a heterogeneous or
doing it in an appropriate way and to encourage completion as random basis to prevent cliques forming
the end point approaches. You could leave the room for a while
and let the groups work without supervision.
The following group structures require some assertive
leadership to set up but allow you to take a back seat as the
process itself takes over the direction of events. Group rounds are particularly useful at
the beginning of any meeting so that
Group round everyone is involved from the start and,
Each person has a brief time—say, 20 seconds or one minute— depending on what the group is asked to
to say something in turn round the group. The direction round speak about, as a way of checking on
the group can be decided by the first contributor, or members learning issues
can speak in a random order. More interest and energy is
usually generated, however, if the first person chooses who
should go second, the second who should go third, and so on.

Buzz groups
With larger groups a break is often needed:
x To provide a stimulating change in the locus of attention
x For you to gain some idea of what the students know
x For the students to check their own understanding.
During a discussion students could be asked to turn to their Tutor
First five minutes
neighbour to discuss for a few minutes any difficulties in
understanding, to answer a prepared question, or to speculate
on what they think will happen next in the proceedings. This
will bring a sense of participation and some lively feedback.
Buzz groups enable students to express difficulties they would Second five minutes
have been unwilling to reveal to the whole class. (A variation is
to allocate three or five minutes each way to the pairs—each
phase is for one-way communication.)

Snowball groups Buzz groups, with pairs for one-way, five-minute communication
Snowball groups (or pyramids) are an extension of buzz groups.
Pairs join up to form fours, then fours to eights. These groups
of eight report back to the whole group. This developing
pattern of group interaction can ensure comprehensive
participation, especially when it starts with individuals writing
down their ideas before sharing them. To avoid students
becoming bored with repeated discussion of the same points, it
is a good idea to use increasingly sophisticated tasks as the
groups gets larger.

Fishbowls
The usual fishbowl configuration has an inner group discussing
an issue or topic while the outer group listens, looking for
themes, patterns, or soundness of argument or uses a group
behaviour checklist to give feedback to the group on its
functioning. The roles may then be reversed.
Fishbowl structure—inside group discusses, outside group
Crossover groups
listens in
Students are divided into subgroups that are subsequently split
up to form new groups in such a way as to maximise the
crossing over of information. A colour or number coding in the
first groupings enables a simple relocation—from, for example,
three groups of four students to four groups of three, with each
group in the second configuration having one from each of the
first.

Circular questioning
In circular questioning each member of the group asks a
question in turn. In its simplest version, one group member
formulates a question relevant to the theme or problem and
puts it to the person opposite, who has a specified time (say, one Crossover groups—redistribution of 12 students (each allocated one of four
or two minutes) to answer it. Follow up questions can be asked if colours) for second period of session

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Clinical review

time permits. The questioning and answering continues

clockwise round the group until everyone has contributed, at
which time a review of questions and answers can take place.
This could also include answers that others would like to have
given. Alternatively, you or the students could prepare the
questions on cards. You could also mix the best of the students’
questions with some of your own.
Horseshoe groups
This method allows you to alternate between the lecture and
discussion formats, a common practice in workshops. Groups
are arranged around tables, with each group in a horseshoe Circular
formation with the open end facing the front. You can thus talk questioning

formally from the board for a time before switching to

presenting a group task. Subsequent reporting from each group
can induce boredom. To avoid this danger, the tutor can
circulate written reports for comment; get groups to interview Board/screen

each other publicly or get one member of each group to

circulate; ask groups to produce and display posters; ask the Tutor
reporters from each group to form an inner group in a fishbowl
formation; or use the crossover method to move students
around.

The group structures described require an explicit task

and topic, and they are possible only if the furniture is
movable. Tutors could also consider experimenting with
furniture to see if other group structures work. The Horseshoe groups
physical configuration is a strong determinant of social
(and hence learning) processes, as is the sequence of Recommended reading
activities
x Brookfield S, Preskill S. Discussion as a way of teaching—tools and
techniques for university teachers. Buckingham: Open University Press,
1999.
Conclusion x Forster F, Hounsell D, Thompson S. Tutoring and demonstrating—a
handbook. Sheffield: Universities’ and Colleges’ Staff Development
This article has emphasised the choices available to you in Agency, 1995.
working with groups. Some of these involve more skilled and x Habeshaw T, Habeshaw S, Gibbs G. 53 interesting things to do in your
sensitive handling of group process from within the group; seminars and tutorials. Bristol: Technical and Educational Services,
others require imaginative management in the setting of tasks 1992.
and the organising of purposeful activities for subgroups. Well x Jaques D. Learning in groups. 3rd ed. London: Kogan Page, 2000.
x Tiberius R. Small group teaching: a trouble-shooting guide. London:
organised and purposeful group discussion can create a firm
Kogan Page, 1999.
foundation for qualities such as openness, networking, and
proactive communication—important ingredients in the process
of personal and organisational change. The value of effective The ABC of learning and teaching in medicine is edited by Peter
group management in professional development and lifelong Cantillon, senior lecturer in medical informatics and medical education,
learning cannot be underestimated. National University of Ireland, Galway, Republic of Ireland; Linda
Hutchinson, director of education and workforce development and
consultant paediatrician, University Hospital Lewisham; and Diana F
David Jaques is an independent consultant in learning and teaching Wood, deputy dean for education and consultant endocrinologist, Barts
in higher education. and the London, Queen Mary’s School of Medicine and Dentistry,
Queen Mary, University of London. The series will be published as a
BMJ 2003;326:492–4 book in late spring.

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