In the past decade, medical education has witnessed a growing momentum of curricular reforms aimed at improving pedagogy and learning outcomes. Many of these reforms have included the introduction of teaching methods aimed at promoting active learning among students. However, while these much-needed reforms are being implemented, medical education finds itself reeling from the impact of recent changes in health care financing to contain costs. The progress that has been made in introducing resource-intensive pedagogic methods that foster active learning is threatened by such cost-containment practices, because those practices result in less time and fewer faculty members for teaching.
Teachers at Baylor College of Medicine were recently introduced to “team learning,” a teaching approach that has been used to successfully promote active learning in professional disciplines other than medicine.1 Team learning brings together theoretically based and empirically grounded strategies for incorporating the effectiveness of small-group learning into large-group, lecture-oriented sessions. In this report, we describe our initial experience in adapting elements of team learning to overcome common learning barriers during a noontime lecture session with internal medicine residents. We describe the effects of team learning on learners' engagement and attitudes toward the usefulness of the session content.
Team Learning at Baylor
In the fall of 1999, Larry K. Michaelsen, PhD, David Ross Boyd Professor of Management at the University of Oklahoma and a Fellow of the Carnegie Foundation, conducted a one-day series of large-group sessions and workshops with educators at the Baylor College of Medicine. Dr. Michaelsen has been a leader in the development and dissemination of the team-learning method.1–3 In his sessions at Baylor, Dr. Michaelsen employed a modified team-learning approach to demonstrate its powerful effects in promoting active participation among learners while covering desired content. His sessions had a great impact on the faculty participants, and several of these faculty proceeded to employ aspects of the team-learning approach in their own teaching. This impact expanded throughout the curriculum as deans and educators at Baylor became interested in employing team learning more widely, based on the positive initial experiences of the faculty who had field-tested it in their teaching. This report details one such field test in an effort to demonstrate the application and illustrate the potential positive effects of team learning in health sciences education.
Characteristics of Team Learning
In-depth descriptions of the team-learning method are available2,3; here, we describe the features of team learning that were salient to our field test. Team learning relies on the division of the class into heterogeneous groups of three to five students each. The teacher assigns groups to solve identical tasks and to simultaneously report their solutions. After each task, the teacher facilitates a discussion where groups defend their different solutions and the teacher articulates key teaching points.2 A critical component of team learning is the construction of the tasks themselves. Effective tasks stimulate higher-level cognitive skills (i.e., the student makes a value judgment based on a concept rather than just identifying the concept), require broad participation within groups to reach group consensus, and lead to competing plausible answers among groups.3 Such tasks foster a lively teacher-facilitated discussion by the entire class that requires groups to defend their answers. This constructive controversy results in greater subject learning, better conceptual structures, and more accurate retention.4
DESCRIPTION OF OUR PROGRAM
Session Content and Setting
In the fall of 2000, we (the present authors) chose to teach a session on effective use of diagnostic tests (part of the evidence-based medicine noontime lecture series for internal medicine residents) in our field test of team learning. We chose this session setting and content for two reasons. First, the noontime lecture series is a teaching forum familiar to most internal medicine residents, and, as the name implies, usually employs the lecture method, a predominately passive mode of learning. There are several common distractions during noontime lectures that include pressing patient-care concerns, eating lunch, and socializing. Since team learning is aligned toward producing active participation among learners, we wanted to observe its effects in a forum that typically achieves little participation.
The second reason we chose this session was for the content on effective ordering of diagnostic tests. Previous work has demonstrated that during the routine care of patients, physicians employ evidence-based practice principles infrequently.5,6 Our experience with residents supports these findings, in that we have observed residents to apply such principles infrequently in their work on the medical wards. We therefore wanted to observe the ability of team learning to promote favorable attitudes toward the utility of evidence-based practice with respect to selection of diagnostic tests, a topic that has direct application to residents' daily decisions in patient care.
Session Goals and Format
Our goals for the session on diagnostic tests included fostering learners' abilities to (1) define the concepts of sensitivity and specificity; (2) define the concepts of positive and negative predictive value; (3) describe the concept of prevalence and if/how it affects the above items; and (4) identify the usefulness of information that given tests provide in a particular situation. We designed the session to be one hour in length divided into three repeating cycles of group task-solving followed by simultaneous reporting of group answers and facilitated discussion among the entire class. A timeline for the session appears in Table 1. A pure team-learning approach would require advance reading/self-directed study by the learners with a readiness-assurance process at the beginning of the session. However, in an effort to eliminate the need for advance preparation by busy and often over-worked residents, we designed a one-page handout that was given to each learner at the beginning of the session. The handout contained the background information necessary to successfully complete the tasks (see Appendix A).
We designed our three group tasks to introduce and stimulate thinking about each of the four session goals. As an example, our first two tasks are described in Appendix B. In the first task (definition of sensitivity/specificity), items 2 and 3 required learners to understand the conceptual definitions of sensitivity and specificity and codify these in language and mathematical terms. Items 1 and 4 required learners to make value judgments based on their understanding of the definitions and defend those judgments to their group and subsequently to the class. In the second task, items 2 and 3 required the learners to understand definitions and apply these definitions to relationships between sensitivity/specificity, positive/negative predictive value, and prevalence. Items 1 and 4 had ambiguity built in to the sentence structure (“same thing” and “tell you whether or not the disease is there”) and required learners to clarify their understanding of the concepts in order to interpret the items. The complexity of items 2 and 3 and the introduction of learners' values and interpretations into items 1 and 4 in both tasks ensured the necessary ambiguity for fostering controversy during the class discussion. Using this controversy during the large-group discussion, the teacher (PH) was able to focus learners on the conceptual definitions of terms and make points about the utility of the concepts.
We conducted the same session at two teaching hospitals on successive dates with the same presenter (PH) and the lesson plan described above. We made qualitative observations based on our own past experience with the noontime lecture forum. In addition, we asked the residents to complete a survey immediately before and after each session about their attitudes toward the usefulness of sensitivity/specificity and positive/negative predictive value, using a two-item scale for each of these concepts. The post-survey asked each resident to complete an additional two-item scale to rate his or her level of engagement during the session. Individual items on all three scales had five response options in Likert style. For each scale, the total score was the sum of the responses for each item. All three scales demonstrated adequate internal consistency (Cronbach's alpha = 0.60 to 0.87).
Our qualitative observations were striking. In a typical noontime lecture at our institution, lunch is served at 12 o'clock, with residents filing into the lecture room gradually until approximately 12:15. This means that the actual session time is usually 45 minutes, instead of one hour. In the past, we have observed up to half of residents leaving the session when the lecturer ran longer than 1 PM. We hypothesized that the team-learning method would keep residents engaged, and therefore designed the session to test this hypothesis by starting at 12:15 and ending at 1:15. We wanted to observe whether residents would leave at 1 PM or, without prompting, continue to stay at the session. On both days, more than 95% of the residents stayed until the completion of the session. In addition, the teacher specifically observed the class during the session in an effort to identify learners who appeared to be disengaged or not “on-task.” No disengaged learner could be identified during either session. We also invited an independent observer trained in peer review of teaching to attend the second session and give open-ended feedback. Her comments corroborated the instructor's observations; with only one or two exceptions, learners' engagement was exceptionally high and “on-task.”
Results of the residents' surveys appear in Table 2. Pre- and post-survey differences in attitudes toward the utility of sensitivity and specificity or positive and negative predictive value revealed statistically significant and educationally meaningful increases in favorable attitudes toward both content areas. On the post-survey, the residents reported their interest and engagement as high (8.5 ± 1.6).
The high levels of learner engagement and significant effects on residents' attitudes that we observed in the study just described and in other teaching exercises at Baylor lead us to conclude that team learning may be a powerful pedagogic tool in medical education and warrants further study. We feel that the strength of team learning is twofold. First, the combination of small- and large-group dynamics allows the teacher to foster a high degree of interaction among learners while retaining control over session content and delivery. Second, the process of requiring small groups to work on a task and then defend their answers to other groups who have worked on the same task fosters ownership and enthusiasm for the lecture content among the learners. Since team learning is a method intended for large groups (teacher—student ratio higher than 1:7), the ability to foster active learning through small-group activities within the large-group setting makes it particularly attractive in the current atmosphere of diminishing faculty resources for teaching.
In teaching the paradigm of evidence-based medicine, team learning may complement other teaching strategies, such as evidence-based journal clubs and evidence-based morning reports.7,8,9,10 Our results suggest that team learning may help to strengthen the attitudinal and cognitive foundation upon which these teaching strategies are based.
Since our study represents only a field test of team learning, our results are limited by a non-random sample of learners, absence of a comparison group taught by traditional methods, and absence of long-term and performance-based outcome measures. However, we hope that our preliminary experiences at Baylor, including the results of this field test, will stimulate others to experiment with team learning in a variety of teaching venues and content areas in medical education. Educators at Baylor plan future controlled studies of the effectiveness of this approach in achieving long-term educational outcomes in the field of evidence-based medicine. Like problem-based learning, team learning may prove to be a teaching strategy that, if successfully implemented, can lead to effective undergraduate and graduate medical education using active learning strategies.
1. Michaelsen LK, Black RH. Building learning teams: the key to harnessing the power of small groups in higher education. In: Kadel S, Keeher J (eds). Collaborative Learning: A Sourcebook for Higher Education. Vol. 2. State College, PA: National Center for Teaching, Learning, and Assessment, 1994.
2. Michaelsen LK, Fink LD, Knight A. Designing effective group activities: lessons for classroom teaching and faculty development. In: DeZure D (ed). To Improve the Academy: Resources for Faculty, Instructional, and Organizational Development. Stillwater, OK: New Forums Press, 1997.
3. Michaelsen LK, Black RH, Fink LD. What every faculty developer needs to know about learning groups. In: DeZure D (ed). To Improve the Academy: Resources for Faculty, Instructional, and Organizational Development. Stillwater, OK: New Forums Press, 1997.
4. Johnson DW, Johnson RT, Smith KA. Constructive controversy. Change. 2000;32:29–37.
5. Tomlin Z, Humphrey C, Rogers S. General practitioners' perceptions of effective health care. BMJ. 1999;318:1532–5.
6. McAlister FA, Graham I, Karr GW, Laupacis A. Evidence-based medicine and the practicing clinician. J Gen Intern Med. 1999;14:236–42.
7. Elnicki DM, Halperin AK, Shockcor WT, Aronoff SC. Multidisciplinary evidence-based journal clubs: curriculum design and participants' reactions. Am J Med Sci. 1999;317:243–6.
8. Green ML. Evidence-based medicine training in internal medicine residency programs: a national survey. J Gen Intern Med. 2000;15:129–33.
9. Green ML, Ellis PJ. Impact of an evidence-based medicine curriculum based on adult learning theory. J Gen Intern Med. 1997;12:742–50.
APPENDIX A Handout Given to Learners at the Beginning of the Session
- Define and understand the concepts of sensitivity and specificity.
- Define and understand the concepts of positive and negative predictive value.
- Understand the concept of prevalence and if/how it affects the above items.
- Be able to have a feel for the usefulness of the information that a test gives in a particular situation.
Some definitions (in words)
- Sensitivity—“Out of all the people who have the disease, this is the proportion who test positive.”
- Specificity—“Out of all the people who don't have the disease, this is the proportion who test negative.”
- Positive predictive value—“Out of all the people who test positive, this is the proportion who actually have the disease.”
- Negative predictive value—“Out of all the people who test negative, this is the proportion who actually don't have the disease.”
Some definitions (not in words)
10. Reilly B, Lemon M. Evidence-based morning report: a popular new format in a large teaching hospital. Am J Med. 1997;103:419–26.