EDUCATION

New York American College of Emergency Physicians

Devjani Das, MD FACEP

Director, Emergency Medicine Clerkship Director, Emergency Ultrasound Division Associate Professor of Emergency Medicine Columbia University Vagelos College of Physicians and Surgeons

Guest Author Duncan Grossman, DO

Assistant Professor and Assistant Program Director Department of Emergency Medicine Icahn School of Medicine at Mount Sinai

Guest Author Isley Arruda, MD

Chief Resident Department of Emergency Medicine Icahn School of Medicine at Mount Sinai

Guest Author Tim Friedmann, MD

Medical Education Fellow Department of Emergency Medicine Icahn School of Medicine at Mount Sinai

Guest Author Geoff Jara-Almonte, MD

Assistant Professor and Associate Program Director Department of Emergency Medicine Icahn School of Medicine at Mount Sinai

Big Ideas for Small Group Learning

Small group learning offers up a fantastic opportunity to diversify weekly residency conference, creating a safe space for learners to ask questions, facilitate near-peer teaching, and focus on procedural skills with individualized attention. Beyond breaking the monotony of traditional didactics, these sessions provide the added benefit of fostering community in our large residency. In a post-Covid and post-Zoom learning era, these activities have become crucial, offering multiple learning modalities, and turning residents into active participants, rather than passive listeners.

General Principles and Recommendations: Size, Split, & Prompting

The size of your small group will depend on the learning experience you envision. If you are aiming to do a lecture, or a panel with Q&A, the success of these groups depends on the delivery of the material and, therefore, the number of learners is less relevant. If you are planning on team-based activities or problem-based learning, where near-peer learning and participation are emphasized, aim for five to seven learners per group. Procedural sessions may need smaller groups or more instructors, to optimize the teacher-to-student ratio and facilitate real-time feedback and guidance.

When designing a small group session, consider how to split your learners. Random assignment can mitigate bias. This can be done by assigning numbers to learners or grouping people by birthdays / alphabetically (either by the learners or online with ChatGPT, Bard, or other available online tools). This may lump learners of different levels together, which can make creating cohesive learning points a challenge. Pre-assigning groups allows you to group learners with similar qualities – interests, life experiences, levels of training, etc. This can take significant time, thought, effort and unexpected learner absences can disrupt the experience. Random assignment within a similar group of learners (i.e. dividing junior residents by birthday month) is a good middle ground between the two techniques.

For case or problem-based learning, the emphasis should be on valuable group discussion, rather than closed-ended questions or simple recall of medical knowledge. For example, “What are the treatment options for angioedema?” is a less helpful small group prompt than, “Do you give all patients with angioedema every medication?”, “When do you pull the trigger for admission versus observing?” These activities can benefit from pre-readings and a flipped classroom model. Depending on the learning goals and objectives for a given session, different debriefing and feedback methodologies can be utilized; consider incorporating approaches such as Plus-Delta, Pendleton’s model, or Advocacy-Inquiry.

Varied Approaches to Small Group Learning

Below is a description of several options for small group learning sessions that we have found successful in our four-year residency program consisting of 100 trainees.

Gamification of Cases

Conventional oral boards cases serve as good practice for reviewing the structure and flow of board exams, but do not cater to all styles of learner or efficient transfer of content . We recognize that it was recently announced that oral boards are being phased out. Nonetheless, to facilitate discussion and peer-based education, we opted for a format inspired by “Who Wants to Be a Millionaire,” facilitated by faculty educators.

Before the small group session, facilitators went through the cases and wrote medical knowledge questions.

In our version, each small group had two teams, junior residents versus senior residents, and each team was given a case. The senior residents went first and as we progressed through the case, each member of the team was given a question. Each team had three lifelines:

Phone an Attending – You can call one attending of your choosing and ask them the question. If they don’t pick up, that’s tough cookies.
One Minute Internet Consult – You have 60 seconds to use one team member’s phone to look up any information and answer the question.
Ask the Audience – Open up the question to anyone on your team. Both teams benefited from hearing each other go through answers in a small, low-stakes environment.

Procedural Small Groups

We have also incorporated procedural teaching into conference, outside of our regularly scheduled simulation curriculum. Rather than elaborate, time-intensive high-fidelity simulation scenarios, we’ve found success in teaching shorter, discrete procedural skills with task trainers.

Shorter sessions have included lateral canthotomy tupperware models, LMA use on airway mannequins and homemade resuscitative hysterotomy task trainers. These sessions were essentially tabletop discussions of the procedure with indications, contraindications, discussion of the pearls and pitfalls and then participation in the procedure with one-on-one coaching by a facilitator

Our most resource-intensive session was a day devoted to nerve blocks. Each station had two ultrasounds, one for live anatomy scans and one for procedural practice. Residents practiced nerve blocks on custom made gelatin models wrapped around pork and skeleton models with individualized assistance from ultrasound-trained faculty members.

Ask me Anything

A key component of resident training is understanding practice variation amongst attending physicians and applying that knowledge to develop an individual practice pattern. To address the nuances of practice variability in particular clinical scenarios, we have organized panels featuring several attendings. In these panel discussions, we offer a chief complaint, case, and/or diagnosis and attendings provide insight into their practice. We aim to cover both common and rare presentations, as well as areas where the literature isn’t clear. We’ve had success using practice panels as small group sessions (juniors vs. seniors, etc.) and larger group formats. We have done practice panels on PEA arrest, right lower quadrant pain in young females, airway management in CHF, hip fractures, angioedema and pediatric neurologic complaints.

Leading up to the panel session, residents are asked to suggest questions or subtopics to discuss. Each practice panel has a facilitator who collates questions and prompts discussion among panelists. For example, our PEA arrest panel covered approximately 15 prompts; these ranged from “What prompts you to give calcium and/or bicarbonate during cardiac arrest?“ to “Evidence shows bringing family into the room at the end of the code can improve closure for the family. Do you incorporate this into your practice and, if so, how?”

We have found that these sessions have been well received by residents across levels of training, but in particular, senior residents have found these sessions very helpful. This also serves as an opportunity for a resident to participate as a panel facilitator; we have had interns, chief residents, and attendings be the panel facilitator.

Ask me Anything

We’ve held “Ask Me Anything” (AMA) sessions in small groups for topics that residents tend to have broad questions about. We have offered critical care and pediatric emergency medicine (PEM) AMAs with faculty experts. These sessions are based on the popular Reddit threads (where users describe themselves or an experience and other users get to ask them questions) and serve as an opportunity to ask burning questions. The AMAs are especially helpful to senior residents seeking to solidify their practice and address any knowledge gaps they may have. We allow questions to be asked before and during the session.

Team-Based Activities

We’ve incorporated several small group activities during which residents compete or work in teams with the primary aims of enhancing teamwork, building community and catering to different learning styles. Whether groups are competing to fill out a “bingo” card of common airway skills, racing to save as many toxidrome patients as possible, or working through an oral boards case, these activities get residents out of their seats and working together. Teamwork is the bedrock of emergency medicine, and it’s just as important to practice those skills off-shift as it is in the emergency department (ED). These activities often require assignment of roles, division of responsibility and group decision-making – all skills vital to the proficient ED physician, but seldom formally taught.

One example is our “airway bingo” session that required each team to select a single participant to complete each airway-centric task (laryngeal mask airway, bag valve mask, fiberoptic intubation, direct laryngoscopy, video laryngoscopy, surgical airway, blood gas interpretation, adjustment of ventilator settings) and then explain the management and common pitfalls with faculty guidance, promoting mutual learning.

Our toxicology station game rotated teams through stations focused on individual high-risk/low-frequency presentations of toxicology patients. Teams worked to answer diagnostic and management questions with visual cues (monitor photos, documented skin changes, rubber snakes, EKGs), deciding on a “final answer” as a group and accumulating points if correct. To integrate faculty guidance and support, toxicology trained emergency medicine (EM) attendings were available throughout as an ‘ask an attending’ feature of the game.

Acknowledging oral boards as both an assessment and educational tool, we conduct team-based cases that empower residents to voice their thought processes and facilitate learning amongst peers. These sessions foster learning on multiple levels, with junior residents recalling basic concepts, while senior learners articulate the application of these concepts and justify the team’s management decisions. Such cases offer an opportunity for learners to articulate and share their thinking while enriching the collective understanding of various case scenarios, a luxury often constrained in the fast-paced high-volume ED setting.

Problem-Based Learning

Problem-based learning activities serve as a basis for lifelong learning by reinforcing the habit of going to the literature to answer clinical questions – even in stressful circumstances. Those situations that require emergency physicians to rapidly access, synthesize and apply medical literature on shift are usually high-anxiety moments involving the care of unfamiliar conditions or unstable patients. Problem-based learning activities provide a unique opportunity to prepare learners for this challenge by utilizing the principle of “train like you fight.” By structuring activities as a competition or race and adding additional distractions such as music, instructors can recreate the time pressures and chaotic nature of the ED in the classroom. At the same time, care must be taken to ensure psychological safety of learners and an emphasis on fun and appropriate challenge goes a long way toward success in your activity.

Small group activities can incorporate a problem-based learning approach in which participants are provided with a clinical scenario or problem that they must “solve.” These sessions simulate the nuances of real-world clinical practice in which care must be individualized to a particular patient or unfamiliar conditions. Participants are asked to engage with resources such as primary literature, review articles and practice guidelines to determine the best course of action in each case and provide supporting evidence. These activities put residents in the habit of considering individualized, patient-centered care approaches to their patients’ treatment plans and brings up discussion and near-peer education regarding utilization of the resources we have available in our hospitals, sometimes even spanning interdisciplinary involvement (i.e. Pulmonary Embolism Response Team, Toxicology on-call, ED Pharmacy, etc.).

Examples of problem-based learning activities we have conducted include a pulmonary embolism management exercise. In this session participants were provided challenging clinical scenarios (semi-stable patient with clot-in-transit, high-risk submassive PE in a pregnant patient) and asked to define strategies for safe anticoagulation and/or thrombolysis based upon evidence and practice guidelines. In another activity participants were provided with vignettes of patients who were suffering toxicologic emergencies and asked to identify the toxidrome and then write the exact order for the appropriate antidote.

These sessions can be tailored to emphasize one or several domains of competence – including practice-based learning and improvement, medical knowledge, interpersonal and communications skills and patient care – depending on the goals of the instructor. Asking learners to engage with primary literature, assessing both its quality and the generalizability to the scenario at hand reinforces evidence-based practice.

Conclusion

Small group activities provide a way to develop and reinforce knowledge and skills critical for the emergency provider. They can promote teamwork between residents, promote connection between faculty and trainees and provide a safe space to ask questions and practice skills. The success of any individual session depends on matching learning goals with the appropriate participants’ breakdown, instructors, resources, instructional modality and content. It has been our experience that adding small group instruction has the potential to enhance the teaching of virtually any topic. The variety of available approaches rewards creativity and some degree of risk-taking in designing sessions. Sometimes things don’t work as expected, and occasionally things flop. Seeking feedback from participants and modeling a growth-mindset will allow educators to continue to develop.

References

van Diggele C, Burgess A, Mellis C. Planning, preparing and structuring a small group teaching session. BMC medical education. 2020;20(Suppl 2):462-462. doi:10.1186/s12909-020-02281-4
Rudolph JW, Simon R, Dufresne RL, Raemer DB. Thereʼs No Such Thing as “Nonjudgmental” Debriefing: A Theory and Method for Debriefing with Good Judgment. Simulation in healthcar : Journal of the Society for Medical Simulation. 2006;1(1):49-55. doi:10.1097/01266021- 200600110-00006
Taylor D, Miflin B. Problem-based learning: where are we now? Medical teacher. 2008;30(8):742-. doi:10.1080/01421590802217199
Wood DF. Problem based learning. BMJ. 2003;326(7384):328-330. doi:10.1136/bmj.326.7384.328