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Initiating small group learning in a Caribbean medical school

Learning environments complying with the cognitive architecture of learning, immersing learning within a meaningful context (contextualism), making learning an active process (constructivism) and promoting learning in groups (collaboration) are more powerful and effective [1]. Undergraduate medical students working and learning in small groups may fulfill many of these requirements. Small group learning has been shown to have a positive effect on a variety of medical competencies [2,3]. The small group offers a learning environment where students can develop their self-directed learning skills and get the opportunity to collaborate with other group members to achieve both individual and group learning goals [4]. A study found that the small group tutorial provided a conductive learning environment which influenced both the students’ personal development and socialization with faculty [4]. The authors proposed that the small group may be useful for integrating a diverse student population into a new academic environment. 
 
Xavier University School of Medicine (XUSOM) is an offshore Caribbean medical school in Aruba, Kingdom of the Netherlands admitting students from the United States (US), Canada and other countries to the undergraduate medical (MD) course. From January 2013 the school shifted to a partially integrated curriculum and from January 2014 to a fully integrated curriculum with all basic science subjects being learned together in an integrated organ system based manner [5]. Students visit a local general practitioner for early clinical exposure and problem-based learning sessions and other small group learning sessions are conducted. Developing self-directed learning (SDL) skills is becoming increasingly important for medical students. Applying the best principles of teaching adults to the education of medical students is important in the process of transforming learners to become and remain effective physicians [6]. 
 
At XUSOM didactic lectures were the predominant teaching-learning strategy under the previous discipline based curriculum. With the integrated curriculum and other changes there was an increased emphasis on SDL and small group work [7]. Students are introduced to small group work and working in a team right from the orientation program at the start of the first semester [8]. Students are introduced to the stages of group formation during an interactive session and interview their partner and introduce him/her to the house in an activity called ‘Meet the experts’. They also play a game titled ‘Crossing the river’. In the institution small group activities and group work are used during the PBL sessions, medical humanities module, medical ethics sessions, clinic visits, case presentations and sessions on critical appraisal of scientific literature (CASL). Four important roles in the group are emphasized during small group work. These are those of the team leader, recorder, presenter and time keeper. The groups are instructed to rotate these roles among members during various sessions. Each group consists of 6 to 8 members and the groups are kept constant through a semester. 
 
First semester students initially begin to work in small groups during the medical humanities sessions where they use case scenarios, presentations, paintings, role plays, and debates to explore different aspects of the medical humanities [9]. The PBL director conducts a familiarization session on PBL before the start of the PBL sessions around week eight of the first semester. The PBL cases are based on the organ system being covered during a particular period. Each group has a faculty facilitator. Usually the facilitator for a group is kept constant during a semester. Gradually the students are provided a greater degree of responsibility and the support provided by the facilitator during the PBL sessions is decreased. The facilitators, PBL director, and members of the curriculum committee are available for help and advice in case students have any problem. Student feedback regarding small group effectiveness during PBL sessions was studied using the small group effectiveness instrument and the findings were shared among all facilitators [10]. Student perception about small group effectiveness was positive. 
 
External experts interact with faculty periodically and have conducted sessions on group facilitation, evaluating students, providing feedback to students at the end of the PBL session and on writing good PBL cases. The author who has a fellowship in health professions education also conducts periodic sessions for faculty on facilitating small groups. During the PBL session facilitators assess students using a structured checklist. Application of knowledge base, clinical reasoning and decision making skills, self-directed learning, group work, attitude, and professionalism are among the different parameters assessed. At the end of the session the group conducts a self-reflection on the areas which went well and those which need improvement. The facilitator also provides the group with feedback regarding what went well and the areas needing improvement. From this semester we have initiated a process of peer-feedback where students provide constructive feedback to each other. 
 
During the CASL sessions the groups critically analyze a research publication. During the first and second semester the emphasis is on critically analyzing an original research paper, during the third semester the group critically analyzes a randomized clinical trial, while during the fourth and fifth semesters students conduct a critical review of meta-analyses and systematic reviews. Small group activities are also used during sessions on the personal or P-drug selection process in pharmacology. Students select a personal or P-drug for a disease condition using the criteria of efficacy, safety, cost and suitability, verify the suitability of their selected P-drug for a particular patient and write a prescription. They counsel a standardized patient (SP) regarding the use of the drug and management of the condition. 
 
During clinical case presentations students are provided with a list of common clinical conditions/diseases. Working in groups they develop a complete presentation (case) of the particular disease. Signs, symptoms, clinical features, laboratory and other investigations and management of the condition are developed by the groups. They then present the case to other groups of students and the facilitators. The facilitators provide critical inputs on the case developed by the group. During visits to the local general practitioner students in groups obtain a history from patients during the first semester and learn basic physical examination skills during the third. As class sizes in the institution are small certain faculty members also use small group activities during interactive lecture sessions. 
 
Flip charts, flip boards, white boards and power point projectors are used by the groups during their presentations. Feedback obtained from students during informal interactions has been positive. Students are slowly feeling comfortable with taking increasing responsibility for their own learning. Faculty have also been familiarized with facilitation skills and concentrating more on the process of small group work and small group dynamics and not acting like content experts during the sessions. 
 
Small group sessions have placed increased demands on faculty time and also necessitated creating separate rooms/facilities for small group work. A separate room with whiteboards, flip boards, flip charts and flexible seating was created. The classrooms have chairs with attached writing surfaces which can be easily rearranged to form small groups. 
 
Initiating small group, activity-based learning in a medical school where didactic lectures were the predominant teaching-learning methodology can be challenging. Small group learning requires a change in the role of the teacher from a content expert to a facilitator of student learning. As the school has a greater number of younger faculties initiating small group learning may have been easier. Students though they had initial reservations were more receptive to small group learning after the process and its advantages were explained to and became evident to them. As the school offers only an undergraduate medical program collaborative group work with other healthcare professionals is difficult to offer to the students. There have however, been occasions where other health practitioners have visited the school and conducted learning sessions for students and faculty which have offered opportunities of inter-professional education. We have had occasional problems with group dynamics in certain small groups. Sometimes group members felt a particular student was not contributing enough to the group deliberations and activities. We instruct the groups to try to resolve the differences on their own and if not possible to obtain help from the faculty facilitator and PBL director. 
 
We plan to conduct more sessions for faculty on facilitation skills, and providing feedback. We are planning to continue with different small group activities for students. We plan to further strengthen the process of self-reflection and peer-feedback during small group sessions.

Learning environments complying with the cognitive architecture of learning, immersing learning within a meaningful context (contextualism), making learning an active process (constructivism) and promoting learning in groups (collaboration) are more powerful and effective [1]. Undergraduate medical students working and learning in small groups may fulfill many of these requirements. Small group learning has been shown to have a positive effect on a variety of medical competencies [2,3]. The small group offers a learning environment where students can develop their self-directed learning skills and get the opportunity to collaborate with other group members to achieve both individual and group learning goals [4]. A study found that the small group tutorial provided a conductive learning environment which influenced both the students' personal development and socialization with faculty [4]. The authors proposed that the small group may be useful for integrating a diverse student population into a new academic environment.
Xavier University School of Medicine (XUSOM) is an offshore Caribbean medical school in Aruba, Kingdom of the Netherlands admitting students from the United States (US), Canada and other countries to the undergraduate medical (MD) course. From January 2013 the school shifted to a partially integrated curriculum and from January 2014 to a fully integrated curriculum with all basic science subjects being learned together in an integrated organ system based manner [5]. Students visit a local general practitioner for early clinical exposure and problem-based learning sessions and other small group learning sessions are conducted. Developing self-directed learning (SDL) skills is becoming increasingly important for medical students. Applying the best principles of teaching adults to the education of medical students is important in the process of transforming learners to become and remain effective physicians [6].
At XUSOM didactic lectures were the predominant teaching-learning strategy under the previous discipline based curriculum. With the integrated curriculum and other changes there was an increased emphasis on SDL and small group work [7]. Students are introduced to small group work and working in a team right from the orientation program at the start of the first semester [8]. Students are introduced to the stages of group formation during an interactive session and interview their partner and introduce him/her to the house in an activity called 'Meet the experts' . They also play a game titled 'Crossing the river' . In the institution small group activities and group work are used during the PBL sessions, medical humanities module, medical ethics sessions, clinic visits, case presentations and sessions on critical appraisal of scientific literature (CASL). Four important roles in the group are emphasized during small group work. These are those of the team leader, recorder, presenter and time keeper. The groups are instructed to rotate these roles among members during various sessions. Each group consists of 6 to 8 members and the groups are kept constant through a semester.
First semester students initially begin to work in small groups during the medical humanities sessions where they use case scenarios, presentations, paintings, role plays, and debates to explore different aspects of the medical humanities [9]. The PBL director conducts a familiarization session on PBL before the start of the PBL sessions around week eight of the first semester. The PBL cases are based on the organ system being covered during a particular period. Each group has a faculty facilitator. Usually the facilitator for a group is kept constant during a semester. Gradually the students are provided a greater degree of responsibility and the support provided by the facilitator during the PBL sessions is decreased. The facilitators, PBL director, and members of the curriculum committee are http://jeehp.org available for help and advice in case students have any problem. Student feedback regarding small group effectiveness during PBL sessions was studied using the small group effectiveness instrument and the findings were shared among all facilitators [10]. Student perception about small group effectiveness was positive.
External experts interact with faculty periodically and have conducted sessions on group facilitation, evaluating students, providing feedback to students at the end of the PBL session and on writing good PBL cases. The author who has a fellowship in health professions education also conducts periodic sessions for faculty on facilitating small groups. During the PBL session facilitators assess students using a structured checklist. Application of knowledge base, clinical reasoning and decision making skills, self-directed learning, group work, attitude, and professionalism are among the different parameters assessed. At the end of the session the group conducts a selfreflection on the areas which went well and those which need improvement. The facilitator also provides the group with feedback regarding what went well and the areas needing improvement. From this semester we have initiated a process of peerfeedback where students provide constructive feedback to each other.
During the CASL sessions the groups critically analyze a research publication. During the first and second semester the emphasis is on critically analyzing an original research paper, during the third semester the group critically analyzes a randomized clinical trial, while during the fourth and fifth semesters students conduct a critical review of meta-analyses and systematic reviews. Small group activities are also used during sessions on the personal or P-drug selection process in pharmacology. Students select a personal or P-drug for a disease condition using the criteria of efficacy, safety, cost and suitability, verify the suitability of their selected P-drug for a particular patient and write a prescription. They counsel a standardized patient (SP) regarding the use of the drug and management of the condition.
During clinical case presentations students are provided with a list of common clinical conditions/diseases. Working in groups they develop a complete presentation (case) of the particular disease. Signs, symptoms, clinical features, laboratory and other investigations and management of the condition are developed by the groups. They then present the case to other groups of students and the facilitators. The facilitators provide critical inputs on the case developed by the group. During visits to the local general practitioner students in groups obtain a history from patients during the first semester and learn basic physical examination skills during the third. As class sizes in the institution are small certain faculty members also use small group activities during interactive lecture sessions.
Flip charts, flip boards, white boards and power point projectors are used by the groups during their presentations. Feedback obtained from students during informal interactions has been positive. Students are slowly feeling comfortable with taking increasing responsibility for their own learning. Faculty have also been familiarized with facilitation skills and concentrating more on the process of small group work and small group dynamics and not acting like content experts during the sessions.
Small group sessions have placed increased demands on faculty time and also necessitated creating separate rooms/facilities for small group work. A separate room with whiteboards, flip boards, flip charts and flexible seating was created. The classrooms have chairs with attached writing surfaces which can be easily rearranged to form small groups.
Initiating small group, activity-based learning in a medical school where didactic lectures were the predominant teaching-learning methodology can be challenging. Small group learning requires a change in the role of the teacher from a content expert to a facilitator of student learning. As the school has a greater number of younger faculties initiating small group learning may have been easier. Students though they had initial reservations were more receptive to small group learning after the process and its advantages were explained to and became evident to them. As the school offers only an undergraduate medical program collaborative group work with other healthcare professionals is difficult to offer to the students. There have however, been occasions where other health practitioners have visited the school and conducted learning sessions for students and faculty which have offered opportunities of inter-professional education. We have had occasional problems with group dynamics in certain small groups. Sometimes group members felt a particular student was not contributing enough to the group deliberations and activities. We instruct the groups to try to resolve the differences on their own and if not possible to obtain help from the faculty facilitator and PBL director.
We plan to conduct more sessions for faculty on facilitation skills, and providing feedback. We are planning to continue with different small group activities for students. We plan to further strengthen the process of self-reflection and peer-feedback during small group sessions. ORCID: P. Ravi Shankar: http://orcid.org/0000-0001-6105-5636

CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.