Tag Archives: small groups

Teaching Multimorbidity – part one

About a week ago I read an interesting article in the August Journal of Comorbidity entitled: Training doctors to manage patients with multimorbidity: a systematic review http://jcomorbidity.com/index.php/test/article/view/87/308 Only two studies satisfied their criteria for inclusion and these were about Multimorbidity workshops.  One of the studies appeared to favour workshops over online modules but both studies were judged to be at risk of bias because of methodology so it is hard to draw conclusions apart from that more research is needed (noting the paucity of research in this area generally).  It is certainly challenging to conduct research and evaluation in this post-graduate context.

Multimorbidity is a clinical area of interest for me and one where I introduced teaching for GP registrars a while ago so I was motivated to look at this again. I thought that this blog should not just raise topics in medical education but could also introduce some ideas about teaching specific clinical topics given that different methods may be more appropriate to different disciplines. The issue of the teaching of the topic has emerged following the increasing recognition of multimorbidity as a growing challenge for the health care system, not to mention its funding.   At some point clinicians and educators started to realise that multimorbidity was more than the sum of its parts and this is very relevant in an era of sub-specialisation. Some educators are also concerned that GP registrars do not have adequate experience managing complex older patients so in 2014 I decided to trial and evaluate a specific teaching approach.  In the process we also looked at registrars’ clinical experience plus feedback from them and from supervisors about what is actually perceived as useful in GP training in this area.  We collected the usual routine feedback and evaluation data that you tend to collect as part of a commitment to quality improvement and augmented this with some specific questions about how the approach worked (because it was different).

In this, and a couple of other posts, I’ll look at

  1. A framework for a workshop program
  2. GP registrars and multimorbidity
  3. Practice teaching ideas and multimorbidity teaching overall

A framework for a workshop session


Given the pessimism around both managing and teaching multimorbidity, and my conviction that the negatives are somewhat overplayed, we took an optimistic and evidence-based approach which built on the co-morbidities already well-covered in training (eg hypertension, diabetes, hyperlipidaemia, chronic renal disease, COPD etc). We treated guidelines as a resource for clinical judgment but emphasised the primacy of being patient-centred.  This is overt in the guidelines from the American Geriatric Society https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4450364/  and is even more appropriate in general practice.  The structure was as follows:

  • We followed a Flipped Classroom model with pre-viewing of some online resources (links, powerpoints) on a blog site which had been set up previously for aged care, polypharmacy and multimorbidity. This introduced the concepts to registrars. It could also be accessed at any time after the session.
  • A conceptual matrix for thinking about Multimorbidity was presented briefly at the workshop http://www.bcregan.com/MM/ In later sessions this was presented just as a few powerpoint slides.
  • A specifically designed multimorbidity template (updated more recently) for management planning was used in small groups in order to work through registrar cases and / or pre-prepared cases.
  • Registrars completed feedback forms in order to evaluate the process and the usual feedback on achievement of Learning Objectives was completed.

The “matrix” model was presented at an AMEE conference in 2014. http://www.amee.org/getattachment/Conferences/AMEE-2014/AMEE-2014-APP-Data/10H-SHORT-COMMUNICATIONS.pdf It was used as a conceptual framework for thinking and learning rather than as a clinical tool and was an attempt at a 2D version of the multi-dimensional thinking and multi-tasking that goes on when managing patients with multimorbidity.  It was a reminder to think about:

  • The interactions between conditions, between medications and between conditions and medications
  • The knowledge gaps that might exist for the doctor
  • The relevant guidelines
  • Patient information resources
  • The patient perspective in negotiating management decisions (the most important aspect)

flowers3  flower-border villandry2

The matrix gave contrasting examples of “easy” and “complex” patients with five co-morbidities. In some ways it was an attempt to simplify complexity – but not too much – and add a conceptual framework to something that can appear random or chaotic.


These were reported on at the GPTEC conference in Hobart in 2015 Teaching multimorbidity is important, do-able and effective and requires a multi-pronged approach. multimorbidity-gptec-aug-2015

The feedback was positive. The small-group discussion was judged to be valuable and pre-prepared cases were the most useful.  The most surprising incidental outcome was that subsequent Learning Plans were noted to include several which (unusually) listed managing multimorbidity as a priority!

In this first twelve months the multimorbidity session was run separately for both Term 1 and Term 3 registrars.

    • 75% Term 1 and 50% Term 3 accessed the online resources prior to the session
  • Interestingly the overall package was evaluated more highly by Term 3 (an average rating of 4.7, on a scale of 1-5, in agreeing to the statement that The session (online resources, ppt and small gps) presented a potentially useful way of looking at patients with multimorbidity 
    • Learning objectives were evaluated after the sessions and, again, Term 3 were more likely to agree strongly that these were achieved (ratings of 4.1 to 4.6)
    • Both groups found the small groups helpful
    • Free text comments showed that the “patient-doctor agenda” focus had been appreciated and some new concepts were found to be useful.
    • Comments and ratings raised the issue of timing – whether the most effective learning in such a complex area occurs rather later in training after gaining some clinical exposure (and despite the fact that they were less likely to access the online resources prior to the session). This would be a good topic for future research. However, funding is focussed on Terms 1 and 2.

Given that most learning occurs in the practice environment we then turned our attention to that aspect. Meanwhile we continued evaluating the approach over the twelve months and monitored the registrars’ confidence levels.  We thought this was important because a lack of confidence is probably the first barrier that hinders initial engagement with the area.  Once registrars are engaged, and if not feeling too intimidated, we reasoned that they would identify learning needs and respond to them.  In addition, it is not a simple area in which to assess “knowledge”, and “effective management” is extremely difficult to measure.

Small groups

I am fresh from a week of watching comedy shows at the Edinburgh Fringe and it made me think of my earlier post about successful presentations to larger groups and how some of this “success” relates to being a performer, even though the size of some of the Fringe venues were about the size of my bedroom and had space for a large small group only!  Certainly the comics were very well prepared – down to the smallest “ad lib” – but these sessions also highlighted to me the differences between speaking to groups and “facilitating” a group (both in purpose and aims).

If you explore the literature you will find that much of it refers specifically to Problem Based Learning (which I experienced as a medical student) and which has quite specific criteria for how groups function.  Despite the many years of PBL, studies on outcomes are still variable which demonstrates how difficult educational research is.  On the other hand, financial stringencies are moving some schools back to lectures, larger small groups or onto online options.  Given this, it would be good to know what we might be losing.

In immediate evaluations registrars in vocational training often rate small groups highly but this may also be because of the added value of interpersonal contact, debriefing, support and so forth, in addition to educational “effectiveness”.

Groups can serve many purposes

They aren’t generally for delivering information but they can function as tutorial groups following on from lectures (undergraduate model) but in post grad training they often function as a framework for case discussion, topic exploration or debriefing. They can be part of Flipped Classroom models. The dynamics of a small group can be used to enhance educational value.  As an educational method, the small group requires more listening and drawing out and sometimes it requires ad hoc changes in direction in response to group needs.  A small group may have a joint purpose and be more than the sum of its individual parts. The facilitator assists the group to achieve their purpose and often feels more responsibility for the development of each member of the group. In addition to the acquiring of information, there is a package of benefits – don’t underestimate the power of social interaction.

group chairs

How hard is it to run a good small group?

Some institutions seem to mistakenly believe that being a health professional automatically qualifies you to run groups but skills are required.  I have to confess that when I trained initially as a social worker, I opted for “casework” over “groupwork” as I much preferred the one-to-one interaction and that probably remains true.  However, that is in a therapeutic rather than educational context and small groups do appear to be powerful tools in medical education.  I find it a pleasure to observe educators with skills (natural or acquired) facilitating groups in a more effective way than I know I do myself.  Registrar comments easily identify what not to do when running a small group – be condescending, fail to contain domineering members, appear unprepared.  I have run groups at all levels and the good thing about registrar groups is that they are very motivated (although sometimes more critical) and generally have good background knowledge. You are often consolidating and applying knowledge rather than just passing it on.

What works best? 

Groups are easier if the members are known to you, as has often been the case in my experience.  It is more difficult if you are parachuted into a workshop situation and told to “facilitate” a random group. This is not really best practice.  Numbers are important and most of the literature agrees on somewhere between five and ten – with minimal hard evidence. Facilitator or not?  This depends very much on the topic and the level of experience of the members.   Registrars often like an educator to be there as a resource but if this is not possible then it is a good idea to have a clear structure for the discussion

Hints for running a small group

  • Set ground rules if need be (and the goals of the group discussion to avoid disappointed expectations)
  • Assign roles to encourage engagement (scribe, timekeeper, facilitator, resource finder)
  • Have a good structure with appropriate resources on hand
  • Utilise member skills if you know the background of your group members eg If you have a reproductive medicine topic defer to someone who has just done a year in obstetrics
  • You can use some similar methods to larger groups (ice breaker, split into pairs)
  • You can’t be an expert on everything and members should be thinking for themselves, so feed questions back to the group
  • Involve everyone. Look out for quiet members and use strategies to quieten the overly noisy contributors.  Have some prepared questions to direct to individuals.
  • If you utilise more senior learners to facilitate groups they need to feel they are also learning and not just being used.

waterfallSmall groups can have many side benefits.  They enable you to get to know students better, to flag those who are struggling in various ways and to encourage further specific learning.  However, these are often seen as intangible benefits when institutions consider the cost efficiency of various methods. It is a meaningful challenge to think how you might evaluate different educational methods.

Practice Based Small Group Learning (PBSGL)

I thought it worth mentioning this interesting approach which has been used for many years in Canada for continued professional development.  It has subsequently been adapted for use in the UK (and particularly Scotland).  It is an interesting way of organising nationwide CPD with some uniformity of topic and approach although it does involve fees.  It has also been implemented in GP Training in Scotland and I was able to sit in with one of these small registrar groups in Aberdeen a few years ago after prior discussions on email with the organisers.  It is obviously a relatively economical approach and I would think it would be very appropriate for more senior registrars.  It provides structured cases and resources on pre-determined topics.  If you are interested have a look at http://careers.bmj.com/careers/advice/view-article.html?id=20000765

I would love to see the Colleges consider this for CPD.