Teachable Moments in Problem-Based Learning: Why am I Paying Tuition to be Taught By My Classmates?

by Christopher Cimino, MD, FACMI, VP of Medical Academics, Kaplan Medical | June 17, 2021
Kaplan Medical Educators

Learning is an instinct we see in mammals, reptiles, fish, birds, and invertebrates. It is safe to say that if learning wasn’t instinctive, a species would quickly become extinct. People like to think humans are different, of course. There have been a variety of formulas devised to separate humans from other animals, such as: Only humans use tools. FALSE. Only humans use language. FALSE. The cautious philosopher will propose a definition that will be difficult to prove wrong: Only humans think about thinking or plan how best to learn. But there is a danger with such a rule. Ask the person on the street and they might give the response, “I never think about that.” 

Many humans resist the idea of planning on how best to learn. As adults, we have accomplished a lot to get past high school and college. It is fair to say anyone who has been accepted to medical school has a lot of experience with “how to learn,” but perhaps not much training on the best ways to learn. How much of their learning was based on instinct and how much based on formal instruction? 

Early on, we were told to write out and repeat the alphabet until we had not only memorized it, but could print each character in a legible manner. Later, when we learned cursive writing, we probably didn’t need to be told to use this same approach, although the required worksheets made it obvious we needed to. Someone might hopefully have taught us how to track and cite references when writing a paper. Some of us may have naturally developed a narrative style to create well-formed paragraphs that connected into a path from premise to conclusion. Or, we might have been taught through a few well-critiqued drafts. As the required amount of content mastery increased, we likely noticed others using highlighters to help focus on the most important content. Each of these steps seems like such a small thing that it barely counts as “learning to learn.”

The Work of Learning

It can feel insulting to adult learners to be told they need a different approach for their learning. Almost as bad is hearing that they will need to, “put some effort into their learning.” That starts to sound like “work.” Learning a large collection of content naturally takes more time, but why should learning a new method of learning require so much effort? It never did before. This is especially true if the new method is going to slow things down just as the amount of learning to be done is mounting. It feels like two steps backward. 

We are familiar with learning knowledge and learning skills, but for most of our childhoods, the learning context is distinct. We learn skills in sports and physical activities. We learn knowledge in a classroom or from books and media. Even when expertise requires a mix of knowledge and skills, one or the other is dominant. The knowledge needed to play the violin is fairly concise, but the skill to play requires many hours. The skill to organize information into a review or report is fairly limited, but the amount of knowledge to make a comprehensive report can be extensive. As we move into more advanced and esoteric endeavors, the need for both skill and knowledge working in concert increases. Making a violin requires both. Creating a captivating narrative requires both. Practicing medicine requires both.

Sadly, performance evaluations often value knowledge over skills or attitudes because it is easier to measure. When I was a student, and early in my career as a faculty member, there was obvious resistance to time spent “learning to interview” or about “healthcare inequalities.” Students appreciated the activity because it felt more like becoming a doctor than hours spent reading and studying, but they also resented the amount of time spent when test scores were how their performance was being measured. Surely they could develop their “skill” with practice in the future when it was more relevant and use the time now to enhance their measured performance. A side effect is that skills and attitude acquisition are perceived as “easy.” 

A multiple-choice test about patient interviewing seems almost laughable. The necessary knowledge is not difficult to obtain and parrot back. Assessing skills is often more time intensive. To a large extent, USMLE Step 2 Clinical Skills and COMLEX-USA Level 2 Performance Evaluation raised the stakes and the attention of students in a way that nothing else did. Even then, it was a struggle, and students would frequently overestimate their abilities. The most confident students seemed to be more prone to unexpected failures. Students looking for an easy path would seek out the “diagnoses,” not realizing that information gathering is improved when you have an open mind. The relevance of clinical skills and healthcare inequalities becomes more apparent when the students are embedded in the clinical environment and either fail themselves or see the system failing. 

Resistance to Change

Imagine telling someone the next 1,000 hours of their learning time will be devoted to making them an “expert learner”. Those 12 to 25 weeks would seem pretty pointless to most people unless there was a really convincing curriculum. Fortunately, the grist of such intensive skills training can be learning something else at the same time. So, a curriculum that includes both study skills training, biochemistry, physiology, and other “hard science” topics might be more easily justified being given those number of hours. Such a curriculum might be very teacher intensive but it would set students up to be more independent learners. The faculty time investment at the beginning would free up time later. Often though, courses are front-loaded with content-heavy lectures which optimizes the ratio of faculty to knowledge presentation. The main lesson students learn is they can be more efficient at acquiring content by skipping lectures. 

The trend away from large group lecturing is helpful in this regard and acknowledges the fact that the students who are not showing up need something else. However, 3 factors contribute to the resistance to change:

  • The more memorization is what is measured, the more self-study will be prioritized
  • If the students are overwhelmed with content, there is no safe space to slow down and adopt new practices before getting up to speed
  • Finally, the attitude that “learning is instinctive” prevents students from seeing how practice at studying and learning can benefit them overall. 

Nowhere is this resistance clearer than in the realm of small group learning and self-study. The first time students experience this, they are bringing a variety of prior instincts and expecting to work as a team seamlessly. It can make sitting quietly and doing the work by oneself seem attractive. 

Teachable Moments in Learning the Process of Learning

There are some obvious counter-arguments to try and break down this resistance. Medicine is meant to be a team sport. Learning to work together is a necessary “skill”. However, clear evidence, generated and communicated by students, that small group learning accelerates learning or “deepens” learning is hard to quantify. Certainly, there is evidence that student satisfaction with well-facilitated sessions is greater than large group lecturing. When the primary blocker is a mismatched attitude, logical reasons will not work as well as immersion in the environment. 

Immersive learning can be enhanced by teachable moments. Learning to identify and seize those moments works well in the clinical environment. The same is true in small group sessions. My experience with Case-Based Learning (CBL) at Einstein College of Medicine suggests there are a number of predictable events. In Kaplan’s work providing facilitated sessions for Rutgers New Jersey Medical School, not only do these moments occur but they can be engineered to occur and become teachable moments.

Teachable Moments #1: Reasoning Without an Oracle

One predictable moment is when a student raises a question and all the participants look at the facilitator expecting an answer. It is at that moment that the facilitator can drive home the point their job is to guide the group and not answer questions. One option is to remain silent. It is an interesting exercise for facilitators to see how long silence can last before a student breaks it. 

Early in group formation, so as not to derail the conversation, I will implement two tactics. The first is to ask students to make some guesses about the answer. Having students explain their guesses can reveal their current level of understanding. It can also lead to healthy debate and participation by quiet group members. The second is to have pending questions written down on the shared board so that a series of questions can be accumulated. When enough questions have accumulated, I’ll encourage two students to take each question and search different resources. That gives everyone something productive to do. No one is left sitting waiting for the discussion to resume, or resuming the discussion and leaving behind those doing the research.  Some interesting discussion occurs if the results are contradictory. It also forces at least something other than Wikipedia to be used as a resource.

Teachable Moments #2: Reasoning with Erroneous Information

A less predictable moment is when someone offers some information to the group that is erroneous and no one challenges it. The facilitator can increase the chances of this happening by the “guessing” strategy described above, but it works even better when it happens spontaneously. Frequently, the conversation will proceed for a while but then hit an inconsistency or a roadblock because of a flaw in the chain of reasoning. The facilitator can have the students explicitly step through the chain to identify the most problematic assumption that needs to be checked. Once found, students will realize the facilitator allowed the group to accept erroneous information. The “scary” teachable fact is first that they are responsible for their own accuracy. The more reassuring second fact is that they discovered the issue on their own or with minimal guidance. 

An interesting discussion can be had about how long to let students go without discovering the error. Usually, it is only a matter of minutes. I did once let a group go from a Part 1 session to the Part 2 session (same case several days later) before they discovered the error. The bigger the interval, the bigger the impact. 

A different problem I worry about is what if I, as the facilitator, don’t detect the error. For a variety of reasons, I favor facilitators who are not experts in the entire scope of the subject matter. It makes it easier to be a facilitator and resist the urge to become the oracle. Reasoning suggests such errors should be no more frequent between two good facilitators with different subject matter expertise. It also seems reasonable that the percent of errors eventually caught by students (close to 100%) would be the same for those detected and those not detected by the facilitator. 

I think a facilitator discovering they accepted an erroneous statement would be memorable for them, but I have not heard of this happening. Maybe they are too embarrassed to report such an event, but I think there is an alternate explanation. Often, even when the facilitator is not a subject matter expert, they not only know the right questions to ask and which statements to test, but can also sense when a statement-put-forward-as-fact seems shaky. Certainly, identifying the key facts in a chain of reasoning can be done, and they can be double-checked as part of the process. This should be done sometimes even if the facilitator is confident that there are no errors. 

Teachable Moments #3: Conflicting Evidence from Trusted Resources

Another great moment is when two people, looking up an answer to the same question, get different results. It is rarely as easy as saying one reference was wrong. Sometimes, the problem is in how the students interpreted the original question. Sometimes, it is in how the consulted reference interpreted the question. 

There are several great points about the process to be made. The first and foremost is that students are entering a world where there are frequently no clear answers. How do physicians deal with uncertainty when lives are at stake? A second is that often there are multiple ways of phrasing a question, and sometimes it is helpful to see multiple approaches and possible answers. The third, but rare point, is that sometimes even when two resources seem directly contradictory, the reason can be a surprising simplification of a complex situation. 

I once had a student refer me to two different well-known neurology texts which each had a different explanation for why the forehead wrinkles on up-gaze in the presence of a supranuclear facial tract lesion. On examination, I found both texts referenced the same primate research paper. The results were clear but lead to two different theories proposed in the paper discussion. The textbook editors had each chosen a different one of the theories to reference in their chapters.   

Teachable Moments #4: The Quiet Participant and the Loose Cannon Scribe

There are a variety of ways to get quiet members to engage. Certainly it helps the shyest members to have a conversation one-on-one about how their thoughtfulness will be interpreted when working in a clinical team. That future environment will be more intimidating and the facilitator can be the quiet member’s secret advocate to manipulate a comfortable space for them to participate. 

One approach is making the quiet member the group scribe, which is why I’ve combined these two situations into the same teachable moment. Frequently, the quiet member will nominate themselves to be the scribe. The teachable moment is they will frequently “quietly'' add information or organization to the shared workspace that is not appreciated by the group. Drawing attention to this draws them into the discussion, and also reveals to the group that the thoughtful member has valuable contributions to make. 

Other tactics are to instigate group disagreements and taking a “vote.” Having the facilitator suggest plausible but erroneous alternatives is one way to do this. Having at least two people disagree provides the opportunity to have everyone vote which side they are on. Having gotten everyone to participate, the facilitator can now ask the two quietest members on each side of the argument to present their choices. 

Teachable Moments #5: The Interruptions and Side Discussions

Frequently in new groups, but also established groups tackling a new topic, the facilitator can spot someone leaning over to whisper something to the person next to them. This is worth interrupting the group discussion and asking if they were asking a question. It may seem trivial like someone who just didn’t hear someone else because of a quiet voice or accent. Other times it was an unfamiliar word or a missing concept. Asking the group if anyone else has the same question almost always results in multiple raised hands. The teachable moment is that if something is not understood by one person, it is likely that multiple people had the same problem. The student asking is often the most surprised by this. The reason they are trying to have a side discussion is they are embarrassed to admit to the group there is something they didn’t understand. 

Getting students to publicize their misunderstandings is an ongoing challenge. The more it can be surfaced as a safe and normal part of the process, the better. It can help for the facilitator to be as modest as possible about their own understanding and role-model their own potential confusion. 

The opposite phenomenon of multiple people responding at once creates a similar problem. Information can get missed by some members. Such outbursts can be golden moments because so many students are simultaneously fully engaged. Gracefully getting each student to make their separate contributions without putting the brakes on the conversation can be challenging. Even if they don’t interrupt each other, the scribe can be left behind in a rapid conversation. This becomes good leverage to get the group to recognize the importance of capturing as much as possible. 

The facilitator can watch for points made that don’t get captured, and then periodically ask the group, “Did everything everyone said get captured?” If no one speaks up, then the facilitator can call on specific people and points made and ask the group if that seems like an important point worth capturing. If yes, then it can be reinforced that it is the responsibility of each individual to get their thoughts and questions across to the entire group. 

Teachable Moments #6: The Vocal Rebel

One challenge that has thankfully grown less prevalent over time is the diehard rebel who does not accept the premise of small group facilitated teaching. Such a member can be disruptive to the group. It can be an interesting exercise to have the group discuss how it should deal with such a member. The emphasis should not be on the disruption, but rather on how the group can accomplish as much as possible despite the disruption. 

The rebel student also should consider how they can get the most out of this time if they are required to attend: is disruption really the best use of their valuable time? Ultimately, the most disruptive students may need to be dealt with like any other professionalism issue. This could be a role model for handling professionalism issues in the future in clinical settings. 

Learnable Teaching Moments: The Work of Teaching

Just as a new learning process requires effort on the behalf of participants to adapt and change, so too implementing a new process requires work on the part of the facilitators. It isn’t sufficient to simply list the rules of interaction. The facilitator needs to reinforce these rules with examples from student experience to show why their learning benefits from these rules. 

For those who feel a calling to teach, they can suffer from the same attitude issues as students; teaching should feel instinctive. Imagine every faculty member devoting 1,000 hours of their time to an intensive course and skills practice on teaching! (The Ed.D.’s readers out there are probably smiling at this.) This is one of the reasons I favor non-subject matter experts. 

Aside from the temptation to become the star of the show and share information, students should be finding for themselves that tracking the content of what is being discussed can get in the way of tracking the process that is occurring. Leading a group to build up a structure of knowledge is more like constructing a course chapter. Leading a group to improve their research, study, and collaboration skills is more like playing a video game with many moving parts. It can feel like work at first to make this shift but with practice, it becomes a lot of fun.

Dr. Cimino has earned a reputation internationally as an award-winning medical educator. He was the founding Assistant Dean for Educational Informatics at Albert Einstein College of Medicine and former Associate Dean for Student Affairs at New York Medical College. He is board certified in Neurology and Clinical Informatics. He served as a member of the NBME Step 1 Behavioral Science Committee and the NBME End of Life Care Task Force. 

See more posts by Christopher Cimino, MD, FACMI, VP of Medical Academics, Kaplan Medical