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Introduction

Benefits of group tutorials

Challenges of group tutorials

Establishing multi-level group tutorials

In the general practice education and training setting, tutorial teaching has traditionally been delivered outside the clinical setting and to a homogenous group of learners. Universities provide tutorial based teaching for medical students, usually on campus. GP registrars are provided with tutorial-type teaching at education workshops delivered by their training organisations.

In the hospital setting, the ward round and hospital or discipline-based ‘grand rounds’ are often an ML learning activity, frequently delivered in the clinical setting. This concept is increasingly being mirrored in VI teaching practices. Multi-level learner group tutorials are being delivered to medical students and GP registrars, as well as to experienced GPs.

The concept of group learning in individual general practices is not new. Group learning has been used as a form of continuing professional development (CPD) for many years in Canada, the UK and Australia. There is an increasing move in general practice to develop communities of practice. In this model, shared learning groups are established across a number of neighbouring practices. Shared learning models increase the learning capacity in a practice. These initiatives are largely supported by practices because they are time- and cost-efficient and build collegiate relationships.

The number and variety of learners in general practices has increased in recent years, and this has necessitated innovation in teaching models. Multi-level learner tutorials have become an accepted form of teaching in general practice since both supervisors and learners find them valuable and effective.

Small group CPD learning in a general practice setting is valued by GPs. Small group learning incorporates personal, social and professional interactions in the learning process. Patient problems are usually the focus of small group learning. Common models incorporate case presentation, topic discussion or demonstration of clinical tasks as the methods of teaching. Video-conferencing is also being utilised more extensively to bring learning groups together as a ‘virtual’ tutorial group.

Registrars appreciate small group learning, particularly when the group has members who are learners at a similar level of training. GP registrars have identified that small group learning focused on individual patient management rather than curriculum topics is a useful addition to their learning plans. Small group learning is appreciated by GP registrars as an opportunity to explore a variety of approaches to patient care. GP registrars are happy to contribute to, or lead, presentations in small learning groups; however, they are often not confident taking the facilitator role.

While group learning has many advantages, which are outlined in the table below, it should also be recognised that this form of learning cannot replace one-on-one learning. The latter is still required to teach some skills and in situations when a safe and confidential context for learning is important.

There are also some challenges in managing group tutorials, and these are listed in the table below.

Leadership by senior GP teachers is important in establishing an ML group tutorial. Supervisors need to create an enthusiastic, respectful and encouraging culture for learning. Skills in facilitation and supportive administration are also important features to promote the success of ML group learning.

One of the supervisors in the practice will usually take leadership of group learning to ensure that tutorials take place regularly. It is also important that the practice manager or designated teaching co-ordinator be involved in the organisation and set-up. In some practices, ML group tutorials also involve other disciplines, particularly practice nurses.

In general practice, the most common form of integrated ML learning involves participants from all three levels of medical learner: GP supervisor, GP registrar and medical student. Junior doctors may also be participants in these groups if they are part of the practice. In most cases, all participants are given the opportunity to present topics or cases and to lead discussions. In some cases, other professional groups from the practice (for example, practice nurses, allied health professionals or practice managers) may be involved.

Key principles to group learning

Key principles are important to promoting a successful group learning process. These are listed below and included in the Appendix resources section.

Considerations for planning group learning

A planned approach to delivering ML group learning that considers skills, needs and resources is important. Providing all the learners in the practice with an opportunity to plan and set the agenda is recommended. Encourage GP registrars and medical students to take on teaching roles within the group.

When planning the schedule and the way the ML learning will proceed in the practice, consider the following:

• What are the capabilities and weaknesses of members of the group?

• Is there a commitment to prepare for the session (for example, through pre-reading or case identification)?

• Are session times appropriate for all participants?

• How can the junior learners be supported to take on teaching and facilitation?

• Is there access to required information technology resources?

• s it possible to establish a dedicated learning space?

• How can we keep the sessions interesting and flexible, while maintaining consistent expectations?

It is best if the case presentations are current cases with which the presenter is struggling, as this promotes group participation.

Protecting teaching time in the practice

One challenge in a busy general practice is protecting teaching time for all members of the group. Protecting teaching time requires planning and effort.

Scheduling

Decide on a time during the week when the practice is least busy (that is, Mondays and Fridays are busy and less suitable in most practices). Schedule the tutorial for the beginning of a session (that is, from 8.00am to 9.00am or from 1.30pm to 2.30pm). When the teaching session commences a session, it is more likely all the attendees will be on time, and the session will need to finish on time because patients are waiting. As a general rule, most learners (and teachers!) are tired later in the day, and emergencies always arise and result in delays.

On-call doctor

Identify one doctor to take responsibility for any interruptions from the practice staff. This allows the key supervisor/s to remain focused on the teaching session.

Timetable and session leader

Prepare a clear timetable in advance. Identify the facilitator and lead presenter in the timetable. Some individuals may be happy to prepare a presentation at the last minute, but most people prefer to have plenty of preparation time.

Enhancing the group connection

Developing group cohesion and trust is an important part of ensuring effective learning takes place in ML tutorials. Below are some suggestions for developing group connection.

• Create personal connection and welcome in the group. Start with simple personal sharing to allow participants to connect. This helps to make the learners feel connected. Initially there may be some resistance, but eventually this can be five-minute sharing that connects people. Try:

  • What is one new thing and a good thing that has happened for you this week?

• Clear the mind by commencing your tutorial with five minutes of mindfulness together. This helps people to settle and focus, especially if they have been busy all morning.

• Role modelling by supervisors is essential. It is important for supervisors to present cases and topics to model expectations and demonstrate their commitment to lifelong learning.

• Model a philosophy that no one is an expert. We are all learning and teaching together.

• Food is always a helpful strategy to build connection and put people at ease. Encourage creative, healthy cooking and sharing.

• Food is always a helpful strategy to build connection and put people at ease. Encourage creative, healthy cooking and sharing.

Developing the curriculum and activities of multi-level groups

Some training organisations have particular requirements regarding curriculum delivery in the practice setting. Supervisors will need to be familiar with such requirements for the different learners and incorporate these needs into the tutorial program.

Using different teaching methods in group tutorials is important in maintaining interest from the group. Avoid repetition in topics and activities so the group tutorials remain interesting to the experienced GPs who will be long-term group members. Keep didactic presentations to 15 minutes or less, to allow for questions and further discussion.

Ideas for sessions include:

• case presentations;

• role playing;

• video debriefing;

• practical skills demonstrations;

• practical therapeutics;

• journal article or clinical guideline discussion;

• clinical topic presentation; and

• interdisciplinary teaching (for example, nurse or practice manager delivering a session).

Case discussions

Doctors in different specialties and different clinical environments often express a preference for the way in which a case is presented. This can be confusing for students, although registrars have usually adapted to the variety of formats during their hospital training. It can be helpful to students and registrars to provide clear instructions as to how they should prepare a case for presenting in the ML learning environment. Having an established case presentation format can save teaching time and ensure that the session remains focused. In general practice, students will often attempt to present an entire long case, which will not be helpful for the learning of GP registrars. Many issues in general practice are not appropriate to a traditional, long-case style. Providing a clear format for presentations in general practice improves the learning experience for all, and helps the learner focus on the purpose of the presentation and the feedback they are seeking. The use of a format also facilitates the learner to reflect and organise the details of their case more succinctly.

The two examples that follow, ‘traditional styles of presentation’ and ‘ISBAR’, demonstrate formats that can be used for case discussions. In hospital settings, the ISBAR is used by medical and nursing staff for clinical handovers. Most students and registrars will be familiar with this form of communication. The ISBAR could be a simpler way for learners to organise their case presentations if it suits the purpose of your small-group learning. ISBAR identifies the patient as the crucial focus of a clinical handover. However, it is important to preserve patient confidentiality in group tutorials, so the patient’s name should remain confidential (sex and age is probably important for the context).

Topics

With learners of different levels, it is important to develop a series of tutorial topics in which all learners can demonstrate expertise. This promotes collegiality and connection in the group, and encourages the more junior learners to contribute. Topics that cover professionalism and communication skills, and those centred on discussing complex questions rather than straightforward medical knowledge will help to engage more junior learners. Topics that do not rely on expertise may promote greater engagement from the full group (for example, medical ethics issues).

Let the group contribute to the program by identifying topics on which they are enthusiastic to receive an update. Often these are excellent topics for medical students to prepare, as it provides an opportunity for them to review the evidence and prepare a presentation. Registrars are able to share recent education from their training organisation workshops, and may be able to present these to the group, reinforcing their own learning. Identify strengths and skills of the group participants. This should include registrars and medical students, many of whom have prior areas of practice and expertise.

Allow space in the tutorial timetable for the latest topics of importance (for example, discussing a recent disease outbreak and its management) or for issues that have arisen in the practice (for example, a new patient with a rare condition).

Here is a list of potential tutorial topics that are not clinical and can be used in the ML learner setting. These topics are likely to generate interactive discussion as they are important to all learners including senior supervisors. In the Appendix resources section, you will find tutorial outlines for the following topics, to assist you with running a session with little preparation.

• Teaching consultation skills

• Managing the violent patient

• Knowing your learning styles

• Establishing boundaries in general practice

• Handling complaints

• Evidence-based medicine

• Doctor self-care

• Studying efficiently and keeping up to date

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