MEDICAL EDUCATION CASE STUDY: The Case of the “Disruptive Learner”: A Small Group Facilitator’s Nightmare

Innotech University has undergone a recent curriculum change that incorporates small group teaching for pre-clinical medical students, adopting a problem-based learning format. Dr. Azuma has been assigned by his Bacteriology department chair to represent the department’s required contribution to the teaching effort. Dr. Azuma is willing but failed to attend the medical education office’s four hour Facilitator Training program. Instead he completes the less intense and inferior on-line version of skills and strategies necessary to involve pre-clinical students in the integrated basic and clinical sciences. English is his second language. His preference is to remain in his research lab, a truer reflection of role as a scientist.

He begins the eight week neurology block small group assignment with trepidation. On the first day he begins the session without setting any ‘ground rules’ for his nine students. He shares his less than enthusiastic regard for the small group, case-based instructional format. His initial conversation on the subject is directed at a student he recognizes from his recent summer research lab. After his prescriptive diatribe they commence reviewing the clinical neurology case when a student answers his cell phone, has a ‘side-bar’ discussion, then becomes highly opinionated on case content to the exclusion of his peers. Tensions begin to rise within the group. The other students anxiously wait for the facilitator to intervene in this rude and disruptive behavior. Yet no action is taken as they complete the case with only a few students offering any independent contributions to the case’s etiologic or patho-physiologic implications.

The students assemble for the second class session finding continued dysfunction within the group. Two students address the issue of the disruptive student with the facilitator after class. Dr. Azuma indicates that he will read the Facilitator Guidelines and try to improve. Yet, no substantial changes occur. A disruptive learner frequently detracts and undermines the cohesion of the learning group, if not appropriately corrected. In desperation the students take their complaint in person to the Course Director.

The Course Director calls Dr. Azuma. “I appreciate your efforts facilitating students in our ‘neuro’ course”, the Director explains. “If you still wish to continue, I can offer some resources to help you be more effective. Would that be OK with you?” Small group facilitators have numerous responsibilities. Likewise, the Course Director responsibilities may include effective management of course content, faculty supervision and assessment. In our case study the Director may offer to consult with the facilitator offering several immediate and long-term strategies to encourage improvement. Perhaps co-facilitating the next small group session to role-model essential skills may rectify disruptive student behaviors. Jointly reviewing the Facilitator Training guidelines may reinforce useful skills. In addition, a short review session with a medical education specialist could assist in managing disruptive behaviors. Finally, obtaining a replacement facilitator could be a difficult or troublesome option.

It is assumed that small group learning challenges and expands students’ understanding of clinical cases with information often derived from lectures, laboratories and reading assignments. Small group leaders may consider several strategies for disruptive learners, as illustrated in our case. Making direct eye contact with the disruptive student may gain their attention. They may redirect the groups’ discussion when the group process breaks down (i.e., “Let’s get back on track” or “Thank you, now let’s hear from others”) are subtle means of altering disruptive behaviors. If needed, take a “time out” or a brief recess for direct, personal feedback with the student. Reflection on important ‘ground rules’ or expectations could mollify inappropriate outcomes. If unable to resolve the learner’s issues then contacting the Course Director for an immediate remedy is appropriate.

Summary:

Disruptive student behaviors are a facilitator’s worst nightmare, often altering the effective group process. Such group disruptions may include: ‘side conversations’; dominating behaviors; non-participant or silent student behaviors. The facilitator has a considerable responsibility when guiding a small group of pre-clinical students in case-based discussion sessions. They are often expected to stimulate student responsibility for achieving self-directed and life-long learning while sustaining the collaborative group process. Effective group problem-solving requires a skilled facilitator who guides, challenges, offers feedback, and intervenes when the process falters. Facilitators, either as content or non-content experts, share a common responsibility to prompt students to think in ways similar to how practicing physicians think.

Perhaps a small group facilitators’ time may be more productively spent in other pursuits more crucial to the academic mission (e.g., scientific research, patient care, etc.). This may be especially pertinent given competing interests for time and scarce resources. Some suggest placing greater emphasis on clinical experts teaching in a more didactic manner^1,2 to increase instructional efficiency. Moreover, content experts who facilitate the small group case-based learning process³ is preferred by students⁴. Likewise, it has been shown that non-content experts spend less time lecturing or discussing student knowledge deficiencies. However, they may enhance student self-directed learning opportunities⁵.

Therefore, it is important to facilitate well-managed learning groups to focuses on learner-centered instruction. Skilled content or non-content experts are able to prevent and manage disruptive behavior. This is essential as we continue to effectively integrate the basic and clinical sciences for educating competent and proficient healthcare practitioners.

Respondents

Students, what should students do if disruptive behaviors interfere with their learning? Faculty/Course Director, what steps are needed to correct an ineffective facilitator, when students complain about disruptive student behaviors?

References

1.Shanley PF. Viewpoint: Leaving the “empty glass” of problem-based learning behind: New assumptions and a revised model for case study in preclinical medical education. Academic Medicine 2007; 82(5):479-485.
2.Shields LM, Guss D, Somers SC, Kerfoot BP, et al. A faculty development program to train tutors to be discussion leaders rather than facilitators. Academic Medicine 2007; 82(5):486-492.
3.Kaufman DM, Holmes DB. The relationship of tutors’ content expertise to interventions and perceptions in a pbl medical curriculum. Medical Education 1998; 32 (3): 255-61.
4.Yee HY, Radhakrishnan A, Ponnudurai G. Improving PBLs in the international medical university: Defining the ‘good’ pbl facilitator. Medical Education 2006; 28 (6): 558-60.
5.Eagle CJ, Harasym PH, Mandin H. Effects of tutors with case expertise on problem-based learning issues. Academic Medicine 1992; 67: 465-9. Facility well informed about cases and their content in the teaching process

Student Response

One of the biggest hindrances to learning is disruptive behavior by someone, no matter the setting. As a student, disruptive behaviors are a common occurrence that each student will more than likely experience at least once, if not several times, during the learning process. In the field of medicine—and academia—disruptive or inappropriate behaviors will happen, and students need to learn how to work and communicate with people who display such behaviors. Small group is the perfect setting to practice these communication skills with others.

The most appropriate initial course of action a student should take if a peer has disruptive behavior is to confront that person. The confrontation may occur privately or immediately after the disruptive behavior happens. The influence of a peer on changing behavior is greater than most can imagine; often greater than that of an authority. A student should express any concerns immediately, and often other students will echo the same concerns. If this is uncomfortable, the student can privately ask the disruptor to refrain from the disruptive behavior.

Often, no other interventions are necessary. However, if they are, then it might be time to seek an authority figure; in this case, the facilitator. Not only should concerns be raised with the facilitator, but also possible solutions to the problem. For example, readdressing small group ground rules or conduct guidelines would alleviate many difficulties.

Faculty Response

While expressing willingness to lead a small group, Dr. Azuma clearly is uncomfortable with, and skeptical of, this format. Moreover, it appears that “willingness” means that he did not strongly object to this assignment and not that he sought it out. The first issue, then, is “How does one obtain ‘buy-in’ from faculty participating in small group teaching?” Many medical school faculty view themselves as, primarily, research scientists. Moreover, most faculty are familiar with a lecture format, having been exposed to it in their own training, while fewer have participated in well-run small groups. The ‘fixes’ are complex. At the institutional level, teaching efforts must be seen to contribute substantially to professional advancement. Training for group leaders may need to be made formal and mandatory, in which case, this training time must be counted as teaching time. If the teaching faculty are not the ones making the decision to pursue a small group approach, then it becomes essential that the reasons for this decision be made clear. Data supporting the efficacy of this method may help to bring skeptical faculty on board. Discussion of the pros and cons of the approach, with full acknowledgement of the drawbacks, may help to draw in less enthusiastic faculty who might perceive this as a new challenge to be met rather than a new burden to bear.
A second issue is “How does a Course Director deal, at mid-course, with an ineffective facilitator?” The Course Director’s response, as presented, would be excellent under most circumstances and covers all major suggestions I might have considered. The behavior of the ineffective facilitator (Dr. Azuma) suggests a complete lack of knowledge of how a well-run group functions, rather than a complete lack of interest. It also leaves open the possibility that Dr. Azuma is uncomfortable in the role of an authority figure who must confront the disruptive student. Assuming that Dr. Azuma continues to express willingness to lead a small group, the Course Director’s response expresses appreciation while making it clear that his effort is falling short of the required standard and that it must be improved. Unfortunately, quite a bit of damage has already been done here: [1] it is already established in his group that the facilitator does not actually value small group activities and [2] a pattern of disruption has become the norm. The students now know that their facilitator does not support (or understand) what they are trying to accomplish in a small group setting, even if the disruptive behavior is removed. Under these circumstances, the Course Director owes it to the students to replace the facilitator in this group. Given that it will be problematic to locate a new facilitator, the Course Director could elect to rotate faculty among small groups. Since Dr. Azuma failed to attend the four hour training program, he could be required to co-facilitate four carefully selected groups for some on-the-job training prior to taking a group alone again. This is more supportive of Dr. Azuma than removing him completely from the course and offers him the opportunity to grow to become a valuable facilitator in subsequent years.
Another issue relates directly to the disruptive student. Some emphasis in any small group exercise should be placed upon the listening skills that a good clinician needs to develop. It should also be made clear that there is an expectation of professional behavior and an understanding of what that entails. To ensure some level of standardization between groups, the Course Director could institute a brief on-line activity, required of all students at the beginning of the course, which would clarify basic expectations and criteria that will be used in student evaluations. It would then be appropriate for the Course Director to take the disruptive student aside and make it clear that he is in danger of receiving a poor evaluation.
A final issue relates to the question of cell phones in the classroom. Under rare circumstances, a student or faculty member may need to accept a phone call during a class. This should be made clear at the beginning of that class period and the call should be taken outside of the classroom. Under no circumstances should a personal call ever be permitted to be taken in the classroom. The same rules hold for texting. It is a good idea to pull out one’s own phone at the beginning of class, turn it off, and request that everyone else do the same.

Administrator Response

A legitimate title for this case study could also have been “The case of the ineffective facilitator: A small group learner’s nightmare”, or perhaps “The case of the dysfunctional small group: A course director’s nightmare”. It could even be called “The case of the disgruntled faculty member: A department chair’s nightmare.” The case illuminates a number of system based issues that are all too frequently seen as roles and responsibilities at all levels of the academic enterprise collide.

Sadly, Dr. Azuma’s small group was doomed to dysfunction from the start through a cascade of events. While Dr. Azuma was willing to carry out the assignment of his department chair, he was not committed to success, as evidenced by his failure to attend the facilitator training session and his underlying lack of belief in the value of case based instruction. Small group teaching in a problem based format is a well established means of actively engaging learners, but the success of the encounter is dependent upon a committed facilitator skilled in leading small groups. Equally important to achieving the educational goals of small group encounters are learners who are prepared for the session and clear about the learning objectives and the expectations of the facilitator. A small group facilitator’s ineffective behavior can be as disruptive to the learning environment as a student’s inappropriate behavior; both serve as barriers to achieving educational goals. Dr. Azuma could have had a very different learning environment had he set a positive tone in the beginning, set clear expectations and provided timely constructive feedback when the student was being disruptive.

The overall success of a course is, in turn, dependent upon the success of its parts. If small group instruction is an integral part of a course, a dysfunctional small group could jeopardize the goals of the course. In this case, the course director had a responsibility to ensure that all small group facilitators were prepared for the task, requiring the training to be mandatory. It is now the responsibility of the course director to step in at this point and either rehabilitate the facilitator through faculty development or replace him.

At the level of the department and the school, faculty should have input in negotiating their work assignments with the department chair. Chairs should tap into the unique talents of each of their faculty and assign their work in a way that best achieves the overall missions of the school. Faculty with a teaching work assignment should participate in faculty development activities that enhance their teaching and the quality of their teaching should be assessed as part of their annual merit evaluations.

In this case, with the appropriate intervention, the disruptive student behavior and the ineffective facilitator’s behavior has a good possibility of being modified, with the potential for a favorable outcome.

Respondents

Student Respondent
Eleanor A. Gradidge, MS2, University of Texas Medical Branch, Galveston, TX USA
Faculty Respondent
Eve Gallman, Ph.D., Adjunct Assistant Professor, University of Illinois College of Medicine at Urbana, Ubrana, IL USA
Administrator Respondent
Toni Ganzel, M.D., Senior Associate Dean for Students and Academic Affairs and Professor, University of Louisville, School of Medicine, Louisville, KY USA