Statistics from Altmetric.com
Most of our learning as doctors happens through individual study. Some takes place with other people, for example at lectures and seminars, but often this is not very different from solitary learning. In effect, one person stands at the front of a room, imparting facts or opinions, while everyone else remains relatively passive. Very few doctors spend time in collaborative learning groups, where everyone examines their own work together and in depth. This is paradoxical, since such groups are probably one of the most effective ways of developing as a professional.
Collaborative learning groups come under many different names, including peer supervision1, action learning sets2 and ‘Balint groups’3, but they all share more or less the same form. A group meets regularly, perhaps every month or six weeks. Everyone sits in a circle, either around a table or just facing each other. In any session, a few individuals have an opportunity to present an extended account of a specific dilemma or challenge they are facing in their professional work – a clinical case, perhaps, or a problem with a colleague. The discussion is then opened up to everyone else. Often, there is a trained facilitator, who makes sure that the group stays focussed on its task, and that everyone follows the ground rules, such as not interrupting, and not trying to dominate the conversation. Typically, there are between six and twelve people present in such groups. A meeting usually lasts an hour or two, giving enough time for proper consideration of all the issues raised.
Most collaborative groups draw on similar principles. There is an assumption that people will learn more from an in-depth study of a few particular cases than from rushing through a large number. Equally, there is a recognition that many of the predicaments we face in our professional lives are complex, and may be shot through with uncertainty. These predicaments may not have any quick or easy solutions but will always benefit from considered reflection. This means being prepared to open one's mind to challenge, and be willing to challenge others as well. Another principle is that the combined minds of a several peers – a so-called ‘group mind’ – will inevitably be better than any single one of them. Each of us is constrained by the limitations of our own experience and ingrained perspective. Hearing ideas from others can therefore open up a variety of options that we may never have considered, especially if the group includes people from both genders and a variety of professional and cultural backgrounds.
Ban on advice
Some people joining collaborative learning groups for the first time are surprised to find that there is usually a strict ban on giving people advice. There are several reasons for this, but they boil down to the fact that people presenting problems needs to keep ownership of them and work out the answers for themselves. Presenters want to air their narratives and expose these to the curiosity of others, without being bombarded with suggestions. A comment like: ‘Why don't you hand the problem over to someone more senior?’ may create the illusion of a way forward, but it will generally be far less useful than asking a set of questions about who is involved in the case, what the key relationships are like, and who holds the power to make a final decision. Nearly always, case presenters find this much more helpful than being told what to do, either directly or indirectly.
People attending groups get help with their professional problems, but they gain other benefits as well. They hear about the problems that others face, and how they go about addressing these. They learn about different kinds of organisations, including their own, and how these function. Groups are also good places to learn how to listen attentively, ask good questions, and gain confidence in expressing your own view. These skills can be extrapolated to everyday work, including clinical encounters. Group members also learn about group dynamics and how to manage these. For example, the psychoanalyst Wilfred Bion described the tendency of groups to veer away from the task, by taking flight into abstract discussion (for example, about politics or the state of the world), or by deciding to characterise one or two members of the group as heroes or villains.4 Interestingly, group discussions can sometimes mirror features of the case being discussed, through what is known as a ‘parallel process.’ A group talking about an angry family who are making a complaint may find that its own members start to argue with each other in a way that is quite uncharacteristic of their normal behaviour. Good facilitators learn to identify and name such processes, and participants learn how to deal with them in their own work setting.
I have been a fan and advocate of collaborative group learning for a long time. However, such activities can take up a lot of people's time, as well as requiring extra resources for training facilitators. Because of this, managers often ask if there is evidence for the effectiveness of such groups. As with all complex educational interventions, collecting such evidence is not straightforward. The different methodologies and contexts for collaborative group learning make it hard to compare like with like, randomisation and control groups are not usually possible, and there are many confounding variables. (For example, an organisation that encourages group learning may also be running other initiatives at the same time in order to promote staff development).
Nevertheless, there is sound evidence from a number of different fields that this kind of learning has a positive effect at many different levels. Among general practitioners (GPs), collaborative learning groups in a number of countries have been shown to bring about significant changes in engagement with patients, performance in psychological approaches to treatment, and in reducing burnout.5 Similarly, a review of ten years’ research into action learning sets in a variety of institutions has shown how these have helped participants to develop broad managerial and leadership skills, improve ability to develop solutions to conflict, and enhance coaching skills.6
In some specialities and in some countries, collaborative learning groups are becoming routine or even mandated. This is now the case for GPs in Denmark and Sweden, and even for consultants in one or two Trusts in the United Kingdom. In many health service organisations here and elsewhere, however, opportunities for collaborative learning groups are still few and far between. Where they do exist, I would urge every doctor to join one. Where they are absent, I would also encourage managers and educators to consider setting them up and funding them. Group dialogue, if properly conducted, can help people to reach the best professional decisions, in a way that written information or even expert advice, can very rarely do.
Twitter Follow John Launer at @JohnLauner