Interactive Teaching Methods for Continuing Medical Education

"David Langford, illustrates the difference between teaching and learning in a little story.
He says, 'You know, last Wednesday I taught my dog to whistle. I really did. I taught him to
whistle. It was hard work. I really went at it very hard. But I taught him to whistle. Of
course, he didn't learn, but I taught.' "
Myron Tribus (2001)

Much has been written about the importance of engaging students of all disciplines in
active processing of curricular learning objectives. This is especially true for students of
health sciences, for whom application of knowledge forms the essence of their clinical
work.

We do sometimes see lecture halls, small and large, filled with students (of all

ages!) being spoon-fed material from PowerPoint presentations. However, many health
science educators have followed the Liaison Committee for Medical Education (LCME),
Association of Faculties of Medicine of Canada, American Association of Medical
Colleges (AAMC), and Accreditation Council for Graduate Medical Education calls for
more interactive teaching methods.
When it comes to the graduated health professional, many Continuing Medical
Education programs attempt to include interactive teaching methods in their curriculum.
Many conferences include break-away sessions with smaller group size and more
opportunity for interactive discussion. However, whether we are dealing with short
update sessions over a day or evening, or longer conferences of several days' duration,
the main format remains the "sage on the stage" model.
Over the last decade, I have helped basic science and clinical lecturers rebuild their
teaching materials into a structured format that stimulates active discussion, problemsolving and application of learning objectives. The primary method that I believe would
benefit lecturers in a CME setting would be use of Team Based Learning. Audience
Response Systems "Clickers" are an additional tool that could be helpful.

Team Based Learning allows a single lecturer to create an interactive learning

environment for up to 300 learners. Unlike Problem Based Learning (PBL) in small
groups, which has a high faculty to student ratio, Team Based Learning (TBL) seems an
ideal way to achieve competencies of cooperative teamwork, understanding, and
application of acquired knowledge, with a minimum of faculty members.
The TBL exercise is structured around the "student" learning some of the basic
knowledge material on his/her own: This can be by reading ahead of time, by attending
a lecture in a conference, or by listening to an on-line podcast at one's leisure. When
the student attends the TBL exercise, he/she is then asked to answer a short
questionnaire called an "IRAT" or Individual Readiness Assessment Test. The IRAT
entails 5-10 multiple choice questions that simply check retention of basic facts. In
undergraduate education, students are graded based on their performance. In CME
venues, "students" could be awarded prizes based on accumulated points through the
exercise.
Following the IRAT, participants break into groups of 5-6 members, and work on the
"GRAT" or Group Readiness Assessment Test. The questions are identical to those in
the IRAT and give the participants a chance to learn from their peers and correct
misconceptions or knowledge gaps. The "unprepared" students are also given a chance
to catch up.

Following the GRAT, the lecturer then reviews the key points in the

questions, allowing the various groups to justify their answers, learning from each other's
as well as the lecturer's contributions.
The most important part of the exercise then follows, The Application Activity. Since
health science professionals must be able to use their knowledge in clinical application,
it is insufficient to simply regurgitate basic facts previously read or heard. The next
component requires its participants to apply the knowledge gleaned during the "RAT's"
to clinical problems.

In the same small groups, participants must agree on correct

answers to multiple-choice questions that pertain to diagnosis and treatment.

Participants are free to use any resources they wish to help them, but the answers to the
questions are not directly found in any one resource: They require thought. We often
use scratch-off answer cards similar to those used in lotteries, simply to make the
experience more entertaining, and increase motivation.

Subsequently the entire group reconvenes with the lecturer and answers are reviewed.
Group members are once again called upon to explain their answers. The lecturer can
take the opportunity to clarify learning points from the readings or lecture or even to add
new material to highlight the objectives. It is also possible that the lecturer follow up the
exercise with a brief summary of the primary "pearls" learned.
During the entire exercise, or during a conventional lecture, Audience Response System
"Clickers" can be used to augment interest and participation. Learning theory has taught
us the short attention span that most students have in the frontal lecture setting. By
breaking up the lecture into 7-10 minute components, peppered with multiple-choice
questions that participants answer via their "clicker",

faculty maintain an interactive

milieu even with a large number of students. The software usually allows immediate
feedback that indicates how many students gave each response. Lecturers can also
make up questions as they go, allowing reinforcement of certain points or correction of
others. Although not crucial to an interactive learning experience, Audience Response
Systems are an additional tool that many CME settings utilize successfully.
These are a small sample of interactive teaching methods that can suit graduate
learners in Continuing Medical Education settings. In order to organize such exercises, I
would require the lecturer's teaching materials at least two weeks in advance: The
lecturer would need to provide me with a list of learning objectives, any suggested or
required reading, and a set of Powerpoint slides that he/she intends to show. I would
construct the learning materials and attain the lecturer's approval of them. My role at the
exercise itself would be an administrative/educational one:

My goal is not to be a

content expert for the clinical material but rather for the educational strategy.

A hypothetical time-line of the TBL exercise is seen below. Grading can be added in
order to give the "best" group a reward/prize etc.

The times can be shortened or

lengthened depending on content. A review exercise at the end of a conference might

be longer, whereas an "evening" CME event might be shorter.
TIMELINE
COMPONENT
00:00- 00:12
IRAT
BREAK INTO PRE-ASSIGNED GROUPS
00:15- 00:30
GRAT
RETURN TO LARGE GROUP
00:30-00:50
DISCUSSION OF "RAT"
QUESTIONS AND ANSWERS
BREAK INTO PRE-ASSIGNED GROUPS
00:55 1:15
APPLICATION ACTIVITY
RETURN TO LARGE GROUP
1:15 1:30
DISCUSSION OF "Application Activity"
QUESTIONS AND ANSWERS
Lecture/Clarification/ Q&A (if desired)

1:30 2:00

Thank you for considering my proposal,

Sheryl Shoham, M.D., C.C.F.P., Diploma in Medical Education

Dr. Sheryl Shoham is a Family Physician who graduated with an M.D. from McMaster University in
1988.

She completed a residency in Family Medicine and has worked in primary practice and

hospital medicine since. For the past ten years she has worked in medical education, developing
curricular materials that focus on interactive, student-based teaching, including various types of
small-group learning methods.

She completed a Diploma in Medical Education at Dundee

University's Centre for Medical Education.

References:

Learning Objectives for Medical Student Education: Guidelines for Medical

Schools, American Association of Medical Colleges, January 1998
https://www.aamc.org/initiatives/msop/
Functions and Structure of a Medical School, Liason Committee for Medical
Education, June 2010
http://www.lcme.org/pubs.htm#fands
The Future of Medical Education in Canada: A collective Vision for MD Education,
2009
http://www.afmc.ca/fmec/pdf/collective_vision.pdf
The essential elements of team-based learning (p 7-27), Larry K. Michaelsen,
Michael Sweet, New Directions for Teaching and Learning, Volume 2008, Issue 116
(Winter 2008), Published Online: Dec 16 2008 4:58PM, DOI: 10.1002/tl.330
Team-Based Learning: A Transformative Use of Small Groups (2002), ed. Larry K.
Michaelsen, Arletta Bauman Knight, and L. Dee Fink (Westport, Connecticut and
London: Praeger)