Small group teaching has been the highlight of a revolution in the medical education over the last 40 years [1]. Small group teaching is a rather broad term without a clear definition. It covers tutorials, seminars and small problem-solving classes. A small group is a number of people who interact in a face to face situation, where the size of the group may vary from a handful of students to around 30 participants. About 8-12 is an optimal number [2,3].
The effectiveness of small group teaching against didactic lectures has been well documented [4]. Small group teaching helps in generating a free communication between the group leader and the members and among all the participants themselves. The faculty who acts as the group leader is a facilitator, who allows the participants to express themselves [3]. In fact, a small group setting provides an ideal opportunity for the teachers to facilitate an active learner participation [2]. Reducing the size of the class will produce many benefits for the teachers and students; for example, the students will receive more individual attention, the teachers will be able to manage the students better, discipline problems are likely to be less and there is more interaction between the students and teachers. When the teacher spends less time in managing the students, more time can be utilized in Sectionteaching [4]. Small group teaching has become an increasingly important component of the undergraduate medical education. The problem-based learning relies almost entirely on the small group teaching methods, and many schools with more traditional curricula have incorporated a significant number of small group teaching sessions into the undergraduate programmes for medical students [5].
The traditional lecture approach has been the core teaching method in the Iraqi medical colleges. Several activities and initiatives, at both the national and individual levels, have been adopted for reviewing the medical college curriculum and for introducing new teaching methods in Iraq, over the past two decades [6]. One of these initiatives was introducing small group teaching at Hawler College of Medicine. This process has started in 2008 for the 5th year students and it was then extended to the 4th year students. It involved dividing the students of each year (around 160) into four groups. The theoretical and practical sessions of each subject would be delivered consecutively for each group over a specific period of time. In the previous didactic large group system, the students learnt different subjects concurrently, according to a specific schedule.
Despite the increased use of small group teaching in medical education, relatively little is known about the students’ perceptions of the small group goals, effective teaching practices, and the methods of evaluation in the small group setting [7]. Moreover, no data are available on the students’ perceptions towards the newly introduced small group teaching approach at Hawler College of Medicine. Therefore, the aim of this study was to assess small group teaching as a method of teaching at Hawler College of Medicine, from the students’ perspectives.
SUBJECTS AND METHODS
This study was a qualitative study which was based on the focus group discussions which involved the students at Hawler College of Medicine. The Hawler Medical University is located in Erbil City of the Iraqi Kurdistan Region. It includes four colleges: Medicine, Dentistry, Pharmacy, and Nursing. The teaching in these four colleges is done in the English language. This University is affiliated to the Ministry of Higher Education and Scientific Research of the Kurdistan Regional Government. The College of Medicine was established in 1977 as a part of the University of Salahaddin. In 2005, the college became affiliated to the Hawler Medical University and it currently comprises 12 different basic and clinical departments. It awards the Bachelor degree in Medicine and Surgery (M.B.Ch.B.) in addition to postgraduate degrees in different basic and clinical sciences.
The study participants were selected from a sample of the three final years in the college (4th, 5th and 6th). These years of study were purposively selected, as small group teaching had been implemented widely in these three years of study in the college. Six focus group discussions were facilitated Between May and August, 2012; two focus group discussions for every year of the study. Two groups were randomly selected from each study year and a convenience sample of 10-12 students from each group was selected. Two members of the research team were present with each focus group; a moderator and an observer. The full explanation of the purpose of the study and the ground rules regarding the confidentiality and anonymity were given at the start of each focus group, before obtaining the participants’ consents. All the focus group discussions were recorded in full with the consent of the participants. The study was approved by the Research Ethics Committee of Hawler College of Medicine. A topic guide was used to lead the discussions and it covered questions on the positive aspects and problems of the small group teaching in the college, in addition to the recommendations for its improvement. Each focus group was terminated when the discussion sufficiently covered the topic and no new information emerged. Each focus group lasted approximately ninety minutes. The six focus groups provided a wide representation of views and sufficient saturations.
All the discussions were conducted in the Kurdish language. The audio recordings of the discussions were transcribed and translated into English. The data analysis was carried out by content analysis, followed by a thematic analysis, with the use of a framework which was adapted from Vaughn et al., [8], to prioritize the topics and to enhance their validity [9]. In the thematic analysis, a greater emphasis was placed on the repeated themes, especially those which were repeated by more than one group, the initially raised themes, strong feelings, or the themes of long discussions. We included the discordant views to highlight the differing experiences or perceptions of the individuals and groups, as was recommended by Kitzenger [10].
RESULTS
The positive aspects of small group teaching
The participants were generally happy with the introduction of the small group teaching and they recognized many positive aspects which were related to this experience. They indicated that this system of small group teaching increased their focus on the study subjects. This was mainly attributed to learning one subject in each period and thus devoting all the study time and focus for/on that specific subject-“Small group teaching is useful because it is continuous; we will learn only one subject and continue with it till we finish it, unlike the last year, when we learnt different subjects at the same time”.
Other students attributed the increased focus to the fact that with smaller groups, the students paid more attention to the teachers and that the teachers were able to convey their main messages easier.
Examples of the relevant quotations included
Now the teachers make us pay more attention to them. In a large group, there were lot of students and if we did not like the subject, we did speak all the time. Now, even if we do not like the subject, we have to focus and listen, because there are fewer students.
This year is better, because we are fewer in number and we can concentrate. Not like the previous year, where those who sat in the last seats were busy and did not even listen to the teachers.
The participants emphasized the role of small group teaching in the stimulation of the teacher-students interaction. They indicated that this system assisted students in asking questions and in conducting discussions, as they had more time and as they felt more comfortable in doing so. The teachers also felt more comfortable in becoming interactive in their teaching.
Examples of the relevant quotations included
As the number of students is fewer, we can understand the subject better and can ask more questions. All of us can practice specific skills in the practical sessions, because we are small in number.
Small group teaching is better, because our contact with the teacher has become easier. We stick to one subject and we have more time for asking and discussing the subject.
The participants indicated that small group teaching could assist in building a better student-teacher relationship, as they spent longer time together and had more direct contact. This would eventually, positively affect the learning process-“Now the relationship
between the teachers and students is better and the relationship among the students is better, because we are small in number and we spend long periods of time with each other. In fact, we have become like a family”.
The other positive aspects with respect to small group teaching, as were recognized by the participants, included, encouraging the students’ attendance, providing a better opportunity to apply a student-centered learning, enhancing a more efficient use of time and assisting in a better understanding of the subjects.
Examples of the quotations which were related to these aspects are shown below
One of the important advantages of this small group teaching is solving the problem of the students’ attendance. Previously, when we were more than 160 students, many students did not attend the lecture and it was not possible for the teacher to record their attendances correctly, but now, most of the students like to attend the lecture and it is possible for the lecturer to see what is going on.
One of the advantages is that the students will read by themselves and sometimes, there will be no lecture, just a prior book reading and this will make the subject more up to date.
There is more time for discussion and more time for the teacher to ask questions.
There is more time for the students to ask questions.
Less time is wasted during the class by recording the students’ attendance.
We understand the subject better because we are small in number, and the class is more quiet.
The problems which are faced during small group teaching
The participants identified many problems which were faced during this experience of small group teaching. The main emphasis was on the poor infrastructure and the lack of proper facilities which were a hindrance in applying this system effectively. The lack of sufficient numbers of lecture rooms, the lack of lecture rooms which were appropriate for small group teaching, the lecture rooms being dispersed over a large area that made the students travel long distances in a short time and a poor organization in allocating the available lecture rooms, in addition to a lack of proper internet and library facilities, were other problems which were recognized by the participants.
Examples of the quotations which were related to the poor infrastructure and teaching facilities included
We have problems with the availability of halls and teaching facilities. Sometimes, we go to the lecture room to find some other group of students using it. Most of the halls are not provided with appropriate teaching facilities like audiovisual aids and other facilities.
The lectures are delivered in widely distributed places, for example, today we were in the College of Pharmacy, then we moved to the Maternity Hospital and then we went to the College of Medicine to attend our lectures.
We have a small unit of the internet in the library, with 12-14 seats for all the students in the college [More than 900 students], and the internet connection is very slow, with frequent interruptions.
Another problem that was strongly emphasized by most of the focus group participants was related to the examination system and the distribution of marks. The students emphasized that the long period between a specific module and the end year examination, with no pre-examination revision, make them poorly prepared for the final examinations-“Because there is a long period between the course and the end year examination and as there is no repetition of the subject till the end of the year, we forget most of the information about the subject, especially the theoretical information”.
The participants thought that the examination system was unfair, as they indicated that the simple questions usually went to the 1st group which took the specific modules and that the later groups were subjected to difficult questions-“The first groups get the common and simple questions and only the difficult and rare questions will remain for the last groups”.
The participants also complained about the unfair distribution of marks, with no consideration of the in-course performance-“Small group teaching is a very interesting idea, but the assessment is not fair, because it does not differentiate between those who regularly attend the classes, prepare the subject and take part in the discussions and those who do not participate. Everything depends on the written examination”.
Another important issue which was frequently mentioned by the focus groups was related to the syllabus. The participants complained about the lack of a clear syllabus which was distributed at the beginning of the course. The syllabus was focused mainly on the theoretical sessions, with frequent changes in it, without a prior notification to the students.
Examples of the quotations which were related to the syllabus included
Many times, the syllabus is changed at the last minute. We prepare for a subject and when we come to the lecture hall, we find that another subject is being taught.
In the beginning of the year, there was no syllabus. The syllabus was distributed after two weeks.
For the practical sessions, we do not have a syllabus, but for the theoretical sessions, they give us the schedule at the beginning of each course. Even the latter is not fixed, as many changes occur in the topics and among the lecturers during the course.
Another problem that was emphasized strongly by the participants was related to the teachers’ performances and commitments. Some students thought that the teachers had not changed their ways of teaching after the implementation of small group teaching and that many of them were very busy. They had many other commitments that hindered them from adopting themselves to the new teaching method or from regularly updating their knowledge.
Examples of the relevant quotations included
Most of the teachers just give lectures in the same way as they give lectures to a large number of students. However, some of them make the lectures more interactive.
Most of the teachers are doctors and they have other commitments. So, they do not have time for updating their lectures and information.
Other problems which were raised by the participants were related to a lack of orientation to small group teaching, a lack of the students’ involvement and tiredness of the students.
Examples of the relevant quotations are shown below
We criticize this system because before starting this system, they did not ask for our opinion.
We thought that we faced some problems because this year was the first year of implementation of this system.
There was no orientation in the beginning of the process and no training on small group teaching.
There were overloads of the subjects and the place. Sometimes, we did not know where we had to go to attend the lectures.
Suggestions for improving small group teaching
The participants made many suggestions to improve this experience of small group teaching. The main emphasis was on changing the assessment system, with the focus mainly on the end of the course examinations, rather than on the end year examination and having clinical revisions before the final year examinations.
Examples of the relevant quotations included:
The end year examination should be cancelled and the end course examination and the in-course assessment should be largely depended upon, because we feel that there is no difference between those who study daily and take part in the discussions and those who do not participate but just study before the examination.
The examination system should be changed. We have to either have an end course examination or the end year examination.
The participants also indicated that the curriculum should be revised and that the students should participate in designing the curriculum-“One textbook should be selected for each subject and all the teachers should depend on this textbook, to avoid conflict between the students and the teachers regarding the answering of the questions during the daily sessions and during the examinations”.
The participants emphasized the importance of the proper orientation of the students and teachers before the implementation of a new teaching system and the necessity for providing training courses to the teachers, to be able to adopt to the new system effectively.
Examples of the relevant quotations included:
A training course should be conducted for the teaching staff on the management of the small group teaching, because most of the teachers teach in the same way as they do in large group teaching and we do not feel any difference between their teaching in small groups and large groups.
More orientation should be given to the students, to let them know what exactly small group teaching means and what is required from them before the beginning of the course.
Small group teaching is a very good idea, but I think that it is better if it is implemented in the early years of the study, ie. in the 1st and 2nd years. Another point is that the teachers should be oriented on how to manage small groups and the study subjects should be more specific and clear.
The participants also emphasized the need for improving the infrastructure and the teaching facilities and a better organization and management of the system-“Preparing suitable teaching halls for small group teaching and providing all the necessary teaching facilities in lecture rooms”.
Other suggestions included a more active students’ involvement, and preparation of the syllabus in advance, as described below:
I think it is better to be implemented in the early years of the study e.g. in the 1st and 2nd years. Another point is that the teachers should be oriented on how to manage small groups and the subjects should be more specific and clear.
The department should provide us with a schedule of the clinical sessions, to avoid repetition of the cases and to cover all subjects through the study of different cases.
DISCUSSION AND CONCLUSION
This study aimed to explore the perspectives of the medical students on the small group teaching at Hawler College of Medicine, to identify the main problems which were faced by this system and the opportunities for its improvement. Even though the experience of small group teaching at Hawler Medical College was relatively new, the participants were generally satisfied with the principles of small group teaching in medical education. They appraised the role of small group teaching in increasing the focus of the students, encouraging a student-teacher interaction and building a better relationship between the teachers and students. Several studies have reported the advantages of small group teaching, which include, an increased retention of knowledge, increased opportunities for asking questions, enhanced learning to solve problems, an enhanced transfer of concepts to new problems, an increased student interest, improved self-directed learning skills and an enhanced ability to work as a team [1, 11, 12]. In fact, an increased student-faculty and a peer-peer interaction improves the communication skills and they provide the opportunity to clarify the points of confusion. Furthermore, a small group size offers opportunities for interactive demonstrations and the student participation, that are impractical in formal lectures [1, 7].
Among the problems which were faced by the experience of small group teaching, the participants particularly emphasized the poor infrastructure and the lack of appropriate teaching facilities for small group teaching. It has been reported that the main disadvantages of small classes include the need to employ a larger number of teachers and to invest on the infrastructure, like the construction of new classrooms [4]. This is of particular concern in the developing countries and in resource-constrained settings, where the financial allocations are limited. In fact, the building of Hawler College of Medicine was not designed to be a college; it was initially set to be a nursing school. A limited extension or renovation was done for the building to become more suitable to be used as a college. Wars, civil strife and sanctions in Iraq and the Kurdistan region during the last few decades have affected the development of medical education and the availability of appropriate teaching facilities and resources [13, 14].
The participants of the focus groups were particularly concerned about the examination system and the distribution of marks. Even though, a part of the discussions was frequently going beyond the issue of small group teaching, proper setting of the examination system and the distribution of marks is essential for insuring fairness in any change in the teaching system. The competitive nature in the medical education and the effect of marks on the future of the students, make examination an important concern for them. A transition from the traditional didactic lectures to this new teaching method will need more preparation. The importance of the issue of examinations and the distribution of marks was also evident in the suggestions which were made to improve the system.
Many other problems like preparation of the syllabus, the poor orientation of the students and teachers and the teachers’ performances and commitments, are related to the organization and management issues, that need to be strengthened, as also is the need for a better preparation for such a change in the teaching system. What actually goes on in small group teaching may at first sight, seem like a mystery to the tutors and students alike [2]. The transitions between the various teaching and learning styles should be subtle and gradual and they require good preparation and orientation among both the students and the teachers [15].
Through the focus group discussions, a new approach was used in the Iraqi context, to guide the scope of this study. Our findings highlight the importance of using qualitative data to facilitate an in-depth and a wider understanding of the challenges which are faced by the new experience of small group teaching. The inclusion of students from the final three years of the college would maximize the exploration of different perspectives within a group setting. The results, therefore, give a reasonable representation of the students and of different opinions and concerns. Although the participants were selected from only one medical school instead of having the sample of a national population of medical students, it is believed that the selection criteria do not differ dramatically between medical schools. Further, the active participation of most of participants in the discussions may indicate that the sample represented the medical student population as a whole.
This study, like any qualitative study, can be subjected to trustworthiness and limitations, particularly in terms of its credibility, dependability and transferability [16]. However, this study had a clear focus and the processes of the data collection and analysis have confidently addressed this focus. The study was also carried out over a limited period of time and therefore, it had a fair dependability. The main limitation of qualitative studies remains the inability in generalizing the findings. However, the data have been carefully collected and analyzed and it was aimed largely at understanding, instead of seeking explanations [17]. The focus group climate was also open and the respondents were free and comfortable to share their information; however; an underestimation cannot be ruled out.
These findings may provide insight for the college management and teachers to improve the medical education system. They may also inform and influence the managers at the university and ministry levels and the policy makers about the wider contextual issues which affect the medical education system in Iraqi Kurdistan. Additionally, more research is needed to explore the perspectives of the teachers and the college administration with respect to the effectiveness of this small group teaching experience.
The concept of small group teaching was well received by the students and many positive aspects of this approach have been highlighted. However, this experience witnessed many problems and it faced different challenges that need better preparations, organization of the resources and orientation of the students and teachers, to insure its success.