Small groups, big possibilities: radical pedagogical approaches to critical small-group learning in medical education

As a medical learner, I attended countless small-group teaching sessions. My experiences within and opinions about small-group learning were continuously remodeled throughout my education. What emerged was an appreciation for the ways in which small-group learning facilitated a shared space for the co-creation of knowledge with peers, and a recognition of the harmful ways in which it seemed to uphold normative learning and oppressive hierarchies within medical education. Now a resident teacher, I find myself in search of ways to radicalize small-group learning in medical education. As you recall your own experiences with small-group learning: Who was there? Who felt safe enough to speak up? How were racist and otherwise oppressive perspectives—whether individual or systemic—addressed within the shared educational space? In this article, I share some of what I’ve learned to date about existing pedagogical approaches to small-group teaching and where we can go from here.

Small-group learning is defined by three distinct characteristics, including active participation, an identifiable and specific task, and facilitated reflection.¹ Examples of small-group learning commonly encountered in medical education may include tutorials, free-discussion, clinical teaching, simulations, problem-based learning, and team-based learning.¹

Vygotsky, a psychologist working in the late 19th and early 20th centuries, is perhaps best known for his work on social constructivism, an influential and foundational concept when it comes to small-group learning.² Social constructivism offers educators a theoretical framework that assumes learning is collaborative and facilitated by social interaction.² Within a social constructivist approach, the educator will recognize the influence of each learner’s sociocultural context and view such ‘scaffolding’ as not only valuable but critical to the collaborative learning process.² In pedagogical terms, this means a small-group facilitator ought to guide rather than instruct their learners, view learners as ‘active co-constructors of meaning’, approach the completion of each task as a learning opportunity, and leverage assessment as a means of achieving shared understanding.²

Vygotsky’s ideas about socially-constructed learning are attractive, but is the application of this and similar theories to small-group learning in medical education the right approach? While small-groups offer the potential for highly effective learning, Gibbs et al. at the London School of Economics and Political Science argue that small-group learning, in its disproportionate emphasis on participation—or in Vygotsky’s terms, co-construction— can inadvertently contribute to the maintenance of harmful power dynamics by centering a normative pedagogical principle of inclusion and democratization of learning that feigns critical engagement with the racist underpinnings of the institution.³

In a sociopolitical climate that necessarily calls on the Western medical institution to deconstruct its racist and colonial foundations, it is crucial to not only restructure educational content but also transform its delivery in a way that facilitates a truly diverse, equitable, and inclusive educational space for learners. If conceptualized and delivered in an anti-racist and decolonized fashion, small-groups may offer a unique environment in which teachers and learners may collaboratively apply nontraditional and potentially transformative pedagogical approaches in order to facilitate critical small-group learning.

An examination of the literature reveals several promising methodologies, including dialogic pedagogy, intersectional feminist pedagogy, and a relationship-centered approach to small-group facilitation, for generating a critical small-group learning environment in medical education^3,4,5

Dialogic pedagogy, described by Skidmore et al. as a critical and collaborative interrogation of the topic of study, invites facilitators to view learning as ‘psychologically transformative rather than additive.’⁴Small group teachers who assume a dialogic pedagogical approach will leverage the journey of learning as fundamentally of educational value, rather than giving emphasis to the destination. Through ‘exploratory talk,’ learners in a small-group setting can shape classroom discourse,⁴ thereby potentially contributing to the eradication of power differentials in a small-group setting and enabling systems transformation. Similarly, Fryer-Edwards et al. highlight a relationship-centered pedagogical approach to small-group facilitation that views the educational exchange as a process.⁵ This process is marked by three distinct teaching practices, including identifying the learning edge of each individual participant, proposing and testing hypotheses to help learners meet their goals, and calibrating learners’ self-assessments to reinforce strengths.⁵ Finally, Gibbs et al. challenge current definitions of inclusion-as-participation using an intersectional feminist pedagogy and critical pedagogical approach to inclusive teaching.³ Specifically, intersectional feminist pedagogy invites facilitators to consider that ‘all speech is not free’ and practices like ‘refusal, silent listening, and reflexive critique’ should also be considered forms of equal participation.³ Certain practices such as establishing group agreements and engaging in circle discussions may serve to promote participation but they are likely not sufficient to facilitate inclusion.³

Small-group facilitators should consider the importance of critical small-group learning that steps outside current pedagogical norms within medical education and can leverage existing pedagogies such as those described here to begin transforming their practice.

Funding Statement

Funding: There was no funding for the completion of this work.

Conflicts of Interest

The author does not have any conflicts of interest due to financial or personal relationships that could potentially bias this work.