DILs, RATs, and SGLs: a primer on team-based learning
Three-letter acronyms* figure heavily in medicine and medical education. Three of these that are intertwined in much of our pre-clerkship classroom-based learning are DIL, RAT and SGL.
These abbreviations are for three key learning event types that, when combined, comprise Michaelsen’s Team-Based Learning (TBL) model. This form of teaching unfolds in three steps and is designed to make best use of students’ and teachers’ time and expertise. The steps are:
Students receive preparatory materials either in a lecture, in a Directed Independent Learning (DIL) assignment, in a module, in previous courses, or preparatory readings. This material is typically fact/knowledge-based information.
Students’ understanding of this material is assessed in some way. This could be through formal Readiness Assessment Tests (RATs). These tests consist of 10-12 multiple choice questions. Each student completes an individual RAT (iRAT), then complete the same quiz in their SGL group (gRAT). The instructor then takes up any questions with which groups had difficulties. This could also be assessed via an online self-assessment quiz or some other method (e.g. completing a previous unit).
Having completed the preparation material, been assessed on their readiness, and having problem areas explained, students are ready to apply this knowledge through cases and problem solving application exercises, what we call Small Group Learning (SGL) session.
Directed Independent Learning (DIL) sessions provide content delivery, followed by Readiness Assessment Tests (RATs), culminating in Small-Group Learning (SGL) events where students engage in application exercises.
SGL sessions provide an opportunity for students to apply material they have already learned in order to extend their learning. Specifically, application exercises:
- Help students develop understanding and apply the course material.
- Address any misconceptions that may have developed, as students apply and integrate knowledge (Kubitz & Lightner p. 66).
- Provide opportunities for students through practice, to transfer what they learned to application questions (Kubitz & Lightner p. 67).
- Ensure students integrate “several different skills to answer application questions that require transfer of learning,” including accessing prior knowledge and identifying which knowledge applies and which does not (Kubitz and Lightner p. 67, citing Ambrose, Bridges, DiPietro, Lovett, & Normal, 2010).
This model means most of non-lecture classroom-based time will be students working in their small groups of seven to eight students. The instructor’s role is to design the cases, ask challenging questions and then emphasize, reinforce, highlight, and clarify key teaching points throughout the session through the case debriefs.
Case application questions balance the line between too easy and too hard:
If questions are too easy: Can’t have spirited discussion when all teams agree on answers.
If questions are too hard: Predictable frustration if groups of well-prepared students cannot arrive at the most reasonable answer because question has design flaws or requires outside knowledge
Here are eight great types of questions that can be incorporated into application exercises:
- What is the key phrase in the case that will cause you to proceed down a particular path?
Change a variable:
- If variable X is changed in the case, how would your approach change?
- You can only order one test from this list. Which is the best one to choose? Why?
- What is the BEST choice, given the case history? Why?
- What’s the NEXT best choice to make?
- Give groups the decision, then ask them to provide a rationale for it.
- Given a particular pathophysiological insult, have groups determine what caused it.
- Given the case history and a particular course of action, what will the outcome be?
- Rank tests, procedures, medications, in order of importance vis-à-vis the case history or learned protocol. Have the group explain why they decided on that order.
If you’re a faculty member looking for assistance with preparing to teaching using TBL methods, please get in touch. If you’re a student with feedback on a particular SGL session or TBL in general, please get in touch, too. Reach me at firstname.lastname@example.org
* As an aside, TLA is the three-letter acronym for three-letter acronyms.
Sweet, M. & Michaelsen L.K. (eds) (2012) Team-Based Learning in the Social Sciences and Humanities. Sterling, Virginia: Styllus Publishing LCC (and Kubitz & Lightner in this volume)
Harris, S.A. and Watson, K.J. (1-1-1997), Small Group Techniques: Selecting and Developing Activities Based on Stages of Group Development. University of Nebraska- Lincoln. digitalCommons@University of Nebraska – Lincoln Paper 378
Five ways being a Geneticist helped me improve my teaching skills
By Andrea Guerin, Year 2 Director and Clinical Geneticist
When growing up, the career choices offered are often dichotomous, do you want to be a lawyer or a firefighter, nurse or entrepreneur, doctor or teacher? In reality, most jobs are a blend of a few different skills. In medicine, doctors can be scientists, can run a business, and for most of us, being a teacher is a large part of our job. At first blush, being a Geneticist and a teacher doesn’t seem to have much in common, but my training in Medical Genetics has significantly influenced my role in education. Here are five examples I’d like to share:
Geneticists are wordsmiths. Language is very highly selected, “cause” not “reason”, “typical” not “normal” and “chance” not “risk”. The language I use with my patients is specific and inclusive, positive and hopefully, precise. Words are important, to convey meaning without an agenda, to educate without prejudice. I use the same thought in the classroom. I am mindful of the implicit biases that can be drawn from words. Words are powerful and their power needs to be recognized and headed.
Medicine is learning a new language. So is education. I’m not going to lie, I had never designed a small group session before coming to Queen’s and I certainly did not know what a Directed Independent Learning event was. When I came, I was disoriented, DILs, SGLs, RATs, GTAs. The terminology was overwhelming. But, like learning the language of medicine, I learnt the language of education too. We’ve added a few more in the past year in undergraduate medical education CBME, EPA, with only more to come.
Technology is forever changing, but good ideas stand the test of time
When I started my residency 10 years ago the understanding of genetic testing was very different. Many tests were not available. Testing was laborious, going from gene to gene, with months of anxious anticipation in between. Now, a decade later, I can order a test that looks at all the necessary genes of the body that have a purpose. Results can be available more quickly. Interpretation is more of a challenge, as we learn more, it becomes more evident the gaps in our knowledge and tying findings to patient symptoms can be a challenge. The concept of having parents and environment contributing to the health of the child is an old one, with influences from Ancient Greece to India. This testing is a reinvention of an old idea — we have only identified the individual factors (genes) that support what has been seen for thousands of years.
When I went to medical school, problem based learning was new. Powerpoint was a staple of lectures. There were almost no laptops. We would never have thought to work in groups while in the same classroom. That was an activity reserved for afternoon sessions, segregated into rooms under the watchful eye of a faculty facilitator. Marks were given from formal assessments, not team assignments or readiness assessment tests. That’s not to say assessments were not happening, they were just less formalized. It was a gut feeling. Did the clinical skills tutor think you were professional? Did the small group facilitator see that you participated? Now, assessments, both summative and formative are happening all the time. The actual process has become more concrete and transparent, but the idea has not changed.
It’s all developmental
Genetics is one of only a few specialties where the patient population spans from before cradle to grave. When I see a patient with a concern, I endeavour to find out when it started. An understanding of development, both physical and emotional, is key to my practice. You must walk, before you run.
Education is no different. The expectation must be adjusted to where the student is in their education journey. It’s okay to not know the differential in the first year, but in fourth year, students must be equipped with the knowledge and expertise to generate a differential and initiate management. Expectations need to match where the learner is, just like my patients.
No person is an island
Genetics is a team sport. In clinic, amongst clinician and researchers spanning the province, country or world, we work together to solve diagnostic mysteries and provide good patient care.
Education is the same. Teachers, admin support, education support, technical support and student support and feedback are essential to the teaching process. Behind every teacher, there is a team supporting them in their journey.
Comfortable with the uncomfortable concept of unknowns
After years of education, I will never be done learning. There is always more to learn, and no physician, despite years of practice and experience knows everything. When I counsel patients I always raise the possibility of an unknown. A confusing result, a question left unanswered. There is no crystal ball.
Education continues to surprise me, but I am open to the concept of something new, unknown. Can we produce excellent physicians using different teaching methods? Of course we can. Each of my colleagues had different curricula, different forms of instruction. There is more than one way to teach — the “best way” is still unknown.
What’s in a name? That which we call a rose
By any other name would smell as sweet.
So mused the ill-fated heroine in Romeo and Juliet, about her equally ill-fated love.
In medicine and in teaching, however, names can mean a lot.
The late Dr. Kate Granger of the United Kingdom was one of the strongest advocates for using names with her #hellomynameis campaign – launched while she lived with terminal cancer. As explained in a BBC article following her death in July 2016, the campaign “encouraged healthcare staff to introduce themselves to patients.”
“A by-product of her own experiences of hospital in August 2013, it grew out of the feelings of unimportance she experienced when the doctor who informed her that her cancer had spread did not introduce himself,” the BBC wrote. Granger had explained it this way: “It’s the first thing you are taught in medical school, that when you approach a patient you say your name, your role and what you are going to do. This missing link made me feel like I did not really matter, that these people weren’t bothered who I was. I ended up at times feeling like I was just a diseased body in a hospital bed.”
Learning and using names is important for both teachers and students, long before they reach patients’ hospital beds. For this reason, we emphasize the importance of names in our UGME classrooms and clinical skills environments, too.
“Learning students’ names signals your interest in their performance and encourages student motivation and class participation,” writes Barbara Gross Davis in Tools for Teaching. “Even if you can’t learn everyone’s name, students appreciate your making the effort.”
One of the strategies of learning students names that Gross Davis (and others) suggests is one we’ve adopted at Queen’s UG: having students use name tent cards in the classrooms. This was adopted for two reasons, Dr. Lindsay Davidson, Director of Teaching, Learning, and Integration explains.
“It’s because we start developing professional identity from Day 1, and being a doctor means introducing who you are.”
“And because it helps build relationships,” she adds. “Student-student but also teacher-student—teachers can respond to students as individuals with names not ‘the guy in the ball cap’.”
“We expect all medical students to wear identification nametags for all clinical skills sessions, both in-house and when at health facilities,” says Clinical Skills Director Dr. Cherie Jones. She notes that the Year 1 students don’t have these on Day 1 as these are provided by KGH. “We use paper ones until they are done!” Once the official badges are available, they must be worn.
And it’s not just for students: clinical skills tutors are expected to wear their ID that they use in their clinical settings.
And for all those (like me) who’ve become accustomed to wearing an ID card on a lanyard or on a hip-level clip: IDs are to be worn on the lapel of the jacket—where they can best be seen
“Name tags are important in clinical skills sessions because the Standardized Patients (SPs) and Volunteer Patients (VPs), like to know the names of the students and tutors they are working with and don’t always understand or hear the name when the student introduces themselves,” Dr. Jones explains.
The Clinical Skills policy mimics the name-badge policies at the hospitals in Kingston. “Name tags in clinical settings like KGH are mandatory for anyone interacting with patients, staff, even with visitors,” Dr. Jones points out.
“Not only is it policy in the hospital, but patients like being able to read anyone’s name – not just the students’,” adds Kathy Bowes, Clinical Skills Coordinator.
So, remember your ID badge, use your name tent cards in the classrooms, use people’s names. And me, I’ll be pinning my hospital ID badge in the right place the next time I’m heading over to KGH for a meeting.
Because names matter. To everyone.
Teaching, Learning and Integration Committee Summer Update
By Lindsay Davidson, Director of Teaching, Learning, and Integration
As classes (at least in years 1 and 2) have now ended, and teachers are perhaps thinking about courses that will resume in the fall, I wanted to provide you with an update of items from the TLIC. Some of these may already be familiar to you, but perhaps some are “new”. If you need any further information, please feel free to contact me directly or one of our Educational Developers (Theresa Suart from Years 1 and 2 and Sheila Pinchin for Clerkship and the “C” courses).
- Resources attached to learning events – these include lecture notes, classroom slides, required pre-class readings and optional post-class readings/resources. MEdTech is enabling a new feature for the upcoming academic year. Teachers will be required to review and “publish” each resource every year – with the option of adding in delayed release if appropriate. The goal of this is to provide students with an up-to-date, curated set of resources, deleting old files. Please direct any questions about this to Dr. Lindsay Davidson.
- Remember: “less is more”: Students report that when there are an excessive number of files, they often read few/none of them in advance.
- Clearly designate what is MANDATORY to review PRE-CLASS by indicating this in the “Preparation” field on the learning event, and checking the appropriate boxes on the menu when you review the resources.
- AVOID using dates on your slides/slide file names – students are sometimes disappointed to see that the file dates from 2009 or prior.
- The Curriculum Committee has approved a new learning event type – “Games” – reflecting several sessions already existing in the curriculum. This is defined as “Individual or group games that have cognitive, social, behavioral, and/or emotional, etc., dimensions which are related to educational objectives”. This type of activity might include classroom Jeopardy or other similar activities designed to allow students to review previously taught knowledge (content delivered either independently or in the classroom) and to provide them with formative feedback on their understanding. The instructional methods approved by the Curriculum Committee include:
Please direct any questions about this to Theresa Suart.
- Workforce – The Workforce Committee has recently adopted some changes including the following:
- Addition of credit for teachers who grade short answer questions or team worksheets
- Doubling of credit for teachers who develop new (or significantly renovate) teaching session
- Limit of one named teacher per DIL event
- Limit of one teacher per SGL event (gets additional credit to reflect session design, learning event completion, submission exam questions); additional teachers credited as tutors (credit for time in the classroom) – the Course Director may be asked to clarify who is the “teacher” and who is/are the “tutors”
- Reduction of credit for large classroom sessions (that are not new/newly renovated and/or do not involve grading)
Please direct any questions about this to Dr. Sanfilippo.
- Tagging of Intrinsic Role objectives. The TLIC and the Intrinsic Role leads recently held a retreat. One of the items that was identified was “overtagging” of sessional objectives with intrinsic role objectives such as communicator, collaborator, professional etc. by well meaning teachers. We are undertaking a comprehensive review of how these Intrinsic Roles are taught/assessed in the curriculum and would ask teachers/course directors NOT to tag sessions with these unless there has been a direct communication with the relevant Intrinsic Role lead.
- Communicator: Dr. Cherie Jones: email@example.com
- Collaborator: Dr. Lindsay Davidson: firstname.lastname@example.org
- Leader: Dr. Tony Sanfilippo: email@example.com
- Advocate: Dr. Jenn Carpenter firstname.lastname@example.org
- Professional: Dr. Rachel Rooney rooneyr@KGH.KARI.NET
- Scholar: Dr. Heather Murray email@example.com
Please direct any questions about this to Dr. Lindsay Davidson.
- DIL feedback from students. Over the past year, we have received useful feedback from students regarding the content and structure of Directed Independent Learning (DIL) sessions in Years 1 and 2. This will be collated and communicated to Course Directors shortly. Theresa Suart will be in contact with teachers/Course Directors should any sessions be identified for review/revision.
- Online modules. We have developed a process to facilitate the development of high quality online modules, often used as resources in DIL session. These are highly appreciated by students and are used for review in clerkship as well as pre-MCC exam. The current list of modules is available here: https://meds.queensu.ca/central/community/ugme_ecurriculum If you would like to create (or revise) a module for your course, please complete the linked intake form: https://healthsci.queensu.ca/technology/services/elearning/online_learning_modules/get_help
- New wording of learning event notices. You may have noticed this over the past year. The wording of the 3 email notices received by teachers has been revised. In particular, it has been streamlined and customized to provide specific, focused reminders prior to the scheduled teaching. We would appreciate any feedback or suggestions that you have about this change.
- Video capture In 2016-17, lecture sessions were video captured in select year 1 and 2 classes. We will be analyzing how these videos were used by students over the summer and will likely be continuing this into the fall. Please provide any feedback or comments that you have about this pilot to Theresa Suart.
Feel free to get in touch:
- Dr. Lindsay Davidson – firstname.lastname@example.org
- Sheila Pinchin – email@example.com
- Theresa Suart – firstname.lastname@example.org
Decoding Learning Event Types
Tucked on the right-hand side of every Learning Event Page on MEdTech are notations about the date & time and location of the class, followed by the length of the session and then the “Breakdown” of how the time will be spent. In other words: the learning event type.
We use 14 learning event types* in the UGME program. The identification of a learning event type indicates the type of teaching and learning experience to be expected at that session.
Broadly speaking, our learning event types can be divided into two categories: Content Delivery and Content Application.
For content delivery, students are presented with core knowledge and/or skills with specific direction and/or commentary from an expert teacher. Content delivery learning events include:
- Directed Independent Learning (DIL) — these are independent learning sessions which are assigned curricular time. Typically students are expected to spend up to double the assigned time to complete the tasks – i.e. some of the work may occur in “homework time”. DIL’s have a specific structure and must include:
- Specific learning objectives
- A resource or set of resources chosen by the teacher
- Teacher guidance indicating the task or particular focus that is required of students. This may be a formal assignment, informal worksheet or study guide.
- The session must link to a subsequent content application session
- Formative testing in the form of MCQ or reflective questions are an optional component of DILs
- Lecture – Whole class session which is largely teacher-directed. We encourage the use of case illustrations during lectures, however these alone do not fulfil the criteria for content application or active learning.
- Demonstration – Session where a skill or technique is demonstrated to students.
For content application (sometimes described as “active learning”), students work in teams or individually to use and clarify previously-acquired knowledge, usually while working through case-based problems. These learning event types include:
- Small group learning (SGL): Students work in teams to solve case-base problems which are revealed progressively. Simultaneous reporting and facilitated inter-team discussion is a key component of this learning strategy which is modeled on Team-based learning. SGL cases may be preceded by in class readiness assessment testing (RAT) done individually and then as a team. This serves to debrief the preparation and provide for individual accountability for preparation.
- Facilitated small group learning (FSGL): Students work in teams and with a faculty tutor to solve case-base problems which are revealed progressively. While there is structure to FSGL cases, students are encouraged to seek out and share knowledge based on individual research.
- Simulation: Session where students participate in a simulated procedure or clinical encounter.
- Case-based Instruction (CBI): Session where students interact with guest patients and/or health care providers who share their experience. Builds on prior learning and often includes interactive Q+A component.
- Laboratory: Hands-on or simulated exercises in which learners collect or use data to test and/or verify hypotheses or to address questions about principles and/or phenomena, such as Anatomy Labs.
The other learning event types we use don’t fit as neatly into the content delivery/content application algorithm. These include:
- Clerkship seminar – instruction provided to a learner or small group of learners by direct interaction with an instructor. Depending on design, clerkship seminars may be either content delivery or content application.
- Self-Directed Learning (SDL) is scheduled time set aside for students to take the initiative for their own learning. A minimum of eight hours per week (pro-rated in short weeks) is designated SDL time.
- Peer Teaching is learner-to-learner instruction for the mutual learning experience of both “teacher” and “learner” which includes active learning components. This includes sessions that require students to work together in small groups without a teaching, such as Being a Medical Student (BAMS) sessions, the Community Based Project and some Critical Enquiry sessions.
- Career Counseling sessions, which provide guidance, direction and support; these may be in groups or one-on-one.
Two other notations you’ll see are “Other-curricular” and “Other—non-curricular”. Other—curricular is used for sessions that are directly linked to a course but that are not included in calculations of instructional methods. This includes things like examinations, post-exam reviews, and orientation sessions. Other—non-curricular are sessions of an administrative nature that are not directly linked to a particular course and are outside of curricular time, for example, class town hall meetings and optional events or conferences.
Incorporating a variety of learning event types in each course is important to ensure a balance of knowledge acquisition and application. Course plans are set by course directors with their year director, in consultation with the course teachers and with support from the UG Education Team and the Teaching, Learning, and Integration Committee (TLIC).
— With contributions from Lindsay Davidson, Director of Teaching, Learning, and Integration
*In 2015, Queen’s UGME adopted the MedBiquitous learning event naming conventions to ease sharing of data amongst institutions. For this reason, some learning event type categories may be different from ones used here prior to 2015, or ones used at other, non-medical schools or medical schools which have not adopted these conventions.
Year in Review? Why wait until then?
When I worked as a journalist (about a million years ago), an annual task was writing “Year in Review” articles. These were summary or “round up” stories with the highlights of the previous year.
The stated intent was historical record, reminders and reminiscing; marking highs and lows, significant events and momentous occasions. On a more practical level, these stories could be compiled fairly easily, mostly in advance, and take up copious column inches in our weekly paper in the week between Christmas and New Year’s when nobody was reading anyway and the editorial staff wanted to take extra time off from covering newer news. Closely tied to these were “Resolutions You Should Make Now!” advice columns.
With this cultural backdrop assigning retrospection to the turn of the year, it’s easy to become cynical about such things—and reduce thoughtful review to top-ten lists and cliché-ridden commentary. For educators, however, the importance of review should not be treated so lightly. Review and reflection are important. We expect our learners to do it. Educators should give it just as much attention.
Review and reflection are integral to effective teaching practice. January is a great time for this, but so is June, or September, or some other month. Right now, for some, a semester has recently ended, for others, it’s just beginning. There are benefits to both retroactive and proactive review – and in doing it more frequently than an annual check-mark on a to-do list.
So, instead of a ‘year in review’ summary, or even a list of new year’s resolutions for medical education, here’s a sample framework for incorporating review into your teaching practice. (Use it annually, or more often, as needed).
Theresa’s Five Step Review and Revise Process
Step 1: Review & Reflect
Whether you’re considering a whole course, a few teaching sessions, or a single seminar or other learning event the process is the same. Consider:
- What happened? What worked? What didn’t? (If you’re forecasting: What could be some pitfalls? What am I worried about?)
- For anything that didn’t go well, or didn’t accomplish what I planned: How can I fix it? (Forecasting: Do I have a back-up plan? Do I need one?)
- What’s a manageable change? Do I have the knowledge, skills and ability to do this? Where can I get support and/or resources? (Forecasting: Do I have the resources I need? What kind of feedback could be helpful to me on my teaching sessions?)
Step 2: Reconsider
Once you’ve reflected on what’s happened, or what you have planned, consider:
- Did I meet my objectives (or will my plan meet my objectives)?
- Are there things I did (or I’m planning) that are just out of habit?
- What should I change to make my course/session/seminar more engaging/relevant/appropriate?
Step 3: Find Resources
When you revise your teaching plans, you may also need additional resources. This could be in the form of your own skills, materials, input from colleagues. Consider:
- What support do I need to get to where I’d like to be?
- Do I have the abilities to do what I plan? If not, how could I acquire the necessary skills?
- Are there existing materials that could help me? Do I need to develop new materials? Who could help with that?
- Who could I call on for support or assistance?
- What sort of time frame do I have?
Step 4: Refine your plan
Sometimes, what we’d like to do just isn’t in the cards this year—there can be a lot of constraints on our teaching in time, materials, scheduling. It’s important to refine revisions into things that are manageable and realistic. Sometimes you are in a position to make large-scale changes to how you deliver your learning events, other times, not. Avoid the “all-or-nothing” plan: Incremental changes are better than no changes. It’s better to be good, than to be perfect. Consider:
- How realistic is my plan?
- Are there things I consider “must haves” and things that are “nice to haves”?
- If I could only make one change in my teaching right now, what would it be?
Step 5: Reflect & Review
At the end (or the beginning) – take another look. Good teaching really is an iterative process with the cycle of review, revision, redeliver.
Sometimes the best way to review and reflect (and plan) is to talk it out with a colleague. Bouncing around ideas can bring new perspectives and inspire you and others to add to your teaching toolbox. If you’d like to chat about your teaching any time, get in touch with the Education Team.