Developing Educational Leaders: The Teaching Scholars Program at ...

Medical Education Fellowships

Developing Educational Leaders: The Teaching Scholars Program at the University of California, San Francisco, School of Medicine Jessica H. Muller, PhD, and David M. Irby, PhD

Abstract A Teaching Scholars Program (TSP) was established in 1998 in the University of California, San Francisco (UCSF), School of Medicine with the mission of building knowledgeable and skilled educational leaders, teachers, and scholars. Conducted through the Office of Medical Education (OME), the TSP is a 10-month program that accepts 12 scholars per year. Financial support for the program, including salary support for co-directors and staff, is provided by the OME. Scholars’ departments are required to provide release time for one afternoon per week for 10 months. The TSP provides participants with an intensive weekly seminar series,

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n 1998, a Teaching Scholars Program (TSP) was established at the University of California, San Francisco (UCSF), School of Medicine with the mission of creating knowledgeable and skilled educational leaders, teachers, and scholars. This 10month program provides scholars with an intensive weekly seminar series, collaborative learning experiences, mentored projects, and a network of educational colleagues. Background: Improving UCSF’s Educational Mission

A 1996 site visit by the Liaison Committee on Medical Education survey team resulted in a report that criticized the UCSF medical

Dr. Muller is professor, Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California. Dr. Irby is vice dean for education and professor of medicine, University of California, San Francisco, San Francisco, California. Correspondence should be addressed to Dr. Muller, Box 0900, Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA 94143-0900; telephone: (415) 476-6051; e-mail: ([email protected]).

collaborative learning experiences, mentored projects, and a network of educational colleagues. The weekly seminars use an interactive format to address topics within seven targeted areas: (1) learning theory; (2) teaching methods; (3) curriculum development/ evaluation; (4) assessment of learning; (5) leadership and organizational change; (6) career development; and (7) educational research. Since its inception, 76 scholars have graduated from or are currently enrolled in the TSP. The majority are clinicians at assistant professor rank, although four basic scientists, two medical students, and three OME staff members have also

school curriculum and its lack of educational leadership and curricular oversight. In response to these criticisms, the dean of the School of Medicine sought to make the educational mission equal in quality to the research and patient care missions of the school. In 1997, he recruited a new vice dean for education to pursue this goal. Planning for curriculum reform commenced in 1998 and resulted in a transformation that began in 2000. Integral to the curriculum redesign effort was the creation of an Office of Medical Education (OME) by the vice dean for education. The OME was formed to support UCSF’s educational enterprise across the continuum of medical education, develop the school’s electronic curriculum and educational technology, strengthen the school’s educational research efforts, and expand its faculty development program. The OME launched the TSP and a school-wide faculty development workshop series in 1998. Other OME educational initiatives have included the development of educational research and evaluation resources, an Office of Educational Technology, a Clinical Skills Center,

Academic Medicine, Vol. 81, No. 11 / November 2006

participated in the program. The TSP is highly valued by participants, and preliminary evaluation data suggest that the program has resulted in an increase in educational research, scholarly activities, and the number of skilled and knowledgeable faculty with major leadership roles in medical education at UCSF. Challenges facing the TSP include scholar release time, mentoring time, and follow-up contact to encourage TSP graduates’ postgraduation productivity, continuing educational development, and support. Acad Med. 2006; 81:959–964.

Fellowships in Medical Education Research, and a Medical Education Fellowship for students between their third and fourth years. In addition to the TSP, other faculty development activities have emerged at UCSF. The OME sponsors a general faculty development workshop series throughout the year. Most of these halfday instructional improvement workshops are offered on Tuesday afternoons to allow the scholars to attend. Through the OME we also run faculty development sessions focusing on how to lead discussions effectively for small-group leaders who teach in the first two years of the curriculum. The Department of Family and Community Medicine and the Department of Internal Medicine have had year-long faculty development fellowship programs as well. We also send a cohort of faculty to the Harvard/Macy educational leaders courses annually. The scholarship of teaching and learning is supported by an educational researcher in the OME who works one-on-one with faculty members on their research and

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grant writing. There is also a weekly medical education journal club and works-in-progress series that prior, and occasionally current, scholars participate in, along with other faculty with an interest in educational research. Complementing all of these educational programs is the Haile T. Debas Academy of Medical Educators (AME), which was established at UCSF in 2001. The AME also provides faculty development opportunities, many of which are cosponsored with the OME. For a select few faculty members who wish to become independent investigators in medical education research, we offer a twoyear, 20% funded and mentored Fellowship in Medical Education Research. This is jointly sponsored by the OME and the AME. The TSP Administration

The TSP is conducted through the OME in the Office of the Vice Dean for Education. The co-directors share the development and teaching of the curriculum, while other faculty, staff, and consultants conduct specific sessions on such topics as literature searches, educational technology, educational research, and evaluation. Financial support for the program, including salary support for the codirectors and staff, is provided by the OME. The approximate cost of the program is $50,000 a year. The TSP does not offer stipends to its scholars; however, the scholars’ departments are required to release them from service responsibilities every Tuesday afternoon for 10 months as a prerequisite for admission to the program. The Teaching Scholars

The TSP targets UCSF School of Medicine faculty of any rank who are interested in enhancing their teaching and leadership skills as well as their educational scholarship. Applications are solicited from faculty at all UCSF primary teaching hospitals and programs, including the San Francisco Veteran’s Administration Medical Center, San Francisco General Hospital, UCSF Medical Center, UCSF Children’s Hospital, and the UCSF Fresno Medical Education Program. Applicants must submit an application form, curriculum vitae (CV), and goal statement, as well as a letter of support from their department chair or residency program director, who must guarantee release time for scholars on Tuesday afternoons for the

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duration of the program. The selection process is competitive. The program directors make the selection based upon applicants’ potential to become educational leaders (or current demonstration of educational leadership), ability to devote adequate time to the TSP in relation to their other responsibilities, and nature of their proposed goals and projects. In cases where multiple applications come from one department, the directors request additional information from the department chair to help make the decision. From 1998 through 2006, 76 scholars graduated from or are currently enrolled in the program. Table 1 lists demographic characteristics of current and graduated TSP scholars. Five individuals who were admitted did not complete the program because of illness, family obligations, or departure from the university. The number of individuals participating in the program each year has increased over time, from six in the first year to 12 in the last three years. The majority are at the assistant professor rank when they take part in the program. While most participants are clinicians, we have had four from the basic sciences, two medical students participating in the Medical Education Fellowship between their third and fourth years, and three staff members from the OME. Regardless of their backgrounds, all participants are expected to meet the same level of performance, and we have found that the nonclinicians’ perspectives and knowledge contribute greatly to group discussions. The TSP Curriculum

The overall goal of the TSP is to produce educational leaders for UCSF. The TSP provides scholars with the knowledge and skills needed to become educational leaders by offering them learning experiences in seven targeted areas: (1) learning theory; (2) teaching methods; (3) curriculum development and evaluation; (4) assessment of learning; (5) leadership and organizational change; (6) career development; and (7) educational research. The specific learning objectives are outlined in List 1. To complete the program successfully, scholars are expected to attend a weekly three-hour seminar, complete sessionspecific reading assignments and exercises before the seminar, assume responsibility for leading some of the

discussions, and complete a scholarly project. They are also encouraged to attend the school-wide faculty development workshop series sponsored by the OME, as well as to participate in a TSP mentoring program. The weekly seminars use an interactive discussion-based format to address topics within the seven target areas over the course of the year. List 2 highlights the curricular components of the TSP. We begin the year with a discussion of different learning theories and how they relate to clinical practice. This theme is picked up later in the year when we discuss technology and learning, and the literature on physician and teacher expertise in medicine. Interspersed throughout the year are sessions on teaching skills. These include large and small group teaching methods, one-onone clinical teaching skills, and team learning. We begin our examination of curriculum development and evaluation by discussing different curriculum models. Using the book, Curriculum Development for Medical Education: A Six-Step Approach by Kern et al.,1 we engage the scholars in the process of curricular design, implementation, and evaluation by asking them to bring to the group their own curricular projects as “cases” to work on in small groups. To address issues of assessment, we have sessions on reliability and validity, and performance and attitude assessments, as well as course, teacher, peer, and self-assessment. The focus of the leadership and organizational change module focuses on identifying different leadership styles, applying leadership skills, understanding how to bring about organizational change, and developing teams and coalitions. We define leadership as the ability to achieve remarkable results through others, and we expect every member of the group to exercise leadership in some arena. Career development encompasses sessions on career planning and academic advancement, mentoring, CV review, and preparation of the Educator’s Portfolio. Finally, we provide a series of seminars during the year on various aspects of educational research, including quantitative and qualitative research methods, defining research questions, searching the literature, and survey development. A typical TSP session begins with a brief introduction to the topic of focus by one



Table 1 Demographic Characteristics of Teaching Scholars in the University of California, San Francisco, School of Medicine Teaching Scholars Program from 1998 –2006 Demographic characteristics

No.

% of all scholars

Number of scholars 1998–2006 76 ......................................................................................................................................................................................................... 1998–1999 class 6 8 ......................................................................................................................................................................................................... 1999–2000 class 6 8 ......................................................................................................................................................................................................... 2000–2001 class 9 12 ......................................................................................................................................................................................................... 2001–2002 class 8 11 ......................................................................................................................................................................................................... 2002–2003 class 11 14 ......................................................................................................................................................................................................... 2003–2004 class 12 16 ......................................................................................................................................................................................................... 2004–2005 class 12 16 ......................................................................................................................................................................................................... 2005–2006 class 12 16 Rank at time of TSP participation ......................................................................................................................................................................................................... Professor 3 4 ......................................................................................................................................................................................................... Associate 12 16 ......................................................................................................................................................................................................... Assistant 49 64 ......................................................................................................................................................................................................... Clinical Instructors 2 3 ......................................................................................................................................................................................................... Fellows 4 5 ......................................................................................................................................................................................................... Chief Resident 1 1 ......................................................................................................................................................................................................... Medical Students 2 3 ......................................................................................................................................................................................................... OME Staff 3 4 Women 45 59 Department type ......................................................................................................................................................................................................... Clinical 67 88 ......................................................................................................................................................................................................... Basic science 4 5 ......................................................................................................................................................................................................... Other (medical students & OME staff) 5 7 Departmental affiliation ......................................................................................................................................................................................................... Medicine 31 41 ......................................................................................................................................................................................................... Pediatrics 8 11 ......................................................................................................................................................................................................... Family and Community Medicine 5 7 ......................................................................................................................................................................................................... UCSF Fresno Medical Education Program 5 7 ......................................................................................................................................................................................................... Psychiatry 4 5 ......................................................................................................................................................................................................... Anesthesia 3 4 ......................................................................................................................................................................................................... Otolaryngology 3 4 ......................................................................................................................................................................................................... Biochemistry 2 3 ......................................................................................................................................................................................................... Dean’s Office, School of Medicine 2 3 ......................................................................................................................................................................................................... Medical students 2 3 ......................................................................................................................................................................................................... Other (external to UCSF) 2 3 ......................................................................................................................................................................................................... Cellular and Molecular Pharmacology 1 1 ......................................................................................................................................................................................................... Dermatology 1 1 ......................................................................................................................................................................................................... General Surgery 1 1 ......................................................................................................................................................................................................... Laboratory Medicine 1 1 ......................................................................................................................................................................................................... Neurology 1 1 ......................................................................................................................................................................................................... Neurological Surgery 1 1 ......................................................................................................................................................................................................... Orthopaedic Surgery 1 1 ......................................................................................................................................................................................................... Pathology 1 1 ......................................................................................................................................................................................................... Physiology 1 1

of the instructors. Scholars may then be asked to reflect on and/or write about a personal experience or connection with the topic. Individual scholars then take turns leading the seminar discussion, based on the particular articles they had been assigned to read prior to the seminar. Interspersed throughout the discussion are interactive activities, such

as in-class writing assignments, break-out groups, or team learning activities. For example, in one of the sessions on learning theories, the scholars begin by identifying a powerful and purposive learning experience and describe what made it effective. In the ensuing discussion, scholars make connections from these experiences to theories of


learning. Scholars then write their own definitions of learning, which they exchange with others in the group. Later in the session, we use team learning to stimulate deeper understanding of learning theory and instructional practices through the use of an individual and group readiness assessment test and discussion. Appendix 1 is a sample lesson plan for the session on “Theories of Learning.” A major goal of the TSP is the completion, presentation, and possible publication of a scholarly project. Following Boyer’s expanded definition of scholarship, these projects can reflect the scholarship of discovery, integration, application, and/or teaching.2,3 While the majority of scholarly projects completed by the scholars have focused on curriculum development or evaluation, they have also included educational research, the creation of instructional materials, and the development of assessment methods. We encourage scholars to meet the three key criteria of scholarship: the product should be made public, peer reviewed, and accessible for others to build upon.2 Scholars are required to present their projects to the other scholars at the end of the year, and are strongly encouraged to present to the wider community at an Education Day symposium sponsored by the UCSF AME, and/or at regional (eg, Western Group on Educational Affairs) and national (eg, Association of Professors of Gynecology and Obstetrics, Society of General Internal Medicine, Society of Teachers of Family Medicine, Association of Surgical Educators) meetings. A few examples of scholarly projects that have been presented locally and nationally include: “Teaching Residents to Teach: Developing a Curriculum to Improve Resident Teaching Skills”; “Between the Blackboard and the Bedside: An Examination of the Hidden Curriculum in End-of-Life Care”; and “An Interactive Browser-based Program that Teaches the Infant Neurological Exam.” As much as possible, the co-directors of the program mentor the scholars and assist them with their projects. Recently we have expanded the mentoring program by connecting TSP alumni with current scholars. Scholars are matched

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of the TSP they found most valuable, scholars have written:

List 1 UCSF Teaching Scholars Program Learning Objectives

Finding a group of scholars and legitimizing what I do—I feel like I am more comfortable stating I am a medical educator because the program was stimulating and invigorating to me— making me realize I really enjoy medical education and maybe I can make a career at least in part as a medical educator.

Learning Objectives: At the end of the year-long program, scholars will be able to 1. Analyze how learning theory relates to the design of curriculum and educational activities. • Understand and assess different learning theories. • Apply theories of learning to instructional practices. • Assess the research evidence related to different learning theories. • Analyze the successful use of technology to enhance learning. 2. Demonstrate the ability to use various teaching methods appropriately. • Analyze the relationship between learning styles and teaching styles. • Determine elements of instructional design. • Master various teaching strategies. ▪ Large group ▪ Small group ▪ Simulations ▪ One-on-one • Develop expertise in giving feedback.

New ways of thinking about teaching and learning— often grounded in “common sense” but now I know this stuff is validated—it makes me more comfortable about what we do, and inspires me to do more. Opportunity to meet university leadership and gain a better understanding of the structure of the university.

3. Determine the steps in curriculum development and evaluation. • Identify different curricular models. • Describe the process of curriculum development. • Design a program evaluation. • Determine how to identify the costs of a curriculum. • Analyze approaches for obtaining informed consent for curricular research. • Examine the relationship between accreditation and curriculum.

The quality of the reading materials have really opened vistas re: educational theory and how to approach learning. Although at times the literature was challenging, I think this was a very important part of the curriculum.

4. Master various assessments of learning. • Interpret reliability and validity of measures of tests and assessment instruments. • Analyze the strengths and weaknesses of various assessment strategies. • Design assessments of ▪ Knowledge. ▪ Attitudes. ▪ Skillful performance. • Design a survey. • Select appropriate course and instructor evaluations.

A place to breathe and take time to learn for myself.

The school benefits from the TSP by having an expanding cadre of highly skilled and knowledgeable educational leaders who now have major leadership roles in medical education. Examples of such roles include director of the Clinical Skills Center, director of the Simulation Center, director of the Office of Educational Technology, chair of the curriculum committee and several subcommittees, course directors, residency program directors, continuing medical education directors, and education committee members. In most instances, scholars were appointed to these leadership positions after completion of the TSP program.

5. Analyze leadership in organizations and develop leadership skills. • Discuss leadership styles, behaviors and functions. • Identify leadership opportunities in medical education locally and nationally. • Assess educational leadership opportunities within and outside the university. • Discuss organizational change. 6. Reflect on and plan their academic careers. • Establish career goals and benchmarks. • Describe the academic promotion process. • Revise CV and develop an Educator’s Portfolio. • Develop mentoring skills. 7. Develop skills in educational research sufficient to propose, conduct, analyze, and present a study. • Write a proposal with a well-defined research question. • Select appropriate research designs and measures for given research questions. • Devise an analytical plan that addresses power, analytical challenges, missing data, and procedures. • Identify characteristics of accepted and rejected studies. • Write an abstract for medical education research. • Critique an educational research article.

according to interests and experience. Mentoring may be limited to the scholar’s scholarly project or it may include broader career mentoring. The Benefits of the TSP

Scholars have been very satisfied with the TSP, as is evident in their overall ratings of the program, which have ranged from 4.2 to 4.9 (on a 5-point scale where 5 ⫽ excellent) over the past seven years.

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According to their evaluation comments, they value most highly their enhanced knowledge and teaching skills, increased understanding of curriculum and academic program development, strengthened academic leadership skills and career development, and collegiality of a network of peers interested in medical education and educational research. For example, when asked which aspects

In addition, a number of scholars, in collaboration with the AME, have become strong advocates for educational improvement and have been actively involved in the curricular innovations in the school. The School of Medicine has also been able to recruit highly talented educators to UCSF because of the TSP. This has included recruitment of clerkship directors and fellows who wanted to make medical education research their area of career development. In both instances, the TSP has been a strong



List 2 Curricular Components of the University of California, San Francisco, School of Medicine Teaching Scholars Program, 1998 –2006 Learning

Teaching

Curriculum

Assessment

• Learning theories • Instructional design

• Curricular models • Reliability and validity; Comparisons of methods

• Learning styles

• Large group teaching (lecture, team learning)

• Steps in curriculum development

• Clinical teacher expertise in medicine

• Small group teaching (PBL); simulations (standardized patients & centers) • Strategies for changing attitudes and behaviors; simulations

• Curriculum mapping and supporting technology

• Technology and learning

• Feedback

• Measurement resources; paper and pencil assessments; other cognitive assessments • Performance assessments (OSCE, OSTE, simulations); other assessments

• Accreditation; curriculum oversight

• Attitude surveys

• Faculty development; cost of the curriculum

• Course evaluations; self and peer assessment

• Team learning

inducement for prospective applicants at UCSF. At the same time, the school benefits from the program through increased visibility for UCSF nationally. Through scholarly presentations and publications, UCSF has become known for its innovation and leadership in medical education. This was not true prior to the program’s inception in 1998. A study is currently underway to determine the impact of the TSP on different types of scholarly activities. A survey was conducted with alumni of the program to assess their perceived selfefficacy in education-related scholarly activities. CV analysis was used to compare productivity before and after the program in the areas of educationrelated publications, awards, and leadership. Although we have only preliminary results at this point, the data strongly suggest that the TSP produced significant increases in research and leadership activities. The Challenges Facing the TSP

Release time has always been a struggle for the scholars. Some receive true release time, but most merely have their clinical responsibilities shifted from Tuesday afternoons so they can attend the

• Program evaluation

Leadership

Career

• Defining educational scholarship

• Career planning

• Leadership styles

• Leadership skills • Academic • Data basics: set up promotions database, basic statistics, power process analysis • Mentoring • Writing an abstract • Educational leadership in the university (organizational chart and roles) • Critiquing an article • Educational leadership outside the university (professional organizations) • Organizational • Research change presentation; poster; oral presentation

seminar. Unfortunately, this adds to the time pressures scholars already feel, and curtails the amount of time they can spend on their scholarly projects. Better time protection for participation in the program would lessen scholar frustration and strengthen their active engagement in the program. Mentoring has been the rate-limiting factor in the size of the program. Although the co-directors devote time to mentoring scholars and their projects, their time constraints do not allow them to mentor the full cohort of scholars. We are hoping that engaging TSP graduates in the mentoring program will help to alleviate this quandary. Another challenge we face is how to bring TSP graduates together. Creating a follow-up program to bring graduates together would encourage postgraduation productivity and continuing educational development as well as support. A newly initiated, weekly medical education journal club/works-inprogress seminar appears to be addressing some of this need. A Successful Transformation

The TSP offers a longitudinal educational program for faculty members who share


Research

• Educational research; defining a problem; searching the literature; IRB • CV review; • Research design and methods (qualitative Educator’s and quantitative); Portfolio survey development

a passion for teaching. The success of the program is attributable, in part, to the excellent quality of the scholars, a strong academic and mentoring program, plus department and school support. The school and the departments are well served by the ongoing leadership these faculty members play in the educational enterprise. The scholars bring honor to the school and to their departments through their distinguished teaching, publications, and service both locally and nationally. The TSP produces a cadre of exceptional teachers whose creativity, innovations, and scholarship have transformed the culture of education at UCSF. References 1. Kern DE, Thomas PA, Howard DM, Bass EB. Curriculum Development for Medical Education. A Six-Step Approach. Baltimore Md: Johns Hopkins University Press; 1998. 2. Boyer EL. Scholarship Reconsidered: Priorities of the Professoriate. Princeton, NJ: The Carnegie Foundation for the Advancement of Teaching; 1990. 3. Glassick GE. Boyer’s expanded definitions of scholarship, the standards for assessing scholarship, and the elusiveness of the scholarship of teaching. Acad Med. 2000; 75:877–880.

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Appendix 1 Lesson Plan for a University of California, San Francisco, School of Medicine Teaching Scholars Program (TSP) Session: “Theories of Learning” Session Title: Theories of Learning TSP Goal: Analyze how learning theory relates to design of curriculum and educational activities TSP Strand: Learning Introduction Over the past several decades, three families of learning theories have emerged into the mainstream of education. These include behavioral, cognitive and social theories of learning. Each theory is additive and contributes to our understanding of the complex processes of learning—especially in clinical environments. By understanding these three theories, we can expand the scope of our teaching activities to encompass a broader array of powerful methods of learning. A second objective of the session is to learn how to use team learning by experiencing it. The great virtue of team learning is that it actively engages everyone in the learning process even in large classes. Learner Objectives At the end of the session scholars will be able to: 1. Describe how behavioral, cognitive and social learning theories define learning. 2. Outline the key recommendations for facilitating learning based upon each theory. 3. List the key components of team learning Learning Activities Participants will be asked to identify a powerful and purposeful learning experience and describe what made it effective. Connections will be made from these experiences to the theories of learning. Scholars will write their own definition of learning, wad it up, throw it around the room, read and interpret someone else’s definition. Team learning will be used to stimulate deeper understanding of learning theory and instructional practices. Scholars will be given a readiness assessment test, work in small groups to reach consensus on the answers, and later apply the concepts to a case. In Class Assignment: Write a note to yourself identifying key insights you gained today and how you might apply them to your teaching and your project. Bibliography Required reading prior to this session 1. Irby D. Conceptual Lenses on Learning 2. Mann KV. Thinking about learning: implications for principle-based professional education. Journal of Continuing Education in the Health Professions. 22:69–76,2005. 3. How People Learn. (Handout) 4. Michaelsen L. Three Keys to Using Learning Groups Effectively. (Handout). Recommended Readings 1. Bordage, G. Elaborated knowledge: a key to successful diagnostic thinking. Academic Medicine. 69(11):883–885, 1994. 2. Bowen J, Carline J. Learning in the social context of ambulatory care clinics. Academic Medicine. 72:187–190, 1997. 3. Brown A. The advancement of learning. Educational Researcher. 23(8):4–12, 1994. 4. Bransford JD, Brown AL, Cocking RR. (Eds) How People Learn: Brain, Mind, Experience, and the School. Washington, DC: National Academy of Science, 1999. 5. Bruer, J. Schools for Thought: A Science of Learning in the Classroom. (Cambridge, MA: MIT Press, 1993). 6. Bruffee, K. Collaborative Learning: Higher Education, Interdependence, and the Authority of Knowledge. (Baltimore: The Johns Hopkins University Press, 1993). 7. Cunningham A, Blatt S, Fuller P, Weinberger H. The art of precepting: Socrates or Aunt Minnie? Arch Pediatr Adoles Med. 153:114–116, 1999. 8. Custers E, Boshuizen H. Psychology of learning. In International Handbook of Research in Medical Education. Norman G, Ven der Vleuten C, Newble D (Eds). Boston: Kluwer Academic Publishers, Part 1, pp. 163–183. 9. Gijselaers W. Connecting problem-based practices with educational theory. In New Directions for Teaching and Learning. San Francisco: JosseyBass Publishers, no. 68, Winter 1996. 10. Gruppen L. Implications of cognitive research for ambulatory care education. Academic Medicine. 72:117–120, 1997. 11. Michaelsen L, Knight A, Fink L (Eds). Team-Based Learning: A Transformative Use of Small Groups in College Teaching. Sterling, VA: Stylus Publishing, 2004. 12. Regehr G, Norman G. Issues in cognitive psychology: implication for professional education. Academic Medicine. 71:988–1001, 1996. 13. Smith S, Irby D. The roles of experience and reflection in ambulatory care education. Academic Medicine. 72:32–35, 1997.

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