Making Conference Participatory
Participatory case conferences are more memorable and more fun, but eliciting genuine participation is harder than it seems.
This is the third entry in a series exploring how we can improve residency case conferences. The first piece advocated for making conference shorter, and the second discussed ways to improve retention by reducing the amount of information covered during each conference.
Imagine a case conference on, say, thrombocytopenia. It starts, like most, with an undifferentiated patient arriving—usually to an emergency department— with a nonspecific chief complaint. The facilitator wrings some ideas out of the residents in attendance. Several are asked to share what history-taking questions they would pose to the patient. Some are prompted to nominate some useful physical exam maneuvers. And still others are asked to propose labs and imaging tests.
The data appear, and with them, finally, some diagnostic signs. The audience scans the results and names the abnormalities. Someone calls out the low platelet count. And then comes the question designed to shift the conversation towards the case’s first generalizable learning objective:
“So what is your framework for thinking about thrombocytopenia?”
On its face, this is a sensible question, but I think it’s also the wrong one. It confuses learning objectives with prerequisites. It rewards the senior resident in the room who has the least to gain from the conference—the one who has already mastered the material that the conference is intended to teach—while alienating the residents who privately realize that they don’t know as much as their colleague. Nor is the answer—delivered verbally by an audience member who has not had time to prepare—likely to be retained by those who need to learn the content.
We wind up in this trap, understandably, because we want conferences to be participatory. The alternative, it seems, would be to lecture our way through a framework, but we all remember the preclinical years of medical school well enough to know how just how riveting that would be. And so we try to involve the audience by emulating a technique we’ve seen countless times: asking a question and inviting a volunteer to answer it.
Posing a question to the group like this, though, makes for meager participation because it engages only one person at a time, leaving the rest of the audience idling. A common alternative—to have everyone answer the question, either mentally or via polling software—is not much better, because many residents will not commit to an answer for fear of being wrong.
Generating genuine participation, it turns out, is hard. It requires familiarity with participatory pedagogical techniques and advance planning to decide which activities to employ in a particular moment. The payoff, though, comes in the form of conferences that are easier to learn from and much more enjoyable.
What truly participatory teaching strategies share is that they require a firm pause in the narrative flow of the session. I’ll share some favorites here and explore how they may have been helpful in this conference scenario.
Breakout Pairs and Small Groups: The facilitator could have asked the audience to divide itself into pairs or small groups to draft a framework for thrombocytopenia, which they would then discuss with a neighboring group. There are several advantages here: the size of the group prevents learners from sneaking by without participating, and sharing the product of their work with another group maintains accountability. If groups also contain multiple levels of learners, they can also provide an opportunity for the senior resident to get some teaching practice.
Reflective Writing: Having each learner physically write down their answer to a question allows learners to think at their own pace and emerge from the session with a physical product that they can refer back to later.
Reteaching: After delivering novel content in a lecture format, having pairs of learners reteach the material to one another helps immensely with consolidation and retention while exposing gaps in their understanding that they may not have otherwise realized were there.
Case Inversion: We almost universally start case conferences with, unsurprisingly, the case. An alternative approach would be to start with the relevant framework—in this case, the differential diagnosis and workup of thrombocytopenia. With that established—ideally on a handout available for learners’ reference—we can then introduce the case and use it as a chance for small groups to practice applying the framework they just learned.
Test Questions: Incorporating prepared test-style questions—multiple choice or otherwise—is common, but it is important that they be presented in ways that push all learners to think through them and commit to an answer. Polling software struggles here because even anonymous submitters still want to think of themselves as correct; notice the spike in submissions at the moment the facilitator starts to hint at the right answer. Instead, having learners discuss questions in pairs makes it more likely that they will settle on an answer and, more importantly, articulate their reasoning aloud.
Making conference truly participatory carries a time cost, but more often than not, it replaces time consumed by low-efficiency lecture formats. And it goes hand in hand with efforts to reduce the content load associated with each conference.
Next in this series, I’ll discuss how to select conference topics to maximize conference relevance without sacrificing variety.