Two Heads Are Better Than One, Right?

by Ellen Varner, Pharm.D., PGY1 Community Pharmacy Resident, University of Maryland School of Pharmacy

As I navigate through my first year as a practicing pharmacist, I sometimes find myself acutely aware of just how much responsibility rests on my shoulders.  Occasionally, the requirement to make complex clinical decisions on my own seems overwhelming  and makes me wonder if I missed something important in a class I took.  Although I know it is impossible for one person to know it all, at times I wonder if the collaborative techniques widely used in my school’s curriculum inadvertently created some gaps in my knowledge.  In a profession that often requires a high level of independence, is placing a heavy emphasis on group-work and collaborative learning actually doing a disservice to pharmacy students?

“None of us is as smart as all of us.” ~Warren Bennis

In his book titled Organizing Genius: the Secrets of Creative Collaboration, Warren Bennis, an organizational consultant and leadership guru, describes the rise of the “Great Group.” ¹  The “Great Group” is one that is able to achieve tremendous success often with very limited resources.  The members of the group have high levels of commitment and their collective performance leads to high-output.  This fascination with group-work and collaboration has transformed U.S. corporate culture into one that tends to elevate teamwork above all else.  According to an article published in the journal Small Group Research, by the year 2000 half of all U.S. organizations had moved towards using teams, knocking down walls to create open-plan offices and shared workspaces.² 

Not surprisingly, the entire education system (pre-K to graduate school) in the U.S. has moved to adopt a collaborative approach to learning, hoping to teach students how to thrive in a team-oriented culture.  A report published in 2002 by the Center for Survey Research and Analysis at the University of Connecticut highlights this shift in the structure of classroom learning.  Among the fourth grade teachers surveyed, 55% identify cooperative learning in small classroom groups as their preferred form of teaching; 51% of eighth-grade teachers reported the same preference.  The results from this survey suggest that an increasing number of teachers have de-emphasized traditional methods of classroom instruction, such as lecturing or passing out homework assignments, in favor of creating teams.³ During my own elementary school education, I remember rearranging our neat rows of desks into “pods” – forming small groups we were required to work with throughout year.

Creating groups that facilitate teamwork has also become a major focus of the U.S. healthcare system, partly in response to an Institute of Medicine (IOM) report titled To Err is Human: Building a Safer Healthcare System.  The report details the high rate of preventable medical errors, many of which were thought to be the result of poor or dysfunctional teamwork.  The IOM report suggests that teamwork is required for effective patient management because treatments are increasingly complex, specialized, and risky.⁴ Medical education itself is also shifting to place more emphasis on team-based learning (TBL) and problem-based learning (PBL), which is often conducted using a small-group format.  In many institutions, lectures have been replaced with group-based projects or “fishbowl” activities where students approach patient cases together as a group.  While the importance of teamwork within medicine is difficult to refute, I am more hesitant to accept its dominating prevalence within medical education.

The Case for Individual Study

In Academically Adrift: Limited Learning on College Campuses, the authors question the value of group work.  The book details the findings of a University of Virginia study that tracked a nationally representative sample of more than 2,000 students who entered 24 different four-year colleges.  Surprisingly, the results suggest that college students who spend the majority of their time studying alone learn more than those who work together in groups.⁵  An experiment conducted by the University of Michigan found that people learn better after a quiet walk in the woods than after a noisy walk down a city street.⁶  The question is – why is solitude so important for learning? Anders Ericsson, a research psychologist, theorizes that solitude is so crucial because it represents the only time when a person is alone and can engage in something he calls “Deliberate Practice.”  Ericsson states that “Deliberate Practice” has four essential steps: 1. Identifying tasks or knowledge that are just out of your reach 2. Striving to upgrade your performance 3. Monitoring your progress and 4. Revising accordingly.⁷  For students participating in collaborative learning, it is almost impossible for them to do these important tasks.  Moreover, from an instructor’s point-of-view, group work makes it difficult to identify students who are struggling (step one) and provide individual feedback (step three).

When is Three (or even Two) a Crowd?

While groups and teamwork shouldn’t be avoided, I think it is important for educators to use discretion when designing their curriculum.  Although teaching students how to work in a team is important, putting too much emphasis on collaborative learning may actually be detrimental.  Instead of reserving complex patient cases for group projects, students should also be given the opportunity to approach these challenges as individuals so they can engage in “Deliberate Practice.”  Group projects with collective evaluations can make it difficult to identify knowledge or skill deficits in a particular student.  Further, students who spend too much time working in groups may find that they lack the confidence to complete a task on their own.  Asking students to perform clinical activities, such as patient interviews, on their own can help them to become more confident in their own knowledge and skills.  In addition, participating in a “fishbowl” activity, one where a student can time-out to ask his or her classmates for help while interviewing a patient, does not necessarily paint a realistic picture of real patient-pharmacist interaction.  For pharmacists who work in community pharmacy settings, the ability to work independently and make autonomous decisions is as crucial as being able to work effectively on a team.

References:

1. Bennis WG, Biederman PW. Organizing Genius:The Secrets of Creative Collaboration. New York: Basic, 2007.
2. Devine DJ.  Teams in Organizations: Prevalence, Characteristics, and Effectiveness. Small Group Research. 1999; 20: 678-711.
3. Barnes C. What do teachers teach? A survey of America’s fourth and eighth grade teachers. Civic Report no. 28. Center for Survey Research and Analysis, University of Connecticut, 2002.
4. National Research Council. To Err is Human: Building a Safer Health System. Washington, DC: The National Academies Press, 2000.
5. Arum R, Roksa J. Academically Adrift: Limited Learning on College Campuses. Chicago: University of Chicago, 2011.
6. Berman MG, Jonides J, Kaplan S. The Cognitive Benefits of Interacting With Nature. Psychological Science. 2008; 19: 1207-212.
7. Cain S. Quiet: The Power of Introverts in a World That Can't Stop Talking. New York: Crown, 2012.