November 18, 2014

The Socratic Method for Developing Critical Thinking

by Naaseha Rizvi, Pharm.D., PGY1 Pharmacy Resident, Johns Hopkins Bayview Medical Center

Starting my second week of my internal medicine rotation, my preceptor told me that I would be responsible for leading the pre-round group discussion sessions from now on.  Our “group” included not only the preceptor and myself, but also two advance pharmacy practice experience (APPE) students. I had watched my preceptor lead these sessions effortlessly the first week, so I thought “this can’t be that hard, right?” Wrong! After the first few sessions, I realized the questions that I asked were random and unsystematic.  The students were not benefitting from our discussion at all!  I remembered back to my days as an APPE student.  Some of my best preceptors were able to stimulate critical analysis by asking the right questions in the right order. They got me to think about my thinking – metacognition. I wanted to be able to do this for my students!  I decided to do some research.

There are many ways to teach critical thinking skills to students. A particularly tried and true method was developed by the ancient philosopher, Socrates.   Consequently, the teaching method is called the Socratic Method or Socratic Questioning. After a logical series of specific, systemic questions, Socrates observed that students were able to develop self-generated knowledge and regulate their thoughts.1 The key to this method is to ask the right questions in the right sequence. Poorly thought-out questions can intimidate and confuse students.  Bad questions can even limit a student’s ability to think critically.2 Questions generate an inquisitive mind, a mind that keeps forming new questions to find more answers, which may lead to more questions and so on and so forth.3

Why is it necessary to teach critical thinking skills? In order to provide the best care to patients, practitioners utilize the knowledge that comes from previous patients with similar diseases as well as current medical knowledge. The ability to make a logical and defendable connection between these two sources of knowledge to the current situation is critical thinking.1 Three principles are important to keep in mind when teaching or stimulating critical thinking: 1) it is a skill that takes time to develop; 2) learners must use certain metacognitive strategies; and, 3) critical thinking relies on domain knowledge that the learner already possesses. It is challenging to validate methods for teaching critical thinking and the ability to yield consistently positive results to show improvement.1 Different methods of instruction to develop critical thinking include group learning, case-based learning, concept mapping, and experiential education. The evidence regarding the effectiveness of the teaching strategies in promoting critical thinking is lacking.1

How is the Socratic Method applied? How does it work? The Socratic Method requires the student to look at the deep structure of the question. To do so, they must have basic domain knowledge in the content area. The underlying goal of the Socratic Method is to prove opinions with facts. Therefore the student must have a frame of reference before the Socratic Method may be used. The authors of a recent article in the American Journal of Pharmaceutical Education outline the elements of the Socratic Method (See Table 1). The mnemonic PAPER CLIP (figure 1) can be used to construct a sequence of questions which stimulate deeper thinking.1 Three types of questions are often used: exploratory, spontaneous and focused.2 Exploratory questions show how much the student knows and may be used to introduce a new topic or review past discussions that may relate to the current topic. Spontaneous questions can be used to probe the student in exploring their beliefs and assumptions; they allow the student to reflect on the issue at hand. Focused questions narrow the discussion on what the preceptor would like the student to think about, stimulating them intellectually.2

Table 1. Effective  Socratic Questioning1

  • Raise basic issues
  • Probe beneath the surface structure
  • Pursue problematic areas of thought
  • Aid students in discovering the truth of their own thought
  • Aid students in developing sensitivity to clarity, accuracy, relevance and depth
  • Aid students in arriving at judgments though their reasoning
  • Help students analyze purposes, assumptions, questions, points of view, information, inferences, concepts and implications.

Figure 1.

By using this method of questioning, the student (hopefully) becomes inquisitive and motivated to learn. This method is quite different from another form of questioning called “pimping,” which may do more harm than good in terms of teaching critical thinking.1 Although the effectiveness of the Socratic Method has not been studied, a few articles describe its benefits in health professional education. In one study conducted at the Robert Wood Johnson Medical School, third and fourth year medical students participated in a series of 90-minute conferences.  The instructors used a traditional didactic method as well as the interactive Socratic Method interchangeably.  Each method was used approximately the same amount of time. After the conference, students were given a survey to determine their preference. The majority of students preferred the Socratic Method over the didactic method (93.3 vs 6.7%, p < 0.001).4

After constructing the Socratic questions, it is important to use them in an effective manner.2  Avoid compound questions that require multiple answers as it can cause confusion. Provide a safe environment where students can express their thoughts openly. Questions should be balanced in their cognitive level. Lastly, it is important to provide enough “wait time” after asking a question. For higher-order questions that stimulate critical thinking, as much as 1-2 minutes should be given for best responses.2

The Socratic Method is very well suited for students on experiential rotations.  The learner needs adequate domain knowledge in order for the Socratic Method to be most effective. Therefore, it may not work as well in a first year course where foundational knowledge needs to be acquired. In the pharmacy curriculum, the experiential rotations provide an opportunity for one-on-one interaction.  This is an ideal opportunity for the preceptor to use the Socratic Method. Students on experiential rotations typically have the foundational knowledge needed.  They just need to learn how to apply it towards patient care by learning how to think critically. By developing this vital skill, students will be well equipped to practice pharmacy.

  1. Oyler DR, Romanelli F. The fact of ignorance: Revisiting the Socratic Method as a tool for teaching critical thinking. Am J Pharm Educ. 2014;78: Article 144.
  2. Tofade T, Elsner J, Haines ST. Best practice strategies for effective use of questions as a teaching tool. Am J Pharm Educ. 2013;77: Article 155.
  3. The Critical Thinking Community.  The Role of Socratic Questioning in Thinking, Teaching, and Learning. 2013. Accessed October 25, 2014.
  4. Zou L, King A, Soman S, et al. Medical students' preferences in radiology education a comparison between the Socratic and didactic methods utilizing powerpoint features in radiology education. Acad Radiol. 2011;18:253-6.

October 31, 2014

Service-Learning: From Theory to Practice

by Margaret Miklich, Pharm.D., PGY-1 Pharmacy Practice Resident, University of Maryland Medical Center

Service, combined with learning, adds value to each and transforms both.1
                       -Honnet and Paulsen (1989)

When asked why they’ve chose their career path, many health professionals say “I like helping people.”  I would argue that serving rather than helping people is really what drew them. I initially began contemplating this concept after reading Rachel Naomi Remen’s essay entitled Helping, Fixing or Serving?  In it she states, “Fixing and helping create a distance between people, but we cannot serve at a distance. We can only serve that to which we are profoundly connected.”  I’ve reflected on this concept for many years.

Service-learning embodies the idea that community service and classroom learning can be intimately intertwined.  Service is more meaningful when informed by theoretical frameworks.  And conceptual knowledge is better understood when examined through the lens of real world experiences.

While the first formal service-learning program was established in 1965, it wasn’t until the 1980’s and 90’s that a concerted effort was made to develop the theory and refine the practice of service-learning.2  Today, service-learning activities are pervasive and commonplace in curricula — from elementary school to undergraduate and graduate programs. In 2008, 20% of elementary schools across the nation participated in some form of service-learning.3 In the same year, a Campus Compact survey revealed that 93% of member colleges and universities offered courses that included some form of service-learning.  That’s 24,271 course offerings at 627 responding institutions!4

Given the vast number of service-learning opportunities, it's not surprising that a number of theories have been proposed to explain why service leads to learning.  And there are an even greater number of practices that attempt to guide how to conduct service-learning activities. There are common themes running through the proposed theories.  More important, all agree (proponents and critics alike) that how service-learning activities are constructed is extremely important.5,6 Before we examine the how, let’s take a quick look at the theoretical framework of service-learning.

Service-learning is most often explained using constructivist educational theory.  Constructivists believe that learners construct meaning from their experiences.  Learning is an active process prompted by new experiences and interactions that challenge prior understanding. An essential component of constructivism is for the learner to critically reflect on the new experience. It is only through reflection that learners decide if, when, and how they will alter their current knowledge and perceptions.7

There are several scholars who contributed to the theory of constructivism including Jean Piaget, John Dewey, and Maria Montessori (who developed an educational approach and schools bearing her name). David Kolb (who developed the Learning Style Inventory) used constructivist theory in his work on experiential learning.

Service-learning leads to learning so long as it includes experience, inquiry, and reflection.8 In order for knowledge to be recalled and applied, it must be gained through a situational experience. Inquiry then takes place when this new experience seemingly defies or contradicts prior knowledge.  Finally, reflection demands that inconsistencies between prior knowledge and knew experiences be reconciled.9

Individuals, organizations, and expert panels have all weighed in on how to best construct service-learning activities. While there is significant diversity in the proposed approaches to service-learning, common themes have emerged:

1) Service learning should be integrated into the curriculum or course in a purposeful way. Clear goals for both the service and the learning components must be articulated. Service activities should be designed with course objectives in mind and should clearly connect to learning goals.1,5,10

2) Requiring students to reflect on the experience is critical. Reflection must occur before, during, and after service. Not only should reflection take place at regular and purposefully constructed intervals, but it should be rigorous. Methods for reflecting should be varied and should include written, oral, and nonlinguistic approaches. Reflections should be self-assessed by students and assessed by instructors.1,5,9,10

3) Service-learning should be meaningful. The service activity should address a legitimate, unmet community need. Meaningfulness can also be achieved by allowing students to choose the issue they want their service to address. Moreover, meaningfulness is achieved through the relationships that students form while they are completing the activity.1,5

4) Service-learning requires a significant time commitment. The time commitment should be sufficient for students to have multiple experiences coupled with inquiry and reflection. One experience is unlikely to be sufficient. Moreover, rigorous inquiry and reflection requires elaboration in the form of papers, discussions, and other forms of expression. It is only through inquiry and reflection that students recognize discordance between their prior experiences and modify their knowledge, perspectives, and opinions.1,5,8 All of this takes time!

Three-quarters of colleges and schools of pharmacy reported some form of service-learning in their curriculum in 2002.11 There are many ways to structure a service-learning course but using proven strategies is likely to be more effective. One paper describes a service-learning course at the Worchester/Manchester campuses of the Massachusetts College of Pharmacy and Health Science (MCPHS) and studies student learning.12 The course consisted of five components: 1) service work in community settings; 2) seminars on topics such as communication and diversity, 3) guided journal writing (reflection); 4) guest speakers on community service activities such as homeless shelters and AIDS services; and 5) student-led presentations about their service activities and what they learned.

Let’s examine whether this course followed the best-practices principles for service-learning. Objectives were clearly set and service activities appeared to connect to course objectives. The reflection activities were not described in detail but students were required to answer a series of questions in weekly journal entries. Of note, when compared to the other components of the course, student reported learning the least from the journaling activity. It is difficult to say whether the service activities were meaningful but presumably they met real community needs. Students were allowed to rate their interests and had some say in the service activities they completed. With regard to duration, students were required to participate in two hours of service each week in addition to attending a weekly one-hour session at the school. The time allotted appears to be sufficient for students to make repeated site visits, gain new experiences, develop relationships, and engage in inquiry and reflection.

By understanding constructivist theory and intentionally applying the best practice principles, instructors can successfully implement service-learning activities into their schools’ curriculum. Service-learning is an excellent example of how theory informs practice.

  1. Honnet EP and Poulsen . Principles of Good Practice for Combining Service and Learning. Johnson Foundation, Inc.
  2. Marullo S. Service-Learning: A Movement’s Pioneers Reflect on its Origins, Practice and Future. Michigan Journal of Community Service Learning 1999; 6:133-137.
  3. Community Service and Service-Learning in America’s Schools [Internet]. Corporation for National and Community Service. 2008.
  4. Service Statistics 2008: Highlights and Trends from Campus Compact’s Annual Membership Survey [Internet]. Campus Compact. Boston: MA. 2009.
  5. Billig SH. Unpacking What Works in Service-Learning. Growing to Greatness. National Youth Leadership Council. 2007.
  6. Eby JW. Why Service-Learning is Bad. 1998.
  7. Kaufman DM. ABC of learning and teaching in medicine: Applying educational theory practice. BMJ 2003;326:213-6.
  8. Giles DE and Eyler J. The Theoretical Roots of Service-Learning in John Dewey: Toward a Theory of Service-Learning. Michigan Journal of Community Service Learning. 1994 Fall; 1: 77-85.
  9. Bringle RG and Hatcher JA. Reflection in Service-Learning: Making Meaning of Experience. Educational Horizons. Summer 1999. 179-185.
  10. USCDornsife. Joint Educational Project. University of Southern Californa. 2014.
  11. Peters SJ, MacKinnon GE. Introductory practice and service-learning experiences in US pharmacy curricula. Am J Pharm Educ. 2004;68(1): Article 27.
  12. Kearney KR. A service-learning course for first-year pharmacy students. Am J Pharm Educ. 2008;72(4):Article 86.

Formulating Small Groups for Success

by Christine Ji, Pharm.D., PGY-1 Pharmacy Practice Resident, MedStar Union Memorial Hospital

Have you ever participated in small learning groups? Were you satisfied with how the group experience turned out? Effective small group activities should be designed to promote positive interactions among students where everyone feels connected, engaged, and included. The potential advantage of small group learning is that students from different backgrounds and experiences come together to exchange ideas and learn from different perspectives.1 Before the 1960s, small group learning was relatively uncommon, and the education system was largely focused on what the individual learned through interaction with the instructor. Unfortunately, this created competition between students and final assessments were usually based on individual effort and accomplishment.  Things have changed and small group learning is now widely accepted. Indeed, some teachers prefer this instructional method for students at all levels.2

Small group learning may increase student accountability for acquiring the content knowledge outside of the classroom and applying it to the group discussions. Students reported that they are able to develop their communication skills and ability to effectively work as a team member.  These are important skills in the real world, particularly in work environments. Students also enjoy active engagement in the classroom setting and this can result in improved course grades.3

Despite the benefits that small group learning can offer, not all small groups work well and not all students have a positive experience.  For teachers, it is difficult to find practical guidance and effective methods to create and organize small groups to maximize the chances of success. Some have described group learning as “sinking or swimming together.”4  When small group work really succeeds it's the result of “participants' striving for mutual benefit so that all members of the group benefit from each other's efforts.” 4 Therefore, planning and managing small group learning activities is an important part of the instructional design process. Small group learning should be reflective of positive interdependence, face-to-face interaction, individual and group accountability, social skills development, and group evaluation.6

When assigned to small groups, students have two main responsibilities: learn the assigned material and make sure that all other members of the group learn the assigned material. Students should work together, striving for individual accomplishments as well as team success. Students can encourage and help each other to reach the group’s goals by exchanging needed resources, providing each other feedback to improve performance, and challenging one another to promote a higher quality of a task completion. Students are held responsible for their own contribution and also for achieving group objectives. By practicing in small groups, students are expected to be better prepared to complete similar work in the future. Furthermore, students get to know and trust one another and need to learn how to resolve conflict. Lastly, students learn about how well they perform and adjust learning strategies to better achieve goals. Through group evaluation, students should strive to maintain good working relationships and share feedback about participation. Students should be taught how to celebrate the success of the group and reinforce the positive behaviors of other students.

In terms of formulating groups, there is no “right” way of assigning students.  However, when students self-select groups, they tend to assimilate with people they already know and may exclude students who don’t fit into any group. On the other hand, when teachers randomly assign groups, it saves time and avoids any discrimination; but there is a risk of imbalances that hinder the group’s performance.5 Although it is more time consuming, selecting groups based on certain criteria such as gender, ethnicity, linguistic ability, personality, prior achievement, levels of competency, and work styles to promote heterogeneity may be a better alternative in terms of encouraging positive learning interactions and individual accountability. With regard to group size, it is important to come up with a number that is small enough to have interactive discussions, but large enough to tolerate an occasional gap in the attendance and allow smaller subsets (of 2 and 3 student) to engage in more  focused activities. Groups can be rearranged at the mid-semester point to allow students to rotate and interact with various people.2

For small groups to succeed, it is important to plan ahead. Arrange the physical environment to maximize group interaction and avoid any pitfalls such as students coming to class unprepared, being reluctant or refusing to participate, or letting one student dominate the discussion. It is important to give student adequate time ahead of class time to prepare and, if they not prepared, to ask why. Teachers should try to understand why some students are not participating. The reasons may be due to their past experiences in other classes. It can be helpful to start out with an easy, engaging question and to discuss the goals and outcomes of small group learning with the class ahead of time. During small group discussions, teachers and facilitator should invite everyone to speak and use structured discussion protocols.4


  1. Steinert Y. Student perceptions of effective small group teaching. Medical Education. 2004; 38:286-93.
  2. Kitchen M. Facilitating small groups: how to encourage student learning. Clin Teach. 2012;   9:3-8.
  3. Ferreri SP, O’Connor SK. Redesign of a large course into a small-group learning course. Am J Pharm Educ. 2013; 77: 1-9.
  4. Jaques D. Teaching small groups. BMJ. 2003; 326: 492-4.
  5. Meo SA. Basic steps in establishing effective small group teaching sessions in medical schools. Pak J Med Sci. 2013; 29: 1071-1076.
  6. Roger T, Johnson DW. An overview of cooperative learning. Campbell University, NC. 2013