Problem-based learning (PBL) is a widely used method of teaching and learning in medical schools (
+1,
+2). Students meet in small groups with a tutor and focus on a carefully constructed problem or case. These settings bring into play powerful group dynamics that may affect students' comfort and academic performance.
To our knowledge, there are no published studies of gender issues in small-group learning in medical schools. Studies in other classroom settings, however, have demonstrated that gender dynamics play an important role in learning (
+3—
+6). In a study of students' experiences at the University of Pennsylvania Law School, Guinier et al. (
+3) concluded that women felt alienated and intimidated by the male-dominated atmosphere and Socratic teaching style. Women entered the law school with identical credentials as the men, but men were three times more likely to graduate in the top 10% of the class. The writers postulated that gender-related classroom dynamics led to poorer academic performance among women.
Several studies have demonstrated differences in the behavior and participatory styles of men and women in college classrooms. Krupnick (
+4) found that male undergraduates spoke 2.5 times longer than their female peers. This difference diminished significantly when the instructor was female. The women were interrupted more frequently than the men, and, once interrupted, the women sometimes stayed out of the discussion for the remainder of the class hour. Aries (
+5) noted that student discussion groups composed entirely of women tended to have a turn-taking style of participation. In contrast, in all-male groups, a hierarchical pattern of access to the discussion developed, with extremely uneven amounts of talk per man. In mixed groups, the male style dominated.
Other research suggests that women are more sensitive to interpersonal dynamics in a classroom and that their motivation and performance depends highly on feeling a positive connection to their peers (
+6,
+7). Such findings are consistent with recent theories of women's developmental psychology that suggest that empathic connections are vital for the development of women's self-esteem, energy, and motivation (
+7,
+8). Through linguistic analyses, Tannen has found that women try to confirm and support each other and achieve consensus in their interactions, whereas men more often strive as individuals to achieve and maintain dominance (
+9).
We provide qualitative data on the influence of gender dynamics on learning. We conducted a retrospective evaluation of an experiment at Harvard Medical School in which a PBL cohort was temporarily divided into separate-gender tutorial groups. In 1985 Harvard Medical School started "The New Pathway," a pilot program emphasizing PBL, which subsequently expanded to include the entire student body. Late in the program's first year, the 8 women in the class of 23 students requested an all-female tutorial group for the upcoming 11-week block. Following a decision to institute this "experiment," the students were divided into one eight-woman tutorial group, led by a female tutor, and three groups of five men each, with male tutors. All the groups addressed the same cases and content.
The authors designed a questionnaire based on a review of literature about group dynamics and PBL. Open-ended questions asked the following: 1) why students thought the women felt the need for a separate tutorial, 2) what the students' reactions were, 3) what the single-gender tutorial experience was like, 4) what differences were evident in the mixed groups following the tutorial, 5) what long-term effects this experience had for them, and 6) whether they would recommend the single-gender group experience for other students. The students were asked to rate on a Likert-type scale ranging from one to five their degree of comfort in tutorial groups before, during, and after the single-gender tutorial group (
+Figure 1). In addition, they were asked to rate the importance of this experience in their medical education and their degree of engagement with this issue.
In 1995, 10 years after the original experiment, this questionnaire and a cover letter were mailed to each student in the 1985 New Pathway cohort, explaining that a study was being conducted on "different aspects of the separate-gender tutorial experience" and that their identities would be kept confidential. The answers were removed of identifiers, pooled, and reviewed by the authors. Statistical analyses were not performed because the number of subjects was considered too low to make such analyses valid.
Seven of the 8 women and 9 of the 15 men responded to the questionnaire. The results are shown in
+Table 1.
Both the men and women felt significant discomfort in mixed-gender tutorials. For the women, the comfort level was markedly improved in the single-gender tutorial group but for the men remained unchanged. Once the groups recombined, the women continued to feel a higher level of comfort; for men this remained unchanged. The women, but not the men, felt the single-gender block was a very significant part of their medical education. The women reported being very engaged in this setting, whereas the men did not.
The women described several reasons for wanting an all-women's tutorial group; many of these related to a desire for more connection with their peers.
Before the women's tutorial each group had one or two women. It would have been impossible for us to randomly all end up in the same group. I wanted to know the other women better, the way you got to know people from working closely.
They described dynamics in the mixed group that made them feel disconnected—either isolated, misunderstood, or devalued. They noted that they had a more tentative style and that men would take this as an invitation to make their own comments.
[The women] felt overpowered and ignored by some male members of tutorials who were often outspoken, competitive, aggressive, and who interrupted and/or failed to listen to women in the group.
The women felt that the women's tutorial group experience was a more comfortable and effective learning environment for them than the mixed-gender groups, which led to a feeling of increased self-awareness and self-esteem. Representative quotes included the following.
There was less ‘one-upmanship’ and competition within the group. It was more cooperative. People listened and encouraged participation from all members.
Now I see that it was a vital part of my growth as a physician. It allowed me to become part of things rather than remain separated by my feelings of inadequacy and the expectations of others. I am very grateful for that. I think short-term experiences such as ours can have a very long-term lasting impact.
In the women's group, a sense of connection inspired them to be more energetic and motivated about their work. One woman wrote:
I also felt a stronger sense of obligation to contribute to the group—to try my very best. This was different than prior tutorials. In the women's tutorial, there was no clear leader—we all took turns but it felt more like things were done by consensus. We addressed our individual weaknesses and worked on them as a group.
The women often ascribed the cause of misunderstandings and misinterpretations between genders to their own more tentative style vs. the men's more definite approach. The women noted that they did not fully appreciate this difference until participating in the women's group. Previously, they had just felt "not listened to" in coed groups but could not understand why. By reflecting on their different behavior in the all-women's groups, they identified factors that may have contributed to them having a "lower profile" in the mixed groups. This inspired them to master what was seen as the "male technique"—speaking with a more definite tone and body posture—and become more effective participants in subsequent mixed settings.
I learned about how my presentation in a group could impact the whole group's process. When I presented a fact tentatively in the coed group it was quickly moved over…maybe I was looking for reassurance that people were really listening. I got heard more in the single-sex group…and after it, I learned to present in a way that appeared more confident.
The men perceived the single-sex tutorial experience quite differently. In retrospect most of them understood why the women wanted their own group.
They [the women] felt they couldn't express themselves fully in groups with males, that is, that they were not taken as seriously and that they needed a chance to develop more assertiveness in a secure environment.
However, many of the men were opposed to the single-sex tutorial groups. Some felt rejected, hurt, or angry that the women wanted an all-female group. Several stated general moral precepts in opposition to the separation.
There was a defensiveness due to the implication that a need on the part of the women for a ‘women's group’ meant that the males in the program behaved in a sexist/oppressive/discriminatory manner.
Women in medicine largely function in a largely male-dominated (by numbers anyway) profession and should learn early how to be assertive in male-dominated environments.
The men did not find the single-gender groups to be "special" or "different" in the way that the women did. Moreover, the men did not notice or could not imagine the differences that the women experienced.
In retrospect it was not significantly different from the mixed-sex group from my perspective. Perhaps this is a reflection of the very dominance of males in all the groups, which the [formation of the] female group was, to some extent, an attempt to address.
Several men enjoyed the "male bonding" and greater sense of intimacy that occurred in the men's groups. Unlike the women, however, the men did not note that this type of connection enhanced their motivation or ability to learn the academic material. They tended to focus on the tutorial content rather than on the process or "atmosphere" of the room.
For the most part, the men did not notice the changes in participation and assertiveness that the women described once the groups were remixed. Two men reported that they had largely forgotten that a separate-gender tutorial group ever existed. One-half of the male respondents stated that the single-gender tutorial experience had no effect on their views of gender issues or group dynamics; the other half noted some generally minor, longer term changes.
The experience has made me less defensive in the face of women's demands or requests for environmental changes which [sic] enhance their feeling of comfort or increase the interactions in ways other than the male-dominated standard.
The women students, 10 years after participating in an all-women's tutorial group, felt that the single-gender learning experiment was a critical experience in their medical education that gave rise to lasting changes in their perceptions and ability to manage group dynamics. Many of the women felt that learning about their own styles in the context of the women's group helped them learn how to participate more effectively in coed groups and later on in other professional settings. Several of the men felt that the experience enhanced their awareness of gender issues and discrimination.
These findings, while tentative because of the small number of subjects involved, suggest that men and women experience the dynamics of tutorial groups differently. Our purpose in cataloguing these retrospective evaluations is to raise questions for further study, rather than to provide definitive answers.
Limitations of this study include the lower response rate of the men, potential bias in who may have responded based on their perceptions of the single-gender group, and the possibility that the authors' biases may have influenced interpretations of narrative data. In addition, several variables, such as group size, the ratio of men to women, the stability of the groups over time, the degree of structure of the agenda, and individual characteristics of students, can affect gender dynamics in small group settings and may limit the generalizability of the data obtained in this study. Finally, the study did not examine the importance of the tutorial leader's gender on group dynamics.
The findings of this study have implications for the implementation of PBL in medical schools. First, women are at risk for feeling isolated or devalued in groups. These feelings may influence their motivation and performance in the group. It may be necessary for the group leader to make special efforts to include women and to modify group processes to better address their affiliative needs. Although the increased number of women in medical schools over the past 10 years may be changing the gender balance in small groups, differences in men's and women's styles of participation in groups are likely to persist. Many tutors have had little experience with group dynamics and may have given little thought to issues of gender in this context. Faculty development programs for new and experienced tutors should address this issue, attending to gender dynamics in faculty interactions and using role plays and simulated small groups as stimuli for discussion. In addition, core readings about gender issues in the classroom should be included in tutorial resource lists.
The group and power dynamics described in our study are clearly not limited to gender. Several African American and Latino students of both genders pointed out that their minority status led to similar types of disenfranchisement in the groups that the women described on the basis of gender. As medical school enrollment becomes more culturally diverse, medical educators will need to develop new approaches to address the greater diversity of learning styles. This challenge may be felt more acutely in PBL curricula, in which small groups play a central role in learning. Such efforts are critical in promoting full participation of students in the richness of medical education.
The authors thank Melissa Coco for interviewing subjects and for her contributions to discussions about the project and Drs. Ken Mandl, Carol Nadelson, Malkah Notman, and Irene Pierce Stiver for reviewing the manuscript. The authors thank the members of the first "New Pathway" group at Havard Medical School for agreeing to participate in this study.