Though interpersonal and communication skills are one of the six ACGME general competencies (1), little formal guidance is provided to physician trainees on the subject of participation in and/or leading group discussions. Although group work can be structured, as in the case of “buzz groups” or “think-pair-share (2),” observation suggests that physician trainees usually devolve into one of three common group processes: 1) volunteering, speaking when one cares to; 2) taking turns, going around in a circle; and 3) awaiting selection, speaking when called upon by a leader or facilitator.
Each process has its advantages and disadvantages, and some may be more suited to certain purposes than others. The main criticism of the volunteering process is that some group members may be excluded from active participation. This may be a result of individual reluctance and/or excessive dominance of other group members. Going around a circle has the advantage that everyone has the opportunity to participate. However, members may sacrifice attentive listening to others’ contributions in order to prepare for what they will say. Finally, leader selection has the disadvantage of giving a single person the authority to decide who and when someone is to contribute.
As an alternative to the group processes described above, Mutual Invitation (3) was developed by an Episcopal priest named Eric H.F. Law to facilitate discussion in small-group settings, especially multicultural ones, where power differentials may exist, to ensure that all participants have an equal opportunity to share their ideas and take part in positive group dynamics.
The basic process is outlined below:
Sit in a circle. Group sizes should be no larger than 15; 6 to 8 is ideal. The groups can be facilitated or nonfacilitated. When a facilitator is available s/he is responsible for overseeing the process. S/he usually is also a full participant in the discourse.
Introduce the topic to be discussed, information gathered, or question answered.
Set a time for each individual speaking session. The time limit depends on the total time available, size of the group, and number of topics to be canvassed. A common time-limit is 3 minutes.
Select a person to speak first. If possible, choose someone familiar with Mutual Invitation. If no one is familiar with the process, select someone randomly.
No questions, comments, or interruptions of any type are allowed when someone is speaking.
After the person is finished speaking, s/he pauses briefly. The brief pause at the end of each speaking session is designed to allow group members to reflect on what has been said. In some Mutual Invitation settings, a response period follows the brief pause. Here, listeners may ask the speaker open-ended questions primarily aimed at clarifying what was said.
The person then randomly “invites” another person to speak. When inviting the next person, do not “go around the circle.” Going around the circle leads participants to anticipate and prepare what they will say, thus distracting them from listening to the person who is speaking.
The invited person may choose to speak, or “pass.” An alternative is “pass for now,” which signals that the person is not ready to speak yet, but would like to be invited again later.
Regardless of whether the person speaks or passes, s/he invites the next person. This is particularly important if the person passes, as inviting the next person ensures that everyone actively participates in the group dynamics, independent of verbal contribution.
The process is repeated until everyone in the group has been invited to speak.
Consider the following small-group interactions, first, using unguided group processes and then, mutual invitation.
Six medical students are assigned to an anatomy laboratory group. Two students emerge as the most vocal and confident of the group. The remaining four students are present and observe, but are entirely quiet. The anatomy professor makes his rounds and arrives at this station. He asks if there are any questions, and one of the dominant students says, “No; all good.”
The anatomy professor comes to a station where six medical students are dissecting a lower limb. He says, “A hypothetical patient presents with foot and great toe drop. I’d like to know your thoughts on the matter.” He randomly selects one of the six students, “Can we begin with you?” One of the quiet students begins, “Foot drop is dorsiflexion weakness, and great toe drop is extensor weakness. Several muscles act to dorsiflex the foot, but only one muscle extends the great toe, extensor hallucis longus. The nerve supply to these muscles is the deep peroneal nerve.” The student then asks another quiet classmate, “Can you remember the origin and insertion points for these muscles?” This next student reports on the origin and insertion points for several relevant muscles but cannot remember them all. He asks one of the assertive students for help. This student makes several contributions and asks another student, “anything else?” The fourth student asks the professor, “In this hypothetical, does the patient have difficulty with everting or inverting his foot?” The professor answers, “Only eversion. Why do you ask?” The conversation continues until all students have had a chance to respond and ask questions and until the subject has been reviewed to the satisfaction of both the professor and students.
Resident physicians in a certain department met to discuss proposed on-call changes. The chief residents summarized the specifics of what was being asked of residents, which ultimately resulted in more service for less remuneration. Then they asked for opinions. Several residents angrily expressed that this was not what was described to them during the recruitment interview, that this was nothing short of “bait-and-switch,” and that the class should maintain solidarity in their refusal to comply. Many residents voiced no opinion.
After introducing controversial proposed changes to resident call duties, the chief resident says, “This is an important issue for us, and I would like to know what each one of you thinks about it. Let’s use the Mutual Invitation process.” The first, randomly selected, resident says, “I’m incredibly angry and I think we should refuse.” She invites her friend, who is seated next to her, to speak next. He says, “I agree. If we capitulate to this, what will they make us do next?” He looks across the room, and says to a mild colleague, “Don’t you agree?” This resident sheepishly says, “I’m not thrilled with it. But do we really have a choice?” This resident invites another who states, “Is there any up-side to saying ‘yes’?” After each resident had an opportunity to participate, several possible responses were put to a vote, and the chief residents took the response that garnered the most votes to the residency director.
Faculty representatives from all medical school departments were convened for 2 days to “brainstorm” about changes to the traditional curriculum, where greater integration of and between basic and clinical sciences and earlier exposure to clinical material would be emphasized. Divided randomly into groups of 10, faculty members were friendly, energetic, and optimistic at the outset. But, seemingly unrelated to rank, position, gender, or departmental affiliation, the process quickly devolved into one in which the faculty constantly talked over one another. No one person was able to complete a sentence, let alone a thought, before being interrupted by a colleague. This pattern of interrupting and being interrupted continued for the entire day. On the second day, the energy level was significantly lower. In dyads and triads, fellow group members endorsed “feeling exhausted.” Although most participants returned, a number said that they had considering skipping the second day.
On the second day, one faculty participant began, “I have to confess, I feel drained after yesterday. I don’t think it’s because of what we’re asked to do. Rather, I think it’s our process. For today, can we use Mutual Invitation instead?” Other group members agreed. As compared with the previous day, the pacing of the second day was slower, and members were visibly more relaxed. Ventured ideas were received respectfully, that is, allowed a fair airing and some consideration before alternative or dissenting opinions were voiced. At the end of the day, there was still much left to discuss, but members enthusiastically agreed to continue their work together.
Although Mutual Invitation arose in a religious context, it can be adapted to different small-group settings, including medical education and other professional areas. Initially, this process might seem forced or contrived; but, with a small amount of practice and some persistence, this method begins to feel quite natural. Use of Mutual Invitation in some of our very common settings might result in greater inclusion and respectfulness, better ideas, and, ultimately, even more exemplary results.