Training for complexity and professional judgement: beyond ‘communication skills plus evidence’

Evaluation of the reflecting team as an educational intervention

Background: The reflecting team is a way of exploring clinical or educational dilemmas. A key difference from traditional case discussion is that the case presenter is not actively involved in the group discussion but instead listens to the ideas and thoughts generated, without contributing to the narrative. The origins of the reflecting team are in family therapy and there is little evidence on how successfully the technique can be transposed to clinical or educational practice.Aim: To evaluate the effectiveness of the reflecting team as an educational intervention.Design and setting: Interpretive action research involving 10 GPs who were either enrolled on the Induction and Refresher Scheme or who were members of a learning set of GP educators.Method: Interview data were audio-recorded, transcribed verbatim and thematic analysis was used to identify themes.Results: The reflecting team appeared to be an effective and acceptable intervention. Key features of the reflecting team included the opening up of new perspectives, feeling validated by peers, the need for ground rules and the perception of the reflecting team as a practical tool.Conclusions: The reflecting team is a new way of undertaking case discussion in GP education and seems to offer some advantages over traditional case discussion. It lends itself well to learning groups and it is possible that the idea might be transposed to clinical settings too.

When general practitioners talk about alcohol: exploring facilitating and hampering factors for pragmatic case finding

BACKGROUND

The aim was to explore individual and system factors facilitating or hampering pragmatic case finding, an identification strategy based on clinical signs and targeted screening.

STUDY DESIGN

Two focus groups with general practitioners were interviewed twice, in the context of a four-session seminar on alcohol and complex drug problems, and an additional focus group interview with general practitioners not attending the seminar. Interviews focused mainly on conditions for talking about alcohol, views on collaboration with colleagues, how they deal with complex issues, and strategies for learning and quality improvement.

RESULTS

The participants presented many deliberate strategies for quality improvement and learning together, but there was a tendency to avoid discussing complex case stories or potentially controversial topics with colleagues. Possible barriers to change were presented. The majority of their stories on talking about alcohol coincided well with the concept of pragmatic case finding. The duality between shame and normality, time constraints and a need for structure were the most important individual barriers to an open and respectful conversation about alcohol with patients.

CONCLUSIONS

Our study supports pragmatic case finding as a relevant and viable strategy for talking about alcohol in general practice, and as an alternative to screening and brief intervention. Quality improvement in practice is strengthened when it is adapted to the clinical setting, and builds on and stimulates the GPS' and staff's own strategies for learning and quality work.