INTRODUCTION
Case discussion is embedded within the culture of general practice. It is integral to the way we run routine practice meetings, where issues such as child safeguarding and significant event reviews are discussed. However, the inevitable time constraints we face can produce a culture that privileges efficiency and outcome over complexity, subtlety, and emotion in these discussions. There is also the very human desire to collude by problematising the patient or offering simplistic solutions rather than looking at the wider system.
HOW IT WORKS
In the learning sets I facilitate for GPs on the Induction and Refresher Scheme, we have tried out a new approach when discussing cases — the reflecting team. The reflecting team is designed to be used by groups of practitioners, none of whom need any special training to participate. One person, the case presenter, brings a real, unresolved professional dilemma to the group.1 The group is given the opportunity to clarify any details of the case with the case presenter, after which the facilitator asks the case presenter what in particular they would like help with from the group. The case presenter then faces away from the group and avoids any direct eye contact, for example, by turning their chair away. The group proceeds to discuss the case. Ground rules should be established, namely surrounding confidentiality, respect for the opinions of others, and allowing each person to talk.
The group should avoid turning the case presenter’s narrative into their own — so statements such as ‘when this happened to me’ should be avoided. Opinions should be held onto lightly, with curiosity and questioning being encouraged and certainty discouraged.2 Some facilitators have described the process as being akin to throwing lots of balls up in the air with the hope that at least one will hit home, that is, will open up a new perspective for the case presenter.
THE ORIGINS OF REFLECTING TEAMS
Although there are some similarities with Balint groups, the origins of reflecting teams are different and the ground rules are clearer. The idea of the reflecting team arose from work carried out in the 1980s by family therapists.2 Andersen observed that, if families were privy to the discussions and observations of the therapists who were treating them, this could serve to broaden the family’s perspectives and move their thinking on. When the reflecting team is used in family therapy, typically a team of three or more therapists observe the family therapy session from behind a one-way mirror or actually in front of the family. Then, after the therapy session has ended, the family are invited to listen to the team of observing therapists discussing their situation and offering thoughts and opinions, based on what they have heard. The family may be given the opportunity to respond to these reflections. Andersen proposed that opinions should be offered tentatively and speculatively rather than as truisms, in keeping with the collaborative approach he recommended. It is only recently that the idea of transposing the reflecting team to clinical practice has been considered.1,3
DIGEST AND REFLECT
A benefit of adopting the reflective team approach is that the case presenter is able to hear a wide range of perspectives from their colleagues without influencing the discussion by being part of it, unlike in the traditional case discussion.3 The requirement to remain silent during the group discussion removes the compulsion on the part of the case presenter to react to the conversation but instead allows time to digest and reflect on the opinions and thoughts of the other group members. The group gets feedback about which part of the discussion and which questions they asked were most helpful or caused the biggest shift in thinking.
The reflecting team has been popular with the group of GPs I work with, who are either new to the NHS or are returning after time away.4 In terms of feedback, recurring themes have been opening up of new perspectives; the luxury of not having to respond; feeling validated by realising that colleagues have similar decision-making processes; and being able to listen deeply.
The slowing influence of the reflecting team is an antidote to today’s prevailing discourse of speed and outcome focus. It could be that, by discussing one or two cases in depth, we end up learning more than we would have by skimming the surface of many.
- © British Journal of General Practice 2019