Otago University's Dr Hamish Wilson shared his thoughts on effective peer group discussions at the 2018 Learning and Education Workshop

College news
8 August 2018

 
Dr Hamish Wilson

"I have this patient who..."

Almost all GPs take part in peer groups, using them as a safe, collegially supportive place to talk about clinical issues in confidence.

But Dr Hamish Wilson of the University of Otago Medical School says that, with some guidance, peer group discussions can also usefully focus on ‘challenging’ or ‘heartsink’ clinical situations, where there may be negative responses within the doctor–patient relationship.

While some peer groups already do this, the usual focus on disease management can prevent more in-depth exploration and/or validation of the doctor’s experience. 

With other colleagues, Hamish recently ran two medical education workshops in Auckland at the College conference. The aim was to familiarise GPs with a helpful method for group discussion, and to provide tips for sharing about clinical cases.

The method can be useful for GPEP groups, peer groups and in one-to-one clinical reviews with registrars or colleagues. It is similar to Reflective Practice Groups (RPGs) in registrar training, where someone is designated to facilitate the discussion.

There are several steps that contribute to having a productive discussion; these are summarised below. 


Identifying difficult situations

Identifying that there is a difficult situation (emotionally, not biomedically) is the first step.

The main warning sign is when a patient elicits an unwanted feeling in you, like annoyance, embarrassment, a heart-sinking sensation, powerlessness, loneliness, confusion, anxiety, frustration or even anger.

The ‘feeling’ words used to describe a case are a clue that there are important relationship issues that won’t be resolved by discussing biomedical aspects alone.

Structuring a discussion

The structure of the discussion is important. First, the GP presents the case to the peer group, in five minutes or less. The group members listen with respect and without interruption.
 
The GP outlines the medical context briefly, moving quickly to the main focus: a rich and detailed description of the patient, the setting, their interaction with the GP, perhaps with details of a particular consultation and how it felt at the time.
 
Useful additional comments include answers to questions such as: how does it sit with you?  What’s the ‘pointy bit’? What does all this mean for you as a doctor at the moment? Being honest about the challenges to your composure is key.
 
 Attendees at the 2018 Learning and Education Workshop

Group discussion

The peer group then discusses the case. It’s important that participants are generous, supportive of the doctor and willingly contribute their thoughts and ideas: everyone stands to learn from the discussion.

Members should avoid criticism of current treatment or management, and questioning should steer away from medical details and disease management to keep the session focused on the interpersonal aspects.

Standing in someone else's shoes

The group tries to imagine being in the patient’s shoes, exploring who the patient is as a person in their unique social context and wondering about their possible ‘back-stories’.

This is deliberately quite an imaginative process, with diverse thinking that could help the doctor who may feel ‘stuck’ about what to do.

The group members try to put into words how they themselves might feel in the situation: what is it like for the patient to be seeing this doctor? What is it like for the doctor to be seeing this patient? 

Through this group discussion, the presenter may be able to identify their feelings more accurately. The group also explores possible roles or perspectives of other players in the wider scenario: for example, is the frequent three-way conversation between doctor, patient and carer a relevant factor?

There's no 'right' or 'wrong' answer

The group shouldn’t necessarily aim for agreement or consensus, or solution-finding; rather, it should aim to explore different possibilities and perspectives and offer practical wisdom as opposed to textbook knowledge.

This respects the fact that the doctor will develop their own emotional and clinical strategies in their own time, and that the peer group discussion is one background to this process, presenting a range of ideas and possibilities.

The group may find it supportive to acknowledge that some situations have no easy solutions, and that unlike biomedical discussions, there is no single unifying diagnosis, ‘correct’ answer or ultimate truth where relationships are concerned.

At the close of the session, the presenter ends with their comments and insights. They may find it useful to make notes to reflect on and to come back later to update the group on what happened from there.

Comments from participants at the workshops are listed here as quotes.


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My peer group gets derailed by funny stories and dominating [participants], so I can see how having the structure would help.



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 Putting words to the feeling helps – trying to really nail what the dominant feeling is.



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Usually GPs are people with a strong desire to do something: they’re not used to feeling stuck.



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Learning to keep your mouth shut is the hardest part of it. Not being judgemental, focusing on the discussion.



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It does take time: there’s a gradual deepening during the discussion.



Hamish says that it’s important for the peer group to protect their time together and value it. They should discuss ground rules, including confidentiality. Varying the format of group meetings and having a well-defined structure helps keep everyone engaged.

Talking through the more challenging clinical issues in these ways naturally requires a peer group to adopt a different approach than for normal clinical discussion: it requires the group members to respond differently and the presenter to be open to a wide range of different perspectives.

The culture of the group needs to be supportive for the GP and open to engaging in discussion about non-biomedical factors. The recommendation would be to use such a structure occasionally but not in all sessions and to designate one person to facilitate or lead the group.

If you would like to read more about Hamish’s tips for structured discussion that can help peer groups explore interpersonal issues more thoroughly, check out his article in the Journal of Primary Health Care, Challenges in the doctor–patient relationship: 12 tips for more effective peer group discussion.

You are welcome to contact Hamish with feedback or further suggestions via Hamish.Wilson@otago.ac.nz.

Our National Clinical Lead Dr Liza Lack is also interested in seeing how these ideas continue to develop. You can share your experiences with her via Liza.Lack@rnzcgp.org.nz.