By Peggy Berry Martin, M.Ed., Director of Education for Risk Management Foundation; and Margaret Waterman, Ph.D., formerly Curriculum Coordinator in the Office of Educational Development at Harvard Medical School.

1. Assess the needs and agenda of the audience prior to the discussion.

If the audience for a presentation is unfamiliar, ask the person setting up the meeting about the likely participants. Ask some people likely to attend the program what they are interested in hearing, or any special issues that they see as relevant to their practice. This helps you prepare relevant examples that increase the participants' learning, their satisfaction, and your credibility.

Sources for Closed Claims

1. Clinical risk managers are the best source of malpractice claims material to present in a discussion format. Closed cases from your own practice setting are usually the best because the facts are familiar. These claims also address the loss prevention issues most important for your staff. The disadvantage of using your own facility's cases is that the case (even with facts and names changed) may be inappropriate or embarrassing to defendants for open discussion.
2. Your risk manager and your malpractice insurer's claims personnel can help select closed claims in which the circumstances are available and instructive. These cases come from a common pool of claims and are likely to include many of the same issues in-house files would reveal.
3. Risk managers in several institutions may share closed claim scenarios (with identifiers and facts altered to preserve confidentiality). This could be through a state risk management organization, from the insurer's risk management program, or through informal arrangements with other risk managers in similar institutions.
4. Claims data appearing in national publications can be used. To avoid the attitude that a national case "can't happen here," relate the "outside" case to other case scenarios that did happen in your institution, or use the facts and experience of the institution to demonstrate that such an event could happen there.
5. If no one case on a particular issue is suitable, a composite of several similar claims can be created to illustrate the loss prevention points to be covered.

2. Consider the basic ideas you want to present and how to present them most effectively.

If the objective is to cover several issues (i.e., multiple caregivers, failure to diagnose, poor physician-patient communication), try to pick one case that illustrates all the issues rather than one case for each issue. Limit the number of main points to be discussed—figure on two to four for a one hour program. Keep track of the points you believe the participants should mention, so that you can guide the discussion to any that they have missed if you have time. Allow the discussion to evolve slowly as the participants think about the issues of the case, and as they hear their peers' ideas, rather than rushing to finish two or more cases just because those are prepared. If the time allotted for the case discussion is less than 30 minutes, expect to present just one case (but have a second prepared just to play it safe).

3. Encourage participation.

If possible, have participants sit face-to-face with minimal space between them and you. Some rooms are better designed for case discussion (e.g., those with movable chairs and tables are ideal). But even in a standard auditorium, you can improve the program by encouraging the participants to talk with one another rather than with you. For example: "Dr. Brown, do you think the patient was angry for the reason that Dr. Green gave"? You can also employ body language: e.g., selecting one participant to speak while directing the conversation to another participant by walking or gesturing in his or her direction.

4. Start on time.

Dealing with seating arrangements may be easy compared to getting everyone there on time. Those who are on time should not be asked to wait idly. You might ask them to read through the cases while they wait, or have a short scenario printed or projected for them to focus their attention. Consider having a participant read the case aloud to signal the beginning of the session.

5. Emphasize the value of everyone's contribution.

Many cases are appropriate for joint discussions between attending physicians and residents, or between attending physicians and medical students. But a mixed audience can be intimidating to some members, so efforts need to be made to make all feel included, and all opinions heard. To encourage broad participation, set a ground rule that each opinion be valued equally for the purpose of the discussion at hand. Asking for opinions without putting the less experienced clinicians on the spot is a good way to proceed. "How does this issue affect your work?" or "Have you ever encountered a patient like this one?" may be good questions to ask of trainees.

6. Open with questions that focus the topic but allow for a wide range of responses.

Instead of "Are there any questions about this case?" ask "What are some different ways...?" or "What was the physician's dilemma?" Be careful not to answer your own questions... silence is okay. Wait 10-15 seconds in order to give the participants some time to consider their responses.

If the case is a good one, you rarely need more than one provocative opening question. The attendees will generate plenty of discussion with little prompting. The more common problems are getting the participants to wait until a colleague has finished before talking, and keeping them on the case you presented (rather than discussing their own experiences).

7. Record the participants' main ideas.

Write your comments down on a board or flip chart to help participants confirm that their ideas are being heard. This also makes it easier to reference those ideas later in the session. If possible, have an assistant do this to free you to concentrate on the group interaction. Record the main ideas discussed to check that all the important points in the case are mentioned.

8. Encourage participants to share their own relevant experiences.

You can also plan to have participants share their own experiences, although the discussion may have to be "controlled" if one individual starts dominating it. Saying "Thanks for sharing that...let's hear from someone who has not spoken" may help move the discussion along. If the talkative individual becomes too persistent, you might offer to discuss his or her specific situation (privately) afterwards. Gently bring the discussion back to the topic at hand.

9. Plan sufficient time for discussion.

Schedule time to a) talk about the case, b) review the lessons to be learned, c) deal with questions that may surface as a result of the discussion, and d) summarize the important points. If the case is short and the time allotted is brief, consider sending the written material out in advance for participants to read beforehand. A quick review of the facts should then be sufficient to begin the discussion.

10. Anticipate being asked questions you cannot answer.

You may not be able to answer every question raised. Having a team of co-presenters (risk manager, claim representative, attorney) available may be useful for addressing the variety of questions that could surface. If you are leading the discussion alone, ask participants to write down any unanswered questions so you can consult an appropriate colleague and get back to the questioner. You might also ask your risk manager or in-house attorney to do a follow-up session, if a particularly troublesome issue has been raised. Following up with additional written material on that specific issue could also help.

Selecting Claim Abstracts

1. The clinical facts must survive simplification. Abstracts used for discussion must be short; clinical facts must be kept to the minimum necessary for participants to understand the case. Do include enough pertinent information so that participants don't feel that relevant facts were left out.
2. The loss prevention issues must logically follow from the case facts. What went wrong and what could have been done differently to change the outcome should be clear.
3. The facts described should reflect current medical practice, be clinically correct, and make sense in this shortened version of the case.
4. Although the claims are closed, some circumstances could cause embarrassment for certain participants, or might be too politically sensitive to use. If you think a case might be too close to home, select another.
5. Use claims in which the defendant prevailed as well as those in which the plaintiff proved negligence. Such claims (defendant prevailed) can illustrate what practices may have contributed to a defendant verdict (e.g., documentation) and any issues that could have been a problem but did not result in liability (e.g., delayed diagnosis resulting in no change in outcome).

Conclusion

When learners can articulate important concepts themselves, they retain them more readily. A facilitator or discussion leader through appropriate questioning and management of discussion helps participants recognize issues and propose solutions. The leader keeps the discussion on track, highlights the important issues raised, encourages everyone's participation, sets and maintains boundaries for discussion, acts as timekeeper, summarizes important issues, and teases out relevant points not mentioned by the group.

Closed malpractice claims provide a powerful focus for case discussion and are particularly relevant to physician audiences when a peer is the discussion leader or one of a team of presenters. Risk managers can provide claims to be used for case discussions, advice on the relevant issues, and an eagerness to help physicians prepare case discussions for other caregivers. Physicians and risk managers can form effective partnerships to use claims-related education as a powerful loss prevention tool and to promote positive learning from negative circumstances.

Acknowledgment

Segments of this article are based on Twelve Suggestions for Small Group Teaching developed by Lewis First, M.D., Margaret Waterman, Ph.D., and Anita Feins, M.D., for the Pediatrics Faculty Development Project at Harvard Medical School in Boston.

Originally published in Forum, Vol 18 No 6, March 1998