There’s Got To Be A Better Way. Don’t get me wrong – journal clubs and in-services are great. They help keep your residents and clinic staff up to date with the latest and greatest. But, let’s face it – they can sometimes be a bit boring. What if there was a more interesting and clinically relevant way of promoting reflective and evidence-based practice?
Several years ago while working at Massachusetts General Hospital (MGH), I was introduced to a new form of interactive literature appraisal called Case Conferences. Around the year 2000, the MGH Physical Therapy department went through a time of reflection and Case Conferences was born from that process.
Through introspection, the department realized that a lot of interventions their therapists provided to patients were based on past experiences as opposed to actual evidence. Not only were interventions inconsistently applied from clinician to clinician, but there were also disparities when it came to therapist’s insights into individual patient values and how to integrate those values into the therapy plan of care. They also realized that their staff members were at various levels of clinical development. Therefore, each therapist had a different degrees of comfort when it came to formulating a clinical question, searching and critically evaluating the literature, and applying the literature to a patient’s care.
When the MGH therapy department leaders reflected on ways to address their standards of practice, they realized that there were several limitations to the traditional methods of disseminating evidence to their staff. For example, the standard in-service format did not promote group discussion and critical evaluation of actual physical therapy practice in their department. The topics presented during in-services were not always clinically applicable to a therapist’s current case load. And, most importantly, in-services did not allow each staff member opportunity for reflective practice.
The Goals of Case Conferences
The therapy department at MGH realized that traditional methods were not going to achieve the department’s new focus – promoting evidence-based discussions that were patient focused and reflected a patient’s values. In addition to coming up with a standardized set of evidence based tests and measures to improve consistency of PT examinations across the hospital, they also developed a new education format called Case Conferences.
Here are the four main goals of Case Conferences:
1) To aid participants in understanding the value of the PT Examination and how the data collected influences clinical decision making and ultimately the patient.
2) To promote active dialogue, clinical thinking, and self-reflection among physical therapists.
3) To identify clinically-relevant questions and perform skilled literature searches to answer those questions
4) To increase evidence-based practice.
Case Conferences – Keeping It Real Since Year 2000:
As you can see by its goals, Case Conferences has an innate flexibility in how it is applied. I will discuss some ideas for creative application, but first let’s cover the traditional approach. The original Case Conferences format was designed for a small group of up to 10 participants who would meet twice a month for an hour. The group contains people with various levels of clinical experience but should have at least one clinical expert or clinical specialist in the group who acts as the meeting facilitator.
A patient case is selected from one of the group members (see The Secret’s In The Sauce, below). The original physical therapist examination note, with patient-identifiable factors removed, is passed out to the group at least 5 days prior to the first meeting. Each of the group participants reads through the note and reflects on the case….Is there data in the note that needs clarification? Why was this test selected over that test? Is there data to support the exam’s assessment statement? The participants look up definitions for any terms they don’t know within the note (ex. What is a troponin?) or any tests and measures in the note that they are unfamiliar with (ex. What is the MiniBESTest?).
During that first meeting (aka Case Conferences Part I), the team critically discusses and reviews the patient case by dissecting the therapist’s examination note. The goal of Part I is NOT to make the therapist feel defensive about their examination! Instead, the group tries to really get inside that therapist’s head in order to better understand his or her clinical decision making – Why were you thinking what you were thinking when you were thinking it? By the end of Part I, the group identifies a clinical question specific to the case at hand.
This clinical question can be about anything clinically relevant to the case. Let’s face it – as PT’s, we come up with multiple clinical questions per day. We just might not realize we are doing it! That’s the beauty of Part I – it allows us to uncover those clinical questions within ourselves and to learn how to phrase them in a way that helps us to search the literature for an answer. The clinical question could relate to a commonplace issue in clinical practice (How do I accurately identify what my patient means when she says she is “dizzy?”), a practice setting or clinic site issue (Should our facility promote early mobility in a patient who has had a CVA less than 24 hours ago?), or a current trend in PT literature (What evidence-based interventions are available for people with Parkinson’s Disease that promote neuroplasticity and neuroprotection?).
After the clinical question is selected by the group, each of the participants perform an independent literature search and then submit abstracts of 3 to 5 articles to the group facilitator. The leader then picks out one (or sometimes two) of the submitted abstracts that best addressed the clinical question and then and passes out the full article(s) for some light reading.
During Case Conferences Part II, the team critically evaluates the article(s), much like a standard journal club. More importantly, the group discusses immediate application of the article’s juicy center to the patient from Part I. This also gives the group an opportunity to discuss how to apply the discussion take-away points to similar patients that are currently on their caseload.
The Secret’s In The Sauce:
Dare I be so bold as to claim that the selection of the case is the most important element of Case Conferences? Well gosh darn it, yes – I dare! So here are some important things to keep in mind when selecting your case:
• Every clinician, regardless of clinical experience, has an opportunity for their case to be selected for discussion. This allows for developmental opportunities for new graduates as well as opportunities to dissect clinical decision making of experienced staff.
• The case selected should represent a day to day element of clinical practice. While a rare diagnosis can spark interesting discussion, that discussion may not be clinically relevant to a therapist’s current practice (see goal #3).
• The patient should be currently receiving physical therapy or have been recently discharged – that way things are fresh in the presenting therapist’s mind.
Variety Is The Spice Of Life:
While Case Conferences was originally developed to address the needs of a very large therapy department at one of the nation’s top hospitals, the program’s goals are wonderfully aligned with what we strive to achieve with our residents. However, the traditional Case Conferences format just didn’t work for us. Luckily, the goals of Case Conferences allow for many alternative models of the program that still achieve the same goals.
Last year we piloted a WebEx version of Case Conferences and had very positive feedback from the residents. We kept true to the Part I/Part II model, but instead of in-person group meetings we performed the meetings online. In that way, we were still able to meet the goal of group dialogue but we didn’t add increased travel and scheduling stress to our residents and mentors.
Here are some other ideas when implementing Case Conferences into your clinic or residency program:
• You could consider a topic series where the cases focus on a specific topic or diagnosis over a series of months (ex. Stroke – Month 1: MCA, Month 2: ACA, Month 3: Cerebellar).
• You could use video to supplement the examination findings (Are you really seeing what you think you are seeing?) Some of our residents last year chose to take patient videos which lead us to many interesting case-based discussion points and clinical questions.
• You could have a hands-on lab portion in addition to or instead of Part II. Use that case on BPPV differential diagnosis as an opportunity to brush up on your vestibular testing skills!
• Some departments are multidisciplinary, so why not include your fellow rehab staffers in the discussion? It facilitates team building and thinking outside of the PT box.
• Consider writing up a summary of the Part I and Part II discussion for participants (and even non-participants) to refer back to when they see a similar case
When it comes down to it, Case Conferences is an excellent vehicle to promote critical discussion, self-reflection, and evidence-based practice in your clinic or residency program. No matter how you choose to implement the program, it is a great tool to foster clinical expertise in physical therapy practice among your peers.
Finale: Let’s Give Credit Where Credit’s Due
I would like to give a special thank you to Kristin Parlman, PT, DPT, NCS, who is a fabulous physical therapist and a wonderful mentor. Kristin was not only instrumental in guiding my personal Case Conferences journey but also gave a fascinating presentation at CSM 2007 called The Use of Case Discussions to Facilitate Evidence-Based Practice in Neurologic Acute Care Physical Therapy. Much of the information above is based on those personal experiences and Kristin’s CSM 2007 lecture.