July 19, 2021

Listen to what Coach KB has to say

Bruce Peyser, MD, FACP
Director of Education and Teaching, Duke Primary and Urgent Care
Physician, Duke Primary Care Pickett Road

Professor of Medicine, Duke University School of Medicine

Duke Primary and Urgent Care are changing the workflow for reviewing clinical cases, referred to as our peer review process.

We have been using the electronic RL6 system to report cases and facilitate practice-based review. This is the same system we use to report safety events across the network and health system. We had paused further expansion of this system until appropriate upgrades had been implemented, but now we are ready to resume spreading this capability. Each provider is expected to submit at least four cases throughout the year, and everyone will be involved with reviewing the cases that are submitted. Our goal is to have a peer review champion at each practice who will help lead this process and make sure all the cases are closed. These individuals will be trained by Jayne Genier so they are familiar with the computerized system used by Duke to confidentially analyze and review the cases.

Though I admit to my usual New Yorker skepticism pertaining to all things new and different, I think this process represents a valuable teaching opportunity for all involved. When asked to think about how to best maximize learning in these settings, multiple individuals suggested I interview Dr. Karl Bernat because he had created a number of effective peer review sessions in the past. So I gave him a new name, Coach KB, and I asked him what had worked best for his groups.

Coach KB first emphasized he has had to be quite organized about the process, and he recalls sending emails to his colleagues weeks in advance reminding them of the upcoming peer review session. He would encourage his providers to think of cases when they had learned from an omission, or an error, or a complication. When he would actually lead the session for 45 minutes, he found it was too much to try to cover every case submitted. So he would usually focus on only a couple of cases that appeared to be the most interesting or instructive to the group.

Additionally, Coach KB said he found it quite helpful to project the cases onto a screen so that all could look collectively at the timelines, labs, etc. To enhance efficiency, he would designate someone to write notes from the sessions and enter this data into the RL6 system. This would “close the loop” on cases that had been discussed and allow them to be appropriately closed. It is important to keep in mind that this is an opportunity to learn and that it is not intended as an exercise in judging one’s colleagues.

It turns out that collaborative learning theory is quite helpful when it comes to structuring these quarterly sessions. This method encourages working together and emphasizes that for many problems there are different viewpoints and perspectives. With collaborative learning, we tend to learn from each other and no one has to be designated as a student or teacher. We also know that collaborative learning often pushes teams to achieve higher levels of thinking. As an example, think back to when two famous individuals worked together in a basic computer programming class in middle school. Bill Gates and Paul Allen obviously benefited from that collaboration and went on to create Microsoft.

So my take-home points here would emphasize the importance of being organized and realistic about what can be achieved. Be sure to involve everyone in your group. Create a positive learning atmosphere (once the pandemic ends and we resume in-person meetings, maybe provide food), and ask for feedback at the end of the session to see what works and what might be improved upon. I would also emphasize trying to focus on two to four main points and not try to cover too much. Once we are further along in this implementation, we will continue to encourage exploration of clinical areas we have been challenged with, such as hypertension management and readmissions.

I would experiment with the process, and look at how your group goes about reviewing and discussing the cases. If you have some success in this area, please let me know so I can share best practices with everyone. And if you have any troubles or challenges, I am sure we can ask Coach KB what he thinks as well!