Our palliative care interdisciplinary team (IDT) meets every morning, and reviews nearly all the patients on the inpatient service, new patients seen in the outpatient clinic, outpatients in need of active management of some aspect of their care (typically pain medication), and patients under our care who have died. It’s a unique and comprehensive meeting that gives us the opportunity to hear about each of our patients from the beginning of our interactions with them, making transitions between providers and location of care much easier than what I am accustomed to. I haven’t seen other IDTs in action so I was curious to see how other programs do it. As it turns out, the Mt Sinai team presented a model not just for an IDT meeting, but specifically how they do their weekly case conference.
They have developed a highly structured model for presenting a pre-selected case to their interdisciplinary team, called “Bring it to the table” (BITTT), referring to the goal of presenting cases that bring a need for help with a tricky management issue, interpersonal dynamic, or with learning potential. Under their old system, they found that the medical side tended to dominate the discussion, and part of the motivation for revamping their conference was to encourage greater participation by the non-medical members of the team. To that end, the facilitator for their conference is typically their chaplain. There are time limits placed on each section of the conference, with time for the clinical case presentation, clarifying questions from the group, and group discussion. This has improved attendance and participation in their conference, and particularly participation by the non-medical members of the team as there is time dedicated for them to ask questions. The time limits imposed also allow for two case presentations weekly, one by each consult team.
As part of the structure of their conference, the facilitator asks the presenting team: “You bring this case to the table because…” with the team filling in their reasoning. I loved this question, because it does force the presenter to be thoughtful and focused on what they are hoping to accomplish with their presentation. This was a very common theme when I was a chief resident and helping residents to prepare for their M&M presentations, when they often chose cases that were extremely complex past the scope of what could be presented in an hour, and needed to identify what specifically they were trying to communicate to the audience. This skill of identifying your teaching (or learning) objective is not intuitive to all learners and educators and I think is really critical for those of us entering the world of clinical education. I love the explicit emphasis placed on it by the Mt Sinai team. My team does some case presentations in our weekly palliative care conference, and while I think the strict structure of the BITTT model does have some drawbacks, it’s worth considering for us as our section grows and the potential for conference chaos increases.
Does your program have a regularly scheduled case conference? How does it work?
Meredith MacMartin, MD, HPM Fellow at Dartmouth-Hitchcock Medical Center