During reflection, the faculty helps participants carefully describe the situation and identify factors that could be generating and/or maintaining the status quo (e.g., fears, fixed attitudes, competing interests). Disciplined reflection may also reveal unrecognized resources and points of leverage for change.

During reflection, faculty must exercise restraint by using questions and comments to help the participants articulate their own understanding of the case. Though physicians are problem-solvers by nature, in this situation the faculty should not offer advice until the presenter has clarified his/her understanding of the case. During this time, the faculty should instead focus on asking “who-what-when-where-how” questions to elicit facts about the case and “why” questions to help the presenter articulate his/her understanding of the case.

Faculty have a two-fold responsibility in guiding the reflective process. First, they must help the group identify the information necessary to develop a specific plan suitable for the presenting case. Second, they should invite other participants to describe analogous cases to frame the problem in a larger context of issues that physicians face. Often this will include the seasoned faculty sharing similar scenarios from their own experience with the group. In turn, the participants will leave with not only a plan of action and a framework for future challenges, but also with an understanding that their problems are not unique. Although the eventual goal is to develop a plan of action for the presented problem, faculty must maintain a balance of broadening the discussion while focusing the action plan on the presented case.

It is crucial to encourage a robust conversation that elicits analogous situations from the group, including the faculty. If not, then participants and faculty – all of whom are problem solvers by nature – may become too focused on the initially presented case, firing advice, suggestions, etc., at the presenter. This can create the mistaken impression that the presenter is the only one who has encountered such a difficulty. As a result, participants may become reluctant to offer cases due to fears of being “henpecked” or “singled out” by the discussion.

As mentioned above, when exploring the presented or analogous cases, the participants must use the “who-what-when-where-how” questions to establish the relatively objective, observable aspects of the circumstance (e.g., what is the task at hand, who is involved, who did or said what). These questions will help participants describe aspects of situations that are less obvious, but nonetheless part of the picture, such as their impressions regarding the feelings and perspective of the other parties involved (e.g., concerns, motivations) as well as clarifying their own internal experiences (e.g., emotions, attitudes, or principles that guide action). During this time, faculty must exercise discretion and avoid questions that steer the group towards a specific solution. Instead they must remember the seminar’s goal is to support the learners’ rehearsal in reasoning through very complex situations.

Inevitably, participants begin offering suggestions. Because suggestions are always rooted in explanations — stated or unconscious — faculty should ask for the hypothesis or diagnosis that logically leads to that suggestion, or why that suggestions should work in the situation being discussed. If the discussion stays focused on the central question, the faculty will notice an emerging pattern of factors at play in this and similar cases (e.g., an adjustment to a bad diagnosis, cultural or language differences between patient and provider, complicated family dynamics, or lack of clarity in responsibility of physician or institution.) Noting these factors will be useful in the third component: Formulation of a Working Hypothesis/Working Diagnosis.

During this period of reflection/systematic analysis, the group will:

  • Fully describe the important features of the challenging circumstance — who-what-when-where-how — from the perspective of the objectives and interests of key stakeholders, the strategies or solutions have been attempted to date, and the outcomes;
  • Compare and contrast the features of the presenting case with other experiences of the participants and faculty; and
  • Describe factors that may be generating or maintaining the problems in this or similar cases (the “why”).

Once the group has accomplished the above, faculty can summarize the major categories of factors identified in the discussion and transition to the next component, Formation of Working Hypotheses/Diagnoses.