Case Rounds Redefined: Bess, Geevargis, Tai

A submitted guest post from Megan Bess, Nira Geevargis, and June T. Tai: 

 

As a clinician, have you ever struggled with conducting case rounds? Perhaps the students don’t seem to engage and offer perfunctory descriptions of their work. Or, they wander off track from the originally presented topic. Case rounds are envisioned as a way to practice skills, transfer the experiences and learnings of one person or team of students to a larger group, and build community. However, conducting rounds can feel challenging for even the most experienced clinician.

In our recently published article, Case Rounds Redefined: Multidisciplinary Perspectives in Reflective Practice, we explore the possibilities of the case rounds process. Many clinicians lead seminar discussions of students’ field work. The format of the discussion can vary from a quick check-in with each student around the table, to a more in-depth discussion of one student’s field work. With in-house clinics, students work in the same discipline and take turns presenting a problem or decision point in their matters. The clinic group then, in turn, examines possible paths forward.

Externship seminars build on the pedagogy of case rounds, but adjust the nature of the discussion to account for the differences in the externship program structure. Typically, externship seminars include students in a variety of disciplines, with different organizations.^[i] Externship rounds, therefore, are not tied to the details of specific cases but rather focus on the students’ processing of their fieldwork experiences or how they grapple with a professional issue.^[ii] Students reflect after an event and must recognize and reconcile their previous knowledge, experiences, or expectations with their version of the reality of the situation.

I.   The Case Rounds Structure

When facilitating the annual American Association of Law Schools Clinical Section’s Teaching Methodologies Case Rounds, Professors Megan Bess and Nira Geevargis use a case rounds structure that includes seven stages:^[iii]

(1) issue selection;

(2) presentation of the issue without interruption;

(3) clarifying questions to get a full picture of the issue;

(4) problem definition;

5) presentation of the goals;

(6) advice, next steps, and solution; and

(7) reflections on lessons learned.^[iv]

Each has adjusted the format depending on their instructional goals or the needs of their students. To consider the possibilities of how case rounds can be adjusted further, we delved into literature discussing similar practices in other professional training programs.

II.   Rounds or Reflective Practice Groups in Other Professions

Case rounds evoke the rounding process used by medical professionals to care for patients in the hospital and also train residents. In medical training, rounds can refer to patient-specific case discussions, or broader reflective practice group discussions.

Arabella Kurtz promotes the adoption of reflective practice groups in healthcare settings as a way to use group intellectual and emotional resources to consider clinical practice issues. She provides a model that starts with the experience of one group member and utilizes the reactions of others for support and guidance.

Similarly, Schwartz Center Rounds provide a forum for the staff providing patient care to share the emotional and ethical challenges they face. Members of the care team present a case and describe how the situation impacts them, and the other participants in the group have an opportunity to reflect and comment. Facilitators guide the discussion so that it does not focus on clinical care, but rather on the experience of caring for patients and their families.^[v] Because participants in Schwartz Rounds reflect on the work done as opposed to pending clinical problems, the model highlights the value to participants of expressing emotions and connecting to others in the field. Studies show the reflective Schwartz Rounds approach can be effective for helping healthcare workers process emotions and relieve stress.^[vi]

Outside of the medical profession, other professions, like social work and teaching, use similar structured and facilitated reflective discussion methods. Examining each of these approaches gives insight into ways to meet different goals or highlight varied skills when conducting rounds.

III. Revisiting rounds: the goals and the structure

As instructors, clinicians can consider the goals for their rounds session and – borrowing from other disciplines’ structures – modify the structure of rounds. An instructor focused on curiosity and listening might emphasize each individual phase more, encouraging students not to jump to conclusions. In these cases, an open-ended conversation without a definite solution might be preferable; the attention is on the process. On the other hand, an instructor with a foremost goal of addressing supervision issues at externship placements might focus on making sure the presenter identifies a feasible solution, acts on it, and reports back to the class.

Similarly, if autonomy is a goal, instructors might spend more time on the topic selection process or only hold rounds when there is a topic that students request to discuss in rounds. They may also allow students to continue discussing issues raised in previous rounds sessions if additional processing is needed.

Finally, if an instructor senses that the students need to have shared emotional processing, providing space during the rounds for students to journal or discuss their feelings can facilitate that discussion.

Prior to holding rounds, clinicians have choices. What kind of pre-work is appropriate? Who and how will the topic for discussion be chosen? How actively will the instructor facilitate the conversation? What are the ground rules for the discussion? And how often – and for how long – will one conduct rounds?

The approach to facilitation is not static. Once students are familiar with the rounds process, professors may choose to step back from the spotlight as a facilitator and give students an opportunity to lead rounds.

Facilitators should also consider how to encourage participation by all students in the class. Rounds are meaningful, in part, because the process highlights the gray; it shows there are many possible paths one can take when lawyering. Those options are more likely to surface when different perspectives are brought to bear on a problem.

While we have described the benefits of a structured rounds process, we hope to have provided ways to experiment with rounds to facilitate a more reflective process, highlight different lawyering skills, and promote professional identity formation. We would love to hear your ideas for modifying rounds to meet the needs of your students.  Do you have any favorite twists on the structured rounds process?

 

^[i] Robert R. Kuehn et al., 2022-23 Survey of Applied Legal Education, Ctr. for Study Applied Legal Educ. (CSALE), Sept. 2023, at 28, 39-40 (noting 81% of externship courses include students in different types of placements/host offices, e.g., government agencies and nonprofit organizations).

^[ii] Gillian Dutton et al., Externship Pedagogy & Practice 259 (2023); Rebecca Rosenfeld, The Examined Externship Is Worth Doing: Critical Self-Reflection and Externship Pedagogy, 21 Clinical L. Rev. 127, 148 (2014).

^[iii] This method was developed by Alex Scherr (University of Georgia School of Law), Jodi Balsam (Brooklyn Law School) and revised by Megan Bess, Nira Geevargis, and Kendall Kerew (Georgia State College of Law). It is based on the five stages of rounds of conversations described in Transforming the Education of Lawyers: The Theory and Practice of Clinical Pedagogy: (1) description, (2) problem identification and clarification, (3) goals, (4) strategies and (5) lessons learned. Susan Bryant et al., Transforming the Education of Lawyers: The Theory and Practice of Clinical Pedagogy 132 (2014).

^[iv] See a one-page summary of the traditional rounds process and a framework for a more reflective process, available at https://go.uic.edu/ExternshipRoundsMethod; We provide a PowerPoint for professors to use in their classes outlining this rounds process, available at https://go.uic.edu/ExternshipCaseRoundsSlides.

^[v] Jill Maben et al., A Realist Informed Mixed-Methods Evaluation of Schwartz Center Rounds in England, Health Servs. & Delivery Rsch. (Nov. 2018).

^[vi] Rina Meyer et al., Pediatric Schwartz Rounds: Influencing Provider Insights and Emotional Connectedness, 12 Hosp. Pediatrics 703, 705 (2022); Jill Maben et al., A Realist Informed Mixed-Methods Evaluation of Schwartz Center Rounds in England, Health Servs. & Delivery Rsch., Nov. 2018, at  xxvii, 1-2.