GP training: Appraising a case-based discussion

Case-based discussions are an important part of a GP registrar's workplace-based assessment, explains Dr Prashini Naidoo.

Case-based discussions (CbDs) are a series of mini-assessments within the workplace-based assessment. The RCGP defines CbD as ‘a structured interview designed to explore professional judgment exercised in clinical cases which have been selected by the GP trainee and presented for evaluation.’

This article aims to provide GP trainees with a broad overview of CbDs and gives one trainer’s perspective on how I use CbD to help trainees improve their decision-making skills. The RCGP website provides in-depth information on all assessments and is an excellent starting point.

The structured interview

When I conduct a CbD, I focus on the decisions a trainee has made in the case presented to me. Start with selecting a good case.

I ask trainees to keep a CbD mapping sheet (see here for an example) to aid case selection to cover a mix of children and adults, and domains not previously tested.

For example, if trainees have achieved competencies in clinical management over several previous CbDs, I am more likely to ignore the clinical management domain and rather select a case that lends itself to assessing the neglected domains.

By the time ST3s reach primary care, the neglected domains tend to be community orientation and primary care administration whereas data gathering and making diagnoses have usually been covered in hospital rotations.

I also try to select across a range of patients (children, mental health, cancer/palliative care and older adults) and clinical contexts (surgery, home visits and out-of-hours). 

I use the trainee’s written records to prepare my questions, starting off with an easy question progressing to more difficult ones.

The range of questioning is to give trainees the opportunity to be graded, so I may need questions that sift the excellent from the competent. I design questions to explore the professional judgment of trainees, to see why they made the decisions they did. The trainee should feel challenged by the questioning, so it is usual for trainees to feel uncomfortable as the questions become harder. 

Professional judgment

The RCGP says that professional judgment ‘may be considered as the ability to make holistic, balanced and justifiable decisions in situations of complexity and uncertainty. It may include the ability to make rational decisions in the absence of complete information or evidence, and to take action or even do nothing in such situations.’

I pay particular attention to situations of uncertainty, such as the trainee’s decision to admit the patient to hospital rather than to initiate treatment and review the patient in person or by telephone later. Other interesting cases may be ones in which there was a conflict in decision-making, for example, where a patient demands a service that may be difficult to fund.

My opening questions tend to allow the trainee to briefly recap the specific complexities of the case. Therefore, in response to an opening gambit of ‘what challenges did this case raise?’ the prepared trainee summarises the dilemma, for example, this is a case of the patient’s demand versus the resources available, or doing good as opposed to harm, or balancing the needs of the individual versus the needs of society.

My later question may be ‘of the options available to you, what were the advantages or disadvantages of each option?’ The difficult questions may be ‘how did patient’s perception of his ‘rights’ influence your handling of the case? What are your responsibilities as his GP? How do they apply to this case?’

The trainees’ responses tell me about their ability to recognise issues of uncertainty or complexity, how they apply their theoretical medical knowled ge to specific situations, how they use ethical and legal frameworks to sort out the best way forward, and their ability to prioritise options, consider implications and justify decisions.

An example

I pay particular attention to situations of 'dissonance', where there is inconsistency in the trainee's actions and expressed beliefs, usually revealed to me by the trainee expressing emotion.

For example, a trainee may discuss feeling upset by investing quite a lot of time, using motivational interviewing (MI) skills, to help a patient explore their eating problems only to find the patient returning to a different doctor the next day to obtain the requested prescription for orlistat.

The dissonance is between their beliefs that (a) empowering patients is good practice and (b) good practice should change patient behaviour. In this case there was no change in patient behaviour, so the trainee seeks to explain why this happened.

My questioning in the CbD would also explore what the trainee learnt. The trainee who learnt to spend less time on educating patients and restricting options is less highly marked than the trainee who learnt to respect patient's choices even when different from their own.

Here a discussion about using MI to help patients lose weight (clinical management) lent itself to exploring ethical issues, such as patient informed decision-making and respect for autonomy.

Evaluation, grading and feedback

Trainees should be able to justify the decisions they make in everyday practice. Everyday practice is real life, with over-running surgeries, staff that interrupt clinics and patients who do not always speak fluent English.

Trainees should be able to explain why they thought one option was safer, quicker or better, or they should discuss, on reflection, what they would do differently. For me, trainees score highly if they overtly demonstrate the steps of decision-making.

To use an analogy, in a driving test, the learner driver demonstrates to the examiner his driving skills – his ability to recognise problems on the road and to take appropriate action. He is not passed because he gets from A to B. Similarly, the CbD tests the skills of decision-making and not the final action the trainee took with the patient.

In our case of weight loss, the trainee is not passed or failed in the CbD based on whether she prescribed orlistat or not. Marks are awarded for how the patient's readiness to change was explored, how the patient's options were discussed, how the NICE obesity guidance influenced decision-making or how the ethical aspects were considered.

When conducting the CbD, I try to comply with the RCGP recommendation of 20 minutes for questioning and 10 minutes for feedback, but often find that more time is required for feedback. However, I save the feedback to the end to avoid 'teaching' as I go through my questioning. Trainees could ask the trainer 'How could I have obtained a better grade?' to focus the feedback. 

CbDs judge trainees against what an independent and safe GP would do and after telling a trainee he or she ‘needs further development’, I find I need to spend some time advising them on how to develop and signposting them to useful resources.

In our example, the feedback could be generic such as to brush up on the NICE obesity guidance, or read a bit more about ethical frameworks, or more case specific, such as how can we better reconcile the differing patient and doctor agendas here. 

  • Dr Naidoo is a GP trainer in Oxford


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