Random case analyses are a commonly-used teaching method in general practice.
There are similarities with case-based discussions (CbDs) but two big differences are that cases for CbDs are shortlisted by trainees and the questioning sticks to what actually happened without exploring 'what if' scenarios. In RCAs, the trainee's (or trainer's) recent cases may be sampled; the notes reviewed and cases discussed to explore how different clinicians may approach the problem and how issues may be managed in a variety of ways.
This affords trainees the ability to critically review their cases, identify unknown learning needs, systematically build on existing knowledge and be signposted to relevant learning opportunities.
An example of a tutorial learning log is outlined below, followed by an in-depth assessment of the RCAs. By the end of this article, the trainee should be able to correctly identify which ideas or assumptions this trainee held that were challenged by the discussion; what they learnt by discussing 'what if' scenarios; what constructive feedback they received; and what homework resulted.
Example of a tutorial learning log
Subject title: Random case analyses with my GP trainer
What was the subject and aims of the tutorial? To discuss typical GP scenarios and develop an understanding of how to deal with them differently. My trainer also wanted to review my investigation, referral and prescribing activity.
What led to this particular subject being chosen? The doctors recently discussed an audit of their antibiotic prescribing. It was interesting to hear how doctors made their decisions to prescribe and what influenced their choice of antibiotic, especially when they chose to deviate from guidance. In light of this audit discussion, I wanted to review some of my cases with a more experienced GP to gain practical, day-to-day tips on improving my practice. Do I deviate from guidelines and, if so, have I done so in a safe and justifiable manner?
What did you learn? My trainer selected four cases from my most recent routine and duty doctor surgeries. After reading through the notes, she asked me to tell her the story of the consultation. She asked some questions to clarify certain points, then summarised the case. She asked if there was anything in particular I wanted to learn from the case.
The questions my trainer asked, such as 'what did patient want from you today?' or 'what do you think of creating a diary date for the blood test?' or 'what would your choice of medication be if this patient was pregnant or 75 years old or a HGV driver?' made me consider what I had actually done, what I might do differently and where I may deviate from standard guidance for good reason.
For example, in the 24-year-old nursing student with fibromyalgia, where I knew the evidence base supported my prescribing of etoricoxib and duloxetine, I wasn't really sure what analgesia the patient wanted from me; he voiced concerns about all options. My trainer did a role play on how I could ask questions to clarify the agenda. She also discussed the use of 'synthesising questions', which are used in CBT.
What will you do differently in future? I gained some insight into how to clarify the patient's agenda; how I could explain my choice of medication to improve concordance; how to give patients time to express their opinions and work things out for themselves.
What further learning needs did you identify? I need to learn more about 'synthesising questions'.
I need to rehearse ‘My first choice of medication is this, for these reasons. Alternatively we could use these, but I think they will be less helpful for these reasons.’
I need to pause after making an empathetic statement. If I move on too quickly, it looks like I am being perfunctory rather than time-efficient.
How and when will you address these? I will look at the CBT link my trainer emailed. In my next COT, I will look at how I clarified the patient agenda, how I 'gift-wrapped' my treatment plan and how I expressed empathy. Did I make changes and did my consultation improve?
The theory of RCA
In the above learning log, the trainee demonstrated an understanding of what an RCA is - he identified that cases must be selected randomly, they should be recent so the trainee can recount what happened; the trainee and trainer can both identify learning needs; and that the case can be extrapolated to 'what if' scenarios to increase the learning potential.
The trainee reflected on his actions, and developed new insights. He discovered that he was unaware that his failure to pause after making an empathetic statement may be perceived as perfunctory.
Once he became aware of this, through sensitive and challenging feedback he decided that expressing empathy was something he needed to work on (he identified a learning need).
He also intended to do some reading on CBT-style questioning and he identified appropriate learning opportunities and resources. He intended to review his practice in a COT, which would be evidence of a change in consulting behaviour.
The trainee was good at looking at specific behaviours. He thought deeply about whether he really got to the bottom of why a patient presented and questions he could ask to help a patient explore their ambiguous and conflicting feelings. He intends to read further and practise asking these questions.
His emphasis was on examining what he does. He did not seek to justify his actions or defend himself, but to explore different techniques to improve his professional practice.
The trainee provided sufficient detail about his learning. He was clear about what new insights he developed, concise and did not spend a long time describing the four cases in detail.
He touched on the questions he was asked by his trainer and how this made him think more deeply about the case. The trainer deliberately chose questions that challenge the trainee and encourage deeper reflection on practice.
While the trainee reflected on his communication, he didn't really discuss the barriers to him changing. He was concerned about being time-efficient, but he didn't really explore how his proposed consulting behaviours may impact the length of the consultation and what he would do if he overran.
What I liked about this reflective account was its succinct description of what he learnt. He took on board how an RCA sets an agenda (what do you want to learn from today's discussion), appreciated that the challenging questions made him aware of the limits of his knowledge and that the subsequent discussion expanded on what he already knew.
He identified important learning needs and useful, specific and pertinent resources.
I would have liked to know more about the role play. Was it useful and what made it useful? Which skills did he practice and what feedback did he obtain? Was he aware at the end of role-play, of what techniques worked and what needed refining?
- Dr Naidoo is a GP trainer in Oxford. She has written three books on how to pass the CSA. The latest book CSA Practice Cases for the MRCGP was published in January 2016.