READ THIS FIRST: General information on the CBD

[AM]

The official RCGP page on CBDs is:

http://www.rcgp-curriculum.org.uk/nmrcgp/wpba/case-based_discussion.aspx

There is some useful reading material you can download at the bottom of the page.

I will start by pasting the general info on CBDs followed hopefully by some useful tips.

What is case-based discussion?

Case-based discussion (CbD) is a structured interview designed to explore professional judgement exercised in clinical cases which have been selected by the GPStR and presented for evaluation.  Evidence collected through CbD will support the judgements made about the GPStRs at the six monthly and final reviews throughout the entire programme of GP specialty training. The CbD tool has been designed to be used in both hospital and GP settings.
 
CbDs may be carried out by GP trainers or educational supervisors or clinical supervisors, according to the arrangements made in each deanery.

How is a case-based discussion carried out?

The GPStR is responsible for selecting cases, requesting a CbD and ensuring the paperwork is properly completed. The GPStR and the trainer should ensure that a balance of cases are represented including those involving children, mental health, cancer/palliative care and older adults, across varying contexts i.e. surgery, home visits and out-of-hours contacts.
 
In ST1 and 2, the GPStR will select two cases and present copies of the clinical entries and relevant records to the clinical supervisor or educational supervisor one week before the discussion. The clinical or educational supervisor selects one of the cases for discussion. The discussion should be framed around the actual case and should not explore hypothetical events. Questions should be designed to elicit evidence of competence and should not shift into a test of knowledge.
 
In ST3, the GPStR will select four cases and present copies of the clinical entries and relevant records to the trainer or educational supervisor one week before the discussion.
The trainer or educational supervisor selects one or two of the cases for discussion, depending on time available.
 
The trainer or educational supervisor records the evidence harvested for the CbD in the ePortfolio against the appropriate competence areas.
 
Trainers or educational supervisors should aim to cover as many competences as are relevant to each case and can be covered in the time frame. It is unreasonable to expect that all the competences will be covered in a single CbD but if too few are considered useful evidence will be overlooked and there would be inadequate sampling of all the competences. It is helpful to tell the GPStR at the beginning of the discussion which competence areas you expect to look at.
 
It is recommended that each discussion should take about thirty minutes, including the discussion itself, completing the rating form and giving feedback to the GPStR.

How many? How often?

A minimum of six CbDs should be carried out in each of ST1 and ST2 (three before each six month review) and twelve CbDs should be carried out in ST3 (six before the six month review and six before the final review).
 
These minimum requirements apply whether the GPStR is in a placement in primary or secondary care and whether they are in full time training or less than full time training. More CbDs can be done if this is agreed between the trainer and the GPStR. There may be occasions, for example, when the GPStR is short of evidence in a particular competence area and another one or two CbDs might help to fill this gap.

FAQs

Q. What sort of paperwork should the GPStR produce?
A. Just the actual written notes relating to the case under discussion. This might be paper-based or viewed on a computer screen.
 
Q. One or two CbDs at one sitting: does it matter?
A. No, it depends on how much time is available and what is agreed between the GPStR and whoever is doing the CbD.
 
Q. How much evidence relating to the CbD should be retained for quality assurance purposes?
A. Just the completed rating form, a note of areas for feedback and action points arising.
 
Q. How much should the trainer lead the GPStR in the questioning?
A. The trainer is eliciting evidence and may use any questioning style which they consider appropriate.
 
Q. Is it acceptable to use a case which has also been used for a debrief?
A. No, this would not be a CbD. The CbD and debrief should not be mixed but a debrief might occur after the CbD, for educational purposes.

[AM]

I think discussing a few areas of the CBD and parts of the official RCGP documents will be useful, to try to make the information more digestable.  Practical tips that we've picked up from good and bad experiences will be more useful I hope.  But of course, refer to the RCGP for full official details on the ins and outs.

Basically, you need to pick a selection of cases, with your assessor then choosing which to discuss.  While in hospital, the RCGP suggest selecting 2 cases, with the assessor picking one to use.  In ST3 you should select 4 cases, and 2 will be discussed.

Discussions should take 20-30 minutes, with maybe 10-15 mins feedback.

The areas that we are assessed in are:

Practising holistically
Data gathering and interpretation
Making diagnoses/decisions
Clinical management
Managing medical complexity
Primary care Administration and IMT
Working with colleagues and in teams
Community orientation
Maintaining an ethical approach to practice
Fitness to practise

I just want to raise a couple of points at this stage.  Firstly, being marked as needs further development at an early stage really is not a problem so don't stress about it!  The RCGP want to see how you improve throughout your VTS training and if you start off as a competent GP then what's the point of the VTS!!!  

One of the concerns that we all had with this theory was that some assessors (typically in hospital) just put excellent on everything and so if we have another assessor putting needs further development it will look bad. But don't worry - the college/deanery tutors aren't idiots and they know many hospital assessors are very 'just tell me where to click' about our assessments.  If you happen to have a string of assessors who do the assessments properly and put needs further development on everything, the College won't look any more badly on you than someone who gets excellent for everything in week two of ST1.  Although they have made these assessments for us, we have to all remember they've all been in hospital and they all know a consultant orthopod won't think much of filling a CBD out and will just want it over with.

However there are certain sections which realistically you want to be scoring well on earlier than others.  After doing a F1 and F2 year, you don't want an assessor saying you still can't work with colleagues or that you don't have an ethical approach when you finish ST1!  But on the other hand, even if managing medical complexity is not competent until ST3, it's fine.

Secondly, some of the competency areas are just not applicable to secondary care, so insufficient evidence is fine.  Things like primary care admin and sometimes community orientation.

Whenever (hopefully always) you have an assessor doing a CBD properly, the RCGP recommend the following thought provoking questions from them, following in the next post

[AM]

A selection of questions from the RCGP.  The key is to try and plan answers to these questions, and you'll sail through.

Defines the problem
What are the issues raised in this case?
What conflicts are you trying to resolve?
Why did you find it difficult/challenging?

Integrates information
What relevant information had you available?
Why was this relevant?
How did the data/information/evidence you had available help you to make your decision?
How did you use the data/information/evidence available to you in this case?
What other information could have been useful?

Prioritises options
What were your options? Which did you choose?
Why did you choose this one?
What are the advantages/disadvantages of your decision?
How do you balance them?

Considers implications
What are the implications of your decision?
For whom? (e.g. patient/relatives/doctor/practice/society)
How might they feel about your choice?
How does this influence your decision?

Justifies decision
How do you justify your decision?
What evidence/information have you to support your choice?
Can you give me an example?
Are you aware of any model or framework that helps you to justify your decision?
How does it help you? Can you apply it to this case?
Some people might argue, how would you convince them of your point of view?
Why did you do this?

Practises ethically
What ethical framework did you refer to in this case? How did you apply it?
How did it help you decide what to do?
How did you establish the patient’s point of view?
What are their rights? How did this influence your handling of the case?

Works in a team
Which colleagues did you involve in this case? Why?
How did you ensure you had effective communication with them?
Who could you have involved? What might they have been able to offer?
What is your role in this sort of situation?

Upholds duties of a doctor
What are your responsibilities/duties? How do they apply to this case?
How did you make sure you observed them? Why are they important?

[tajmahal11]

Very good information and great effort. I have joined the forum very early however I have not written many messages in the forum. I think we will hae to make a habit of discussing our queries and sharing our thoughts on the forum.

thanks for all this information. You are doing a great job!

[AM]

Thank you very much for your kind words - makes it all worthwhile

Do encourage your other VTS colleagues to get on the forum and start posting!