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CbD

Case-based Discussion (CbD) is a structured interview between your assessor and the GP trainee. The purpose of the CbD is to assess your professional judgement and decision making in clinical cases. The attributes needed to accomplish this include the ability to recognise uncertainty and complexity, applying medical knowledge, using ethical and legal frameworks and prioritising options whilst considering their implications and justifying your decisions.

CbD is one of the tools used to collect evidence for your Trainee ePortfolio, as part of the Workplace Based Assessment component of the MRCGP exam.


How Case-based Discussion (CbD) works
CbDs can be done in primary or secondary care. They can be performed by your GP trainers, or your education or clinical supervisors.


Competencies
Your assessor may focus on 3 or 4 areas but others may choose more. The competencies include:
  • Practising holistically
  • Data gathering & interpretation
  • Making a diagnosis/decisions
  • Clinical Management
  • Managing medical complexity (trainees often struggle with this one)
  • Primary care admin and IMT
  • Working with colleagues and in teams
  • Community orientation (trainees often struggle with this one – by the way, it’s difficult to get in hospital posts!)
  • Maintaining an ethical approach
  • Fitness to practise  (trainees often struggle with this one)

The challenging ones to do in the hospital is community orientation. Occasionally it may be difficult to find a significantly complex case to discuss. The hardest competency to achieve is the fitness of practice as it is hard to encounter cases where this is challenged.


Graded
Each domain is has a 4 point scale ranging from insufficient evidence, needs further development, competent and excellent. Insufficient evidence suggests that the case put forward did to permit a rank as it did not test the competency. Needs further development suggest that the trainee needs further training or support for that domain. It may be that they were rigid in their approach or had a superficial understanding of the problem with a lack of discretionary judgement.
 

Choosing cases for the Case based Discussions (CbD)
The GP trainee chooses and selects the cases that they wish to discuss within your reviews with your trainer. The CbDs should vary in subject matter to reflect the wide spread of specialities encountered e.g. paediatric, psychiatry, palliative care, care of the elderly, cardiology etc. If possible the context as to which they are encounter should vary i.e. whether it was done in the GP surgery, telephone encounter, home visit or out of hours.


GP ST1
Per CbD you should select 2 cases with 1 being chosen and discussed by your trainer. Ensure that you provide adequate time for your trainer to read your case and review the clinical history. You will require 6 CbDs for the ST1 year with 3 performed for the 6 month review and another 3 for your final review 


GP ST2
Per CbD you should select 2 with 1 being chosen and discussed by your trainer. Ensure that you provide adequate time for your trainer to read your case and review the clinical history. You will require 6 CbDs for the ST1 year with 3 performed for the 6 month review and another 3 for your final review 


GP ST3 (registrar year)
You should prepare 4 cases to your educational supervisor and they may choose 1 or 2 for discussion. You will require 12 CbDs for the year with 6 performed for the 6 month review and another 6 for your final review 


The CbD Discussion
The discussion with your trainer should revolve around the actual case itself rather than potential hypothetical events nor a discussion to test your knowledge. An attempt will be made to cover all the competences where possible within once CbD. Often this is not possible. Where not you should aim to have these competencies covered by discussing a case that does cover those domains. Feedback of the case will be documented in your e-portfolio and linked to the appropriate competences. 


How long?
The discussion should take no longer than 30minutes with sufficient time set aside to complete the online form and offering feedback. 


Recommendations
Choosing the appropriate case is essential for achieving a good CbD. Consider complex cases which required several contacts or follow up. This is contrast to a single straight forward consultation without much challenge. Difficult cases that stretched you, even if you feel were completed less well, in fact can generate a lot of conversation and discussion and provide more opportunity and evidence of excellence. 

It may not be necessary to have everything written down about the case within their records. It may be adequate to offer a commentary with your trainer about the issues and challenges of the case. 

Put forward cases that focus on only a few domains or competencies (3-4) and perform them well rather than stretching a single CbD to try and achieve all of them but lacking the quality to do so.