A case in point

Coping with case based discussions

EIGHT weeks into my FY1 respiratory job it dawns on me I need to complete not one, but two, Case Based Discussions (CbD) before the end of this placement. Cue mild panic and a frantic search for an appropriate patient to discuss with a consultant who is willing to listen (and complete the assessment form!).

This was my first encounter with CbD and a useful learning experience. I cast my mind back eight weeks to Trust induction and the wise words issued by our Foundation Programme Director who explained CbD to us while we all gave convincing impressions of rabbits in headlights at the prospect of tackling the e-portfolio.

CbD is a structured discussion of clinical cases managed by the foundation doctor, providing an opportunity for assessment and discussion of clinical reasoning. Assessors must be consultants, GPs, doctors in higher specialist training (ST3 or above/SpRs), associate specialists/staff grade or specialty doctors, and must have training in how to conduct assessments and how to give feedback. FY2, ST1-ST2 doctors, nurses or pharmacists cannot be assessors.

It is best to use a different assessor for each CbD, ideally one being your clinical supervisor. During FY1 and FY2 you have to complete at least six CbDs in each year. Each should focus on a different clinical problem with the aim of presenting a balance of cases including those involving children, mental health, cancer/ palliative care and older adults across varying contexts, i.e. surgery, home visits or out-ofhour contacts.

So here I am on a busy respiratory ward, trying to find the time to complete a CbD. Finding an interesting case that I have been involved with is not difficult. If there’s a learning opportunity, there’s a CbD waiting. I chose to discuss a lady who was admitted with shortness of breath and recently investigated for a pleural effusion. Awareness of the Foundation Programme Curriculum is important as trainees need to show evidence of competence in each clinical area represented in the curriculum.

Next: find a suitable assessor. Every case presented to a senior colleague is an opportunity for a CbD – so don’t be afraid to ask. For me, the consultant of the week seemed keen and we agreed a suitable day with no clinics and good ward staffing levels to cover me for the 20-ish minutes I would be away. I scribble on my jobs list to do background reading but sadly, I return home exhausted, fall asleep and forget. I wake at 6am, realise it is CbD day and consult Wikipedia and patient.co.uk instead. An important lesson here: prepare where possible as you will get more out of the discussion from an education point of view. Remember you are a trainee and while this process is for the portfolio, it’s primarily to benefit your learning.

The format of the CbD was quite informal, with me leading the discussion based on my entries in the clinical notes. It covered seven rated question areas including record keeping, clinical assessment, investigation and referral, treatment, follow-up and future planning, and professionalism. There was opportunity for me to ask questions, “why did we do this and not that?”, “what would happen if…?”, and expand my understanding of overall clinical management.

Lastly, the CbD form should be completed at the time of assessment. Massive error on my part here: my consultant got called away and, you guessed it, the form never got completed as there wasn’t enough time afterwards. Subsequently I had to do two more assessments but at least I was better prepared and ensured I completed the electronic form during the discussion.

My main pointers for CbD:

• Understand you are not doing it just ‘because you have to’ - it benefits your learning and experience too.

• Prepare – be aware of the many distractions on the wards, identify an assessor and set aside time where you will not be interrupted (give your bleep to a colleague if possible).

• Complete the form at the time of assessment - timely feedback is more relevant and action plans can be targeted to your individual learning needs. You do not get much time for focused feedback as a junior doctor so make the most of it.

• A “low score” in the early days is not necessarily a bad thing. It provides an ideal opportunity to demonstrate progression in your training when scores improve in future assessments.

Done well, the CbD can be a valuable opportunity for all those isolated facts you learn as a student to come together and help build your understanding of how to manage the whole patient. Just make sure you give it some thought before the end of the placement.

Further information

The Foundation Programme: Case-based Discussion (CBD): Guidance for Assessors. www.tinyurl.com/7pbaqlg

By Dr Emma Peagam, F1 doctor at Bolton Hospital with contribution from Dr Mayen Egbe, consultant physician and Foundation Programme Director at Bolton Hospital