MRCGP & GP Training

Case Based Discussions (CBDs)

What is a CBD? What's it trying to do?

A CBD is a structured interview about a clinical case with your GP Trainer or Hospital Consultant.
Designed to explore your professional judgement in the clinical case you present.
Professional judgement = the ABILITY to make HOLISTIC, BALANCED & JUSTIFIABLE DECISIONS in situations of COMPLEXITY and UNCERTAINTY.
It tests…
  • Application of medical knowledge
  • Application of ethical frameworks
  • Ability to prioritise, consider implications, justify decisions
  • Recognise Complexity & Uncertainty

This great little video from Guildford GP Training Scheme summarises CBDs really well for those of you who are unfamiliar with them.  Please remember, CBDs done in GP training are far more intense, detailed and structured than anything you have experienced in your Foundation Year training.

How does it work?

  • GP trainee selects 3 cases (in hospitals: 2 cases)
  • GP trainee gives material to trainer 1w in advance
  • Make sure you a balance of cases & contexts (children, elderly, psych, complex, end of life, psych etc)
  • Trainer selects 2 cases & plans structured questions (in hospital: 1 case selected)
  • Each case takes about 30 mins to discuss, plus 10 mins for feedback
  • Trainer judges level of performance & records in ePortfolio
  • 3 grades - needs development, competent or excellent

Some trainers may not want 3 cases.  They may be happy with 1 or 2.   They will read and decide their suitability accordingly.  In some educational sessions, a trainer might do one CBD and one COT, or one CBD and a mini-tutorial.   A trainer may even spend a whole hour on the CBD – because of its complex nature and the subsequent teaching involved.   Discuss with your trainer how he or she prefers to do CBDs.  

How many and when?

You need to do a MINIMUM of

  • 3 CBDs per 6 months in ST1
  • 3 CBDs per 6 months in ST2
  • 6 CBDs per 6 months in ST3

Remember, this is the MINIMUM – you should aim to do lots more!  

Do not leave til the last minute – should be done in a timely way as you progress through the post. 

.CBD isn’t what most people understand by case discussion – it’s a formal, structured exercise which needs preparation by both trainee and educator.  The discussion should be framed around the actual case and should not explore hypothetical events.  So – one should refrain from changing the scenario and asking “what if” questions.  Questions should be designed to elicit evidence of specific professional competences rather than testing knowledge.

Your trainer WILL NOT tell you when you need to submit a CBD.   The RCGP says this your responsiblity and you need to take charge of it.  So, please, do them throughout your training and periodically ask your trainer “Can we do a CBD in the next tutorial?”.

What are the Professional Competencies being tested?

The assessor may select 5 or 6 competencies to look at but others may select more.  It depends on several factors such as the experience of the assessor in assessing CBDs and how ‘meaty’ the subject matter becomes.   The competencies are:

  • Practising Holistically (PH)
  • Data gathering & interpretation (DG)
  • Making a diagnosis/decisions (MD)
  • Clinical Management (CM)
  • Managing Medical Complexity & Health Promotion (MMC) - trainees often struggle with this one *
  • Organisation, Management & Leadership (OML)
  • Working with Colleagues and in teams (WWC)
  • Community Orientation (CO) - trainees struggle with this one; it's difficult to achieve if you are in a hospital post *
  • Fitness to Practice (FTP) - trainees often struggle with this one *
  • Maintaining an ethical approach (E)

Hot tip 1 – Please read the “competency descriptors in detail” document in the downloads section above.   Getting a good and thorough understanding of what exactly each of these competencies mean at an ST1 stage is crucial in making your write up of CBDs easier.   Please read each of them – even if you think you know what a competency means (eg working with colleagues and in teams) – you will find the document provides guidance about each competency in more detail than you could have ever imagined!

Hot tip 2 – Double read the areas which I have highlighted with an * – which trainees often struggle to understand.  

And the Grading - how's that work?

The competences are graded on a clearly defined 4-point scale – we’d expect trainees to progress from ‘needs further development’ to ‘competent’, and rarely achieve ‘excellent’ which is a description of a mature practitioner

Insufficient evidence: 

From available evidence, cannot be placed on a higher point of this developmental scale.

Needs further development: 

Rigid adherence to taught rules or plans. Superficial grasp of unconnected facts. Unable to apply knowledge. Little situational perception or discretionary judgement.

Competent: 

Accesses and applies coherent and appropriate chunks of knowledge. Able to see actions in terms of longer-term goals. Demonstrates conscious and deliberate planning with increased level of efficiency. Copes with crowdedness and is able to prioritise.

Excellent:  

Intuitive and holistic grasp of situations. No longer relies on rules or maxims. Identifies underlying principles and patterns to define and solve problems. Relates recalled information to goals of present situation and is aware of the conditions for application of that knowledge.

Question: To be classed as ‘competent’, does the trainee has to satisfy every single one of the descriptors in the list for that competency as detailed in the “competency descriptors in detail” document?

Answer: No – the descriptors are just there to give you a general idea of the sort of thing which is required. It is always worthwhile having the competency descriptors in one hand and your CBD question maker list in the other. After you’ve asked the questions you’ve developed for the CBD case see how the trainee’s response fits in with the competency descriptors list.

Where do I start?

  • CASE SELECTION
    Select your case wisely.    Do not pick something simple!    The more complex a case, the easier it is to demonstrate evidence of competencies.   Seriously – even if you choose difficult cases where you don’t think you have done well for a CBD – you will perform BETTER than in a simple case like a sore throat or ear pain!   Why?  Because complex cases naturally push you towards your limits and by doing this, your natural skillful performance comes out.   Trust me!   You don’t have to pick a patient you have only seen the once.   Remember, this is a CASE-based discussion – which means you can present someone who you have seen several times over several weeks even!
  • CBD TEMPLATE FOR TRAINEES DOCUMENT
    Once you have chosen your case, download the “CBD template for trainees” document in the downloads list above.   Fill it in carefully.    DO NOT spend a quick 10 minutes on this.    A well written CBD should take you at least 30 minutes.      
        • The first page – you can cut and paste your consultation notes to show how you recorded it. Try and write the summary in your own words though.   Especially if you are presenting a case where you have seen the patient several times.
        • But on the second page – select which competencies you think your case provides evidence for.  Then, in the second column, write down the REASON why you think it demonstrates evidence for that competency area and HOW.  Be specific – and give phrases if you need to.     
        • How many competencies to pick?  Pick around 4-5 (but you can pick more if you want to).   The trainer will probably pick one or two of his own too.  
        • Print out a patient summary print out from your clinical system (eg SystmOne or EMIS etc) and attach it to the ‘CBD template for trainees’.
  • RESPECT CONFIDENTIAL PATIENT INFORMATION
    At the end of the CBD interview, make sure you get the CBD template and the patient summary printout from your trainer and be sure to shred it.   This is your responsibility.   Patient notes, even in the form of CBD write-ups should NOT be left lying around in the tutorial/library/meeting room!

Top Tips for Trainees

  • Case selection is important; it is a case based discussion, so preferably choose cases with a number of contacts, not just a one-off consultation. If the case is straightforward it would be difficult for you to demonstrate excellence, because the level of challenge might be low. We would urge you to be courageous and pick patients that were challenging, difficult, hard work, complex or interesting.  At first, you might think you will fail to get any competencies but you would be surprised.  As said before – these complex cases often help furnish strong evidence for a number of competency areas.
  • If a trainer asks you a question – eg “did you do this and that”, do not lie and say “yes, i did”.  If you didn’t do something, just be upfront about it and say “no, i’m sorry, i didnt do that”.    We are all human and sometimes our minds forget – and as long as we are open about that, that is okay.  But what is far worse a crime is being dishonest.  And your trainer will be able to tell when you are lying and when you are not.  And then it looks really bad.  Wouldn’t you agree?
  •  As you build up cases, try and map out which competency areas are weak and try and pick future cases to meet these areas.  Use the “CBD competency mapping sheet” to help you with this.   It will also serve as an instrumental document in your Educational Supervision meetings.  

Top Tips for Trainers

  • Use the “CBD question maker for trainers” document to help you formulate your questions if you are a newbie.   As you become more and more experienced, you will be able naturally build in supplementary questions dynamically in response to what the trainee is saying.
  • When asking your questions – try to listen to what the trainee is offering as a reply rather than focusing on your next question.   
  • When listening to the trainees reply – use your wise brain to make inferences.  For example, do you believe them?  If not, can they provide more information or evidence?  What exactly did they say for instance – ask them?  Are their any inconsistencies in what the trainee is saying – explore them.   If you feel confident with the trainee’s response and you feel you are happy with the competency being tested, move on to the next competency you want to test.  No point exploring something to the n’th degree when you’re happy enough!  Spend the time more wisely on another competency.
  • As you become more and more experienced, you will be able to ask questions which test 2 or more competencies.
  • One thing I say to all my trainees right from the start is to be totally honest when answering the questions I ask of them.  They will look baffled as they will think “why would I lie” and explain that sometimes, trainees are so desperate to get a tick in a competency that they will just say “yeah i did that” instead of being truthful.  Highlight that we all forget and miss things and it’s okay but we need to be upfront about them.  And also explain that being upfront about forgetting to do something is far less worse than being dishonest.   Wouldn’t they agree?   Having this sort of conversation right at the start just safes a tonne of headaches later on.

Please leave a comment

What do you think of this page?  Is there anything we have missed?  Anything inaccurate, errors or broken links?  Anything you would have liked included?   Or even ask a question to get a discussion going.  Please leave a comment below and we’ll update the page.   If you would prefer to email me or send me something to share with others, contact [email protected]

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