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What is a debrief?

Debriefing is defined as a dialogue between two or more people.   Its goals are to

  • discuss the actions and thought processes involved in a particular patient-care situation, in order to
  • encourage reflection on those actions and thought processes, and thus,
  • explore improvement in  future performance.
In debriefs, you are trying to reach and explore that “blind spot” of Johari’s window.   Learn more about Johari here. 

HOWEVER, in GP training, protecting patients from harm is number one priority.  Trainees have yet a lot to learn, and all of that learning cannot be acquired in “one-go”.  Therefore, measures need to be put in place that ensures patients are not harmed by the deficiencies in trainees’ knowledge, skills and attitudes, whilst they are still learning.

  • Therefore, the MAIN purpose of debriefs is to ensure patients have not come to harm
  • The SECONDARY purpose of debriefs is an educational opportunity to help trainees better themselves.

Debrief differences between ST1/2s and ST3s

For those in GP who are ST1s or ST2s

  • Go through every consultation patient that the trainee has seen.  Trainees at this stage are not ready for independent practice and you must make sure patients are not harmed.

Other Practical Points

  • Don’t forget to debrief on any telephone consultations too.
  • And put measures in place to review home visits.
  • Encourage trainees to remind you “Would you mind debriefing my home visit?”
  • After making sure there has been no patient harm, then discuss the educational aspects of the case

For those in GP who are ST3s

  • ST3s will vary in their ability towards independent practice.   
  • For the ST3 who has just started with you, it is advisable to go through every consultation patient that the trainee has seen.  Although they are ST3s, they are at the beginning of their finishing year and thus unlikely to be ready for independent practice, and you must make sure patients are not harmed.
  • As they move through ST3, their capability for independent practice will increase.   From about the middle of ST3, you may find that the trainee is doing well in terms of independent practice and therefore you don’t have to review every patient.  In this case, you can select random patients in a list to check, explore and educate on.
  • However, if you have concerns over an ST3’s clinical abilities despite being towards the end of their final year, you MUST go back to reviewing every consultation patient that the trainee has seen.  Patients have to be kept safe.

How to slot Debriefs into the timetable

As part of the timetable, agreed periods of protected time debrief should be included. For the debrief, the trainer or one of the other doctors in the practice should spend time reviewing the patients with the trainee to ensure there are no learning points for the trainee, or safety issues from a patient’s point of view.   Remember, debriefs are mandatory.   You must plug them into  the surgery timetable for trainees.  Provide enough time and ensure it is protected – they are an important element for patient safety.

This is often the first exposure to general practice and trainees will have to learn how to use IT and administrative systems.  Trainees will have very different levels of experience and confidence, the timings below are just a suggestion.

  • First 4 weeks 30 minute appointments
  • Then 20 minute appointments for months 2 to 4
  • Then 15 minutes for the remainder of their placement

Debriefs should occur after every patient initially, then slots held for supervising doctors at reguar intervals through out each session to enable trainees to ask ‘on the spot’ advice, every session should be followed by a 30 min debrief to work through all of the patients seen.

Experience has shown that the following schedule of appointment times suits most ST3s- however it will need to be tailored to each individual and in particular those who have done a recent GP placement in ST2 or who are planning an early CSA may need to move to shorter appointements faster.

  • Start 4 weeks 20 minute appointments
  • Then 15 minutes for a further 4 weeks
  • Then 10 minutes for 10 weeks before CSA ideally

There should also be plans in place for debriefing.  Initially this should be 10 minutes of trainer time for each registrar patient.  This can quickly be reduced to every 2 or 3 patients and finally half an hour at the end of surgery.  After a couple of months you may no longer plan a specific debrief time for each surgery but there should still be a nominated GP supervising the registrar for each surgery who they can go to for help and advice.

  • Make sure the debriefing doctor knows they are debriefing.   
  • Share out the debriefs between all qualified GPs (doesn’t have to be the GP Trainer).
  • We would suggest once a year in-house teaching session for “Building your skills to teach GP trainees” and include revisiting debriefs and how different doctors do them including training for newbies.

How to do a debrief

The traditional way

  • Go through each patient one-by-one
  • Make sure clinically, the right thing has been done
  • Make sure clinically, the patient is not exposed to avoidable harm
  • Then start educating – pick areas to explore like
      • data gathering
      • making a diagnosis
      • doing investigations
      • clinical management plan & prescribing
      • communication skills 
      • working with colleagues
      • record keeping (how good are the medical notes that have been entered – advise on content, narrative, layout, minimum clinical including recording even absent red flags).
  • A good structured approach that allows you to explore a lot of different areas, if needed, from what could be quite a simple case.

Adding “spice” to debriefs

  • With each patient, think in terms of Knowledge, Skills, & Attitudes (KSA).  
  • For KNOWLEDGE, use Bloom’s Taxonomy to help you – Remember, Understand, Apply, Analyse, Evaluate, Create.  More on Bloom here.
  • Structure the discussion in a Random-Case-Analysis style (RCA).   Alter the scenario and ask “What if…”. Push the trainee – what would they do?  More on Random Case Analysis here.
  • In fact, mix and match – do one or two RCA style, a few via Blooks, a few on KSA etc.
  • Group Debriefs –  as part of a group with other FY2 or GP trainees – so they learn off each other.  Shared debriefs may be particularly beneficial for junior trainees.
  • For the very able near independent ST3 trainee, you could do themed-debriefs.  For example, deciding to just look at the prescribing element for each patient.  Or referrals. Or investigations and bloods.   Or even record keeping.
  • Don’t address every learning need in detail.  Tackle some, but for others, signpost to guidelines and other resources.  This will help you to cover more in less time.  
  • Don’t do all of the talking.  Encourage the trainee to talk at least 50% of the time.   
  • Achieve a balance between telling, asking & exploring. 
  • Link discussions with what trainees might get in their exams (AKT/CSA) – encourages learning on the basis of “assessment always drives the learning” in education.  

Trainer skills required to do a good debrief

Skills required

  • Actively listen.
  • Seek clarification.
  • Pick up on verbal and non-verbal cues.
  • Elicit ideas, thoughts, concerns, feelings.
  • Negotiate – future action, etc.
If you can do good consultation (99.9999% of trainers), then you can do a good debrief.   Use your consultations skills.  Help the trainee to increase self-knowledge of their own strengths, weaknesses and attitudes. 

Identify learning needs

  • Think in terms of the GP curriculum – what do they need to work on?
  • Think in terms of the 13 Professional Capabilties – again, what to work on?
  • As you identify learning needs, some aspects of that learning need can be dealt with at the time. 
  • For others, set homework, and not future teaching sessions to explore again.  Negotiate. 

Other tips

  • Listen and Reflect
  • Ask about urgent concerns/problems first
  • Move away from being the ‘Expert’…
  • Get them to problem-solve for themselves
  • Promote ‘Looking for info when you don’t know it’ rather than ‘giving answers.’
  • If a group, open out issues to the others
  • Some questions may still need a direct answer.  Don’t be afraid of giving answers.  It’s all a balance of answer giving and asking them to explore themselves.
  • If a trainee is unnecessarily verbose, you need to find a way of cutting them short compassionately.  Otherwise, time will fly and you will have covered little.  “Sorry to cut things short, but…”

Chat vs Challenge

  • The biggest mistake most trainers make when doing debriefs is to run it in a style that results in it deteriorating into a chat rather than a challenge.
  • Chats don’t result in educational impact in the way that Challenge does.
  • And don’t equate challenge with aggressiveness or fierceness.  Challenge is simply pushing trainees to think.  They might become a little uncomfortable in the process, but the aim is NEVER to destroy!     With challenge, we are trying to create “Cognitive Dissonance” within the learner.   Cognitive dissonance leads to change.
  • One easy way to challenge is to ask a lot of “What if” questions.  “What if she did have double vision with her headaches.  What would you ahve done then?”

The Outcomes of Good Debriefs

Good debriefs result in the following over time…

  • Trainees learn the basics of good safe patient management
  • They also learn lots of factual knowledge
  • The process will encourage them to seek help form their colleagues when unsure what to do.
  • Debriefs can help boost self-confidence – more skills than they think
  • Through discussions, they learn to respect other people’s opinions
  • They learn to cope with uncertainty – sometimes there are just no answers!
  • Trainers and the pracitce get peace of mind that patients are not exposed to harm
  • Patients get peace of mind that consultations are reviewed by a senior.

A quick legal tip

Remember, a debrief’s prime purpose is to ensure what the trainee has done with the patient is safe.   During a debrief, the clinical supervisor will often tell the trainee things they have missed out on or things that they have done wrong and what should be done to rectify them.   Most trainees are diligent and get the changes done in a timely way.  But….

  • What if a trainee fails to do what you asked them to do? 
  • Let’s say the patient came to harm and the case went to court.  Clearly the trainee would be at fault.   
  • But you are their supervisor and you would come under scrutiny too.
  • Where do you record what you advised the trainee what to do?
  • If there is no record, how would you tell the court precisely what you advised the GP trainee?
  • Where would be the proof you said that if the trainee claimed you did not?

So, I have a suggestion for you – add a “quick consultation note” for those debriefed patients where an action needed.  You might think this will transpire into a lot of extra work – but it woudn’t be.  If what the trainee has done with the patient is reasonable and safe – nothing to add to the record.  But if you notice something missing or needs changing, then add a quick note like “DEBRIEF – do a CXR” or “DEBRIEF – refer to gastroenterology”.   In this way, should anything end up in court for failure to act – then the responsibility lies mostly with the GP trainee who failed to act on what you advised.

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