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Teaching & Learning

Random Case Analysis (RCAs)

What is a Random Case Analysis?

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Random case analysis is a powerful tool for clinical supervision, teaching as well as assessment. It can identify gaps in knowledge, evaluate clinical reasoning skills and enable provision of critical and timely feedback.

What actually happens?

The Clinical Supervisor (e.g GP Trainer) will pick random patients that the leaner (e.g. GP trainee) has seen during (say) a clinic.  Together they will review what the learner has done.  The Clinical Supervisor will ask the trainee various questions to help define the depth of the learner’s knowledge, skills and attitudes.   In so doing, one can identify areas where the learner needs to build strength.  The Trainer and Trainee can then review those learning needs and decide which to prioritise over the others.

Thus, it’ a great way of identifying learning needs which would otherwise go amiss.   

Random Case Analysis as a Supervision Tool (a bit long!)

What's the philosophy behind RCAs?

  • Random Case Analyses (or RCAs for short) are particularly good for identifying clinical knowledge gaps in the trainee.  So, if you have a trainee where you are not convinced that there clinical knowledge is all up to scratch, DO LOTS OF RCAs and identify and map out those unknowns.
  • In a Random Case, you are picking the clinical case as a starting point for discussion – exploring what the trainee did and why.  But then, you alter the scenario to see what the trainee would do now in light of that change.  And then you change it some more and see what the trainee would do.   The idea is to test out limits of the trainee’s clinical style flexbility and whether the more challenging contexts point to further learning needs in terms of Knowledge, Skills and Attitudes. 
  • How deep you go or how much you change the scenario is up to you.   The general rule is that if the GP trainee “knows their stuff” then move on quickly to the next part of the case or even a different Random Case.  Remember, you are trying to work out the trainee’s learning needs swiftly.    Each case should take about 20-25 minutes.   A good RCA should last at least an hour, preferably 1.5hours, duiring which you should be able to cover 3-4 random cases.
  • Imagine doing one RCA every week = 4x4 = 16 potential clinical areas covered per month!  Isn’t that impressive?
  • The whole process should not be a grilling interrogative session.   But neither should it be a comfortable fluffy chit chat session.    Yes, the trainee should find the questions challenging, but in a positive educational environment – where both parties value it and want to do it because they know what educational benefits result.  And the more comfortable the discussion platform, the more likely the trainee will be open and honest about their inner thoughts and feelings and the more likely you can help with transformative educational change.

Examples of questions

In the following, notice that the questions are centred around two things – 1) what did the trainee actually do?     and     2) what would the trainee do if condition xxxx was applied?   So, the first lot are “What did you do”  questions and the second lot of “What if” questions.   The “What if” questions allow the GP Trainer to go into the world of his or own fantasy – altering the situation to whatever they want to change it to so that the process of learning needs identification is not constrained by the current case.   When working on those learning needs, ask the learner which they would like to prioritise and work on – after all, they know things about themselves that you don’t.   

Data Gathering (Hx, Ex, Ix)

  • Important questions in the History. So, if in the history, the patient had said xxxx, what else would you have asked about in the history.
  • Red flags.  So, if the in the history, the patient had said yyyy, what other red flags would you have asked about?
  • What examination was made?  If the examination had shown zzz, what other examination would you have done?
  • What data did you gather from the tests that have been done so far?

Decision Making  (Diagnosis & Differentials)

  • What diagnosis did you make and why?   What if they said xxx in the history or yyyy was found on the examination.  What diagnosis would you have made then?
  • What were the differentials?  How did you exclude the other differentials?     What are the signs of symptoms of the differential diagnosis of zzz.
  • What further investigations did you do and why?    What if test xxx came back as yyy, what would you do then?

Clinical Management   

  • What did you do?   Did you follow any guidelines?  What do those guidelines say?   
  • What if in the diagnosis was xxx, what would you do then?

Communication Skills

  • How did you explore the patients Ideas, Concerns and Expectations?  What did they say?  What if they said xxx, what would you have done then?
  • How did you explain your uncertainty?
  • How did you explain the risk of xxx?

Examination Skills

  • What did you actually examine and how?  Show me on me what you did?
  • For example: do a 2 minute neuro examination on me.
  • Okay, so you did a knee examination and you feel confident with that.  What if she had a shoulder problem… how good are you with shoulders?

IT skills

  • Is there anything from this case that is also applicable to other patients with a similar condition?  Did you generalise away from this specific case to implement systems changes to help other patients with a similar condition?  If not, why not?
  • Let’s review your notes.  What do you think about your write up?  How could this be improved?

Practising Holistically

  • Did you explore what effect this was having on the patient’s life?  If not, why not?   Is exploring this important for GPs?  What might the patient have said?
  • Were there any cultural aspects of this case?  Why did you not take them into account?   What sorts of things might be important?

Health Promotion

  • Was there an opportunity for health promotion?   Did you do any?  Why not?  What do you feel about health promotion in this case?  Is health promotion worth it or a waste of time?

Organisation, Management & Leadership 

  • Is there anything from this case that is also applicable to other patients with a similar condition?  Did you generalise away from this specific case to implement systems changes to help other patients with a similar condition?  If not, why not?

Working with colleagues and in teams

  • Sounds like you felt out of your depth here.   What did you do?  Did you approach your colleagues for help?  Why not?
  • Was there anything in this case that suggested a team-based approach?   Did you involve others?  How?  Who else could you have involved?  Why didn’t you involve them.  

Community Orientation

  • Any changes in improving or managing the health and social care of the practice population/local community as a result of this case.

Ethical approach

  • What were the ethical aspects of the case.   What if the patient had refused xxxx, then what.   What if the patient could not express consent, then what?

Fitness to practise

  • Did you find this case stressful?  In what way?  What impact did it have on you?  What did you do about it to look after yourself?  Why did you do not do anything about it?

Summary of the RCA process

  • SETTING – preferably away from the computer, use summary print out records (stops you from using the computer too much for other non-relevant stuff). Make sure you have all the resources you might need.
  • ALLOW TRAINEE TO TELL THEIR STORY
  • RECORD POSSIBLE THEMES FOR DISCUSSION
  • CLARIFY ANY POINTS
  • SETTING THE AGENDA – eg should be learner centred; negotiate. “How was that for you” good/bad?, “What would you like to talk about?”, “Did you have any difficulties you would like to explore?”, you, the trainer, may have an agenda
  • CHALLENGE rather than CHAT – Main thing is to stop it from being a chat and make it more of a challenge . Use “what if…..???” questions to achieve this.
  • VARY THE METHODOLOGY – to add dynamism: eg discussion, demonstration, role play
  • EXPLANATIONS & GUIDANCE – give clear explanations, constructive feedback, don’t be afraid to say “I don’t know” or even “let’s go and look it up”
  • CHECK UNDERSTANDING – reading the trainee’s verbals and non-verbal cues will give a clue when they are unsure
  • PLAN FUTURE LEARNING – and set explicit time and date to review
  • SUMMARISE – summarise at the end : what has been discussed, homework, action points

(you may need to clarify and summarise at several points in the case analysis e.g. when moving from one theme to another in the same case)

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