Case Based Discussions

What isn’t a CBD? It’s not a comfortable chat- which can be unfocussed and collusive But,equally, it’s not a formal exam- although there is a grading element, it also has a feedback function So: a structured interview conducted in a relaxed, but focussed, fashion.

What to submit (1) GPR submits cases the week before (!) Choose 1 out of 2 cases in ST1, 2 of 4 in ST3 Should include medical record made by GPR, and may also include PMH, FH, medications, results, correspondance…

What to submit? (2) GPR should be guided to choose situations in which there is uncertainty, or where a conflict of decision making has arisen During GP attachment, encouraged to produce a balance of cases eg children, mental health, palliative care, elderly-surgery, home visit, OOH, significant event.(how do we record this?)

Case Selection by trainer Need to assess all competencies over the training period (GPR responsibility too?) May look at eportfolio to check coverage May have specific concerns about some comp. areas-based on own observation or feedback Avoid pure ‘medical management’ cases Choose most challenging, or the one that demonstrates certain things eg ethics

Preparing Questions Structured Question Guidance Sheet- does not map directly to competencies, but can be used to explore them all Planning sheet to record intended questions, and notes about areas to cover. Responses will influence direction of enquiry Easier to probe competencies in depth if fewer areas are selected

Conducting CBD Approx 30 mins total: 20 mins case discussion Complete mark sheet 10 mins feedback with GPR, share reasons for grading and agree developmental steps/actions

RCGP DVD Thumbnail sketches Consider questions you might ask Consider competency areas you would be tempted to focus on

Case 1- BZP Addict 28 y.o.man requesting script Problems with depression, on benzos previously. Was buying off a dealer-possibly taking 50mg a day. Fallen out with dealer. Requesting help as getting anxious. Still smoking and drinking heavily to cope d/w trainer-can fit with sudden withdrawals- can have 20mg diazepam od, 5 days only, needs to go to subs misuse team Friday

Watch Case 1 Each CBD could go down many different avenues Used as springboard for ethics/ fitness to practise Could equally have gone down medical management, prescribing avenues

Consider what feedback Feedback Recommendations for further development Agreed Action Then see video feedback

Consider what grading Marking sheets Then watch DVD discussion

The World is your Oyster Consider how you might have led the discussion in a different direction to explore some of the competency areas not covered in this CBD

Other useful questions Could you start by giving me a thumbnail sketch of what the case is about? Why did you choose this case? What are the particular difficulties for you in this case? How did you deal with it? What are the advantages and disadvantages.. How does that fit with GMC guidance/Fitness.. ANY OTHERS?

Case 2- Care package problem 84 y lady, home visit Visit 1.30, niece present, d/c from hospital with no care package. Pt upset, niece has organised DN and SW to visit. Pt worried about pain-has oramorph, monitor 2d consider MST.has movicol.Long chat. Addressed concerns re care. No letter from hospital-niece says they were told Ca ovary, scan 1w. Declines treatment. I will call tomorrow to see how going. d/w DN-she will ref Macmillan team

Case 3-Work Stress 54 y man, no PMH of note Seen yesterday by another GP-insomnia- given amitriptyline 25mg 1-2 at night, 56 tabs P: Work stress H: Insomnia 2ry to work stress, 2/52 duration. Took amitriptyline no effect-has had 1 week’s worth because had old tablets. Would like to change medication. E: PHQ-9 scored 16 C:discussed options, needs to sleep. Use short term temazepam max 2/52, start citalopram, rv 2/52, stop amitriptyline

Recommendations for future development Ideas?

Agreed Actions Ideas?