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Case Based Discussions

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.

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Case Based Discussions

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  1. Case Based Discussions

  2. 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.

  3. 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…

  4. 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?)

  5. 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

  6. 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

  7. 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

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

  9. 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

  10. 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

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

  12. Consider what grading • Marking sheets • Then watch DVD discussion

  13. 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

  14. 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?

  15. 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.hasmovicol.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

  16. 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

  17. Recommendations for future development • Ideas?

  18. Agreed Actions • Ideas?

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