Overview

1. Workplace-Based AssessmentCase-Based Discussion (CBD)These slides have been prepared to facilitate discussion on the use of the CBD. The suggested practical group exercise at the end is designed to be used with a training video.

2. Overview How many CBDs? CBD validity and reliability Preparation for the CBD During the CBD After the CBD Group exercise Other examples of CBD Further Reading • What is CBD? • Purposes of CBD • How does CBD work? • CBD settings • Who should use CBD? • CBD Competencies • CBD Form • CBD Blueprint

3. What is CBD? • Mandatory workplace assessment for learning • An in-depth interview between a trainee and a senior trainer • Uses medical records as the basis for focussed discussion, exploring the trainee’s knowledge, judgement and clinical reasoning in the management of challenging cases • Covers a range of clinical problems relevant to the stage of training and specialty • The focus of the discussion can be on any or all of record keeping, clinical assessment, management and professionalism

4. Purposes of CBD • To provide feedback to help the trainee improve their clinical judgement, decision making and professional skills • To encourage a reflective approach to learning • To help the trainee build evidence of their progress • CBDs form one of the indicators that inform the AES’s end of placement report for the ARCP • Individual CBDs are not designed to sign off independent practice.

5. CBD Competencies • Medical record keeping • Clinical assessment • Management and follow up planning • Professionalism • Diagnostic skills and underlying knowledge base • Clinical judgement and decision making • Communication and team working • Leadership • Reflective practice

6. How does CBD work? • The trainee selects the medical notes from a few challenging, complex or difficult cases from which the assessor can choose • The trainee does most of the talking, taking the assessor through the whole period of the case, explaining what happened and why. • The assessor follows up with supplementary questions as necessary • The assessor and trainee make judgements about the management of the case • The assessor provides feedback on progress, covering strengths, exploring development needs and agreeing action plans within a feasible timescale. • The CBD discussion is expected to take at least 30 minutes

7. CBD settings CBD is one of a number of WBAs that should be undertaken frequently with different assessors in different settings. • Case presentations to a departmental/hospital meeting • Patients seen in the outpatient clinic • Patients seen in A&E (especially if not admitted) • Patients managed during nights on-call when the trainee may practice more independently

8. Who should use CBD? Trainee • CBD is applicable to trainees in all training stages Assessor • Consultants • Senior trainees, more advanced than the assessee • Senior SAS grade surgeons Assessors must have received training in the tool and be expert in the clinical problem/task

9. CBD Form • Assessed against the end point for the stage of training • Relates to reflective writing • Summary of clinical problem • Focus of encounter • Complexity of the case • Competency areas • 3-point rating scale • Not assessed for areas not in remit or not observed • Area for written feedback • 4-point global summary • Trainee can add reflection • Trainee can link to syllabus

10. CBD blueprint Assessment blueprints help to ensure that assessment methods are mapped to the domains of Good Medical Practice and the surgical curriculum. A single method will cover some domains and the range of assessments should cover all domains ** Directly assessed * Indirectly assessed

11. How many CBDs? • To be used throughout surgical training • The number will vary according to the trainee’s needs and should be agreed with the trainee’s AES • The majority should be completed with the CS in each placement (with at least one with the AES) • The JCST Quality Indicators state that training posts should offer at least 40 WBAs per year, of which the CBD should be of an equal proportion to other WBA methods. This is checked at the ARCP • Each surgical specialty or training region may also recommend a specific number of CBDs

12. CBD validity and reliability Validity and reliability is enhanced by: • Assessor training and trainee induction • Linking CBD to Learning Agreement objectives • Using trained and qualified assessors • Using CBD as an assessment for learning • Feedback addressing trainee development needs • Using CBD frequently throughout training • Increasing the complexity of the case according to the trainee’s competence and progression • Triangulation with other assessment methods • Trainee reflection on feedback

13. Preparation for the CBD Trainee: • Arrange CBD with the assessor well in advance • Arrange to have the form to hand, either printed or online • Reflect on the case beforehand and bring a piece of reflective writing to aid discussion Assessor: • Receive training in the tool • Ensure it is a case with which you have expertise and be familiar with the medical notes Both: • Make time and arrange a suitable quiet room so that there are no distractions • Agree the focus of the assessment

14. During the CBD Trainee: • Explain: The case and any complexities, the patient’s needs and how they were attended to, your planning, decision making and leadership, considerations, protocols, key people involved, investigations and findings, methods for expanding your knowledge and any research undertaken, any concerns etc. • Reflect on:Links to other cases or events, rationale for your assumptions. Your experience of handling data, information and people etc. What went well, what you learned, further learning and how you intend to achieve it. Trainer: • Use open questions to explore the reasoning behind actions and decisions made e.g. What options did you consider? What were the patient’s main concerns?

15. After the CBD Trainee: • Upload feedback to the portfolio accurately in good time • Record any re-evaluation of your initial reflections in light of the discussion (either in a private or portfolio area), keeping confidential the details of patients and colleagues • Follow up action plans Trainer: • Validate the assessment in good time • If necessary, follow up on any actions agreed • Discuss the trainee’s needs with the AES if necessary

16. Group exercise Purpose: To practice rating CBD, discuss best practice and enhance consistency Technique: With a group of new and experienced trainers: • Group discusses the meaning of the CBD competencies • Group views a CBD video (see ISCP CBD example videos) http://www.iscp.ac.uk/surgical/assessment_discussion.aspx(pause at point of feedback in order to discuss the trainee’s performance) • Each trainer completes the CBD Form ratings and writes feedback comments based on the video • Group compares ratings and discusses written feedback • Each trainer reflects on whether they would adjust their ratings/comments in light of discussion Repeat the exercise with another video (alternatively a case presentation or role play). Further discussion: • CBD uses and settings • Different applications for early years and higher training • Techniques for encouraging the trainee to speak openly

17. Further reading • ISCP Guidance notes on using the CBD https://www.iscp.ac.uk/static/public/cbd_guidance.pdf • ISCP Guidance notes on using the Reflective CBD https://www.iscp.ac.uk/static/public/reflective_cbd_guidance.pdf • ISCP Tips for using CBD https://www.iscp.ac.uk/static/public/cbd_tips.pdf • Academy of Medical Royal Colleges: Improving Assessment http://www.aomrc.org.uk/doc_view/49-improving-assessment