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🗣️  Deep Dive: Case-Based Discussions

🗣️  Case-Based Discussions (CBD)

A Case-Based Discussion (CBD) is a generic feedback tool that can be used to evaluate different and varied competencies. In this section, we will discuss when, why, and how to do a CBD, and how to include CBD as evidence in an appraisal.

What is a CBD?

A Case-Based Discussion (CBD) is an assessment tool used for assessing reflective and analytical skills and gives a supervisor a deeper insight into how you compile, prioritise, and apply knowledge.

It is used to evaluate different your intellectual and professional approach to a case by exploring your:

  • Clinical knowledge
  • Clinical decision making
  • Clinical judgments
  • Professionalism
  • Record keeping
  • Presentation skills

This is not an official list, but an example of the types of higher-order skills that are assessed in a CBD.

When should I do a CBD?

It is not used to evaluate clinical skills (mini-CEX), or technical skills (DOPS) but your ‘hands-off’ deductive and analytical skills, and your overall demeanor. It uses patient records as the basis for the CBD, rather than an observation of a patient interaction or procedure. For this reason, it can also be used to evaluate the quality of record-keeping and presentation skills.

Why should I do a CBD?

CBDs are a great way of practicing your presentation skills, auditing your record-keeping, explaining the complexities of a case, and reflecting on your reasoning for your clinical decisions. CBDs are also useful for facilitating discussions around the ethical and legal framework of practice.

As part of a routine shift, doctors are expected to hand over complex cases or seek advice from seniors on your clinical judgments and management plan. If you are doing this anyway, and your senior is available and willing to give you some structured feedback, then you might as well try to get a formal CBD signed off.

How do I do a CBD?

If you want to do a CBD, then you should discuss it with your assessor in advance.You and your assessor need to agree on a time to do it and set aside about 30 minutes to get it done.

Unlike a mini-CEX or a DOPS, the case is usually discussed days or even weeks after your involvement to allow for a review of the case notes, and some reflection on your practice and judgments.

When you meet with your assessor, you should let them know which capabilities you would like to be assessed on (i.e. presentation skills, record keeping, clinical judgement etc).

Bring a copy of the blank CBD assessment template for your assessor to complete during your case presentation.

Your assessor should question you in a way that encourages you to demonstrate the highest level of ability that you can, based on the capability that they are assessing you for.

Once the case has been discussed and your capabilities assessed, you may wish to reflect on your performance with the assessor. The assessor should then provide you with both verbal and written feedback, including suggestions on future cases and capabilities that still need to be covered.

You should aim to collect multiple CBD assessments from a variety of trainers and should reflect on their feedback and insight.

Do I need to inform the patient before I do a CBD?

No, you do not need to inform a patient before you discuss their case with a senior for a CBD, but you should keep the patient details confidential and ensure that no clinical information that could identify the patient is shared or written down on the CBD feedback form.

Who can sign me off for a CBD?

Of all the WPAs, feedback on CBDs requires the most intellectual analysis, therefore should be assessed by a person who has experience, knowledge, and insight that you do not have. Usually, this means an ST3 or higher (depending on your grade).

Your trainer does not need to know you in advance though you should have a discussion before the CBD takes place to set your expectations for the assessment. When you and your trainer complete the CBD form you should include information on the grade/experience of the person who has assessed you.

It is important to note that different training colleges or Trusts have different criteria on who can sign a CBD and some stipulate that the assessment won’t count unless signed by an ST3 or above.

How do I approach a senior for a CBD?

CBDs can be difficult to get signed off if you are not working in one department consistently. This is because it is harder to follow up on a case between irregular shifts and if you are moving between departments, and finding an appropriate supervisor can be a challenge.

If you are a locum doctor working in a unit for a short time then inform the consultant or senior registrar that you would like to do a CBD and ask whether you can arrange a time to meet with them and bring a case with you. Be prepared to be flexible, stay late, and for unexpected emergencies to result in canceled assessments.

If you are in a substantive post (contracted) then you will have lots of opportunities to get CBDs done. Try to agree with your clinical or educational supervisor at the start of your employment or in supervision about how many CBDs you’d like to do (and what is realistic to achieve) over the period of your employment and try to set a date for your first one. This will give you time to decide on a case and prepare for the CBD.

Can I get all my CBDs from the same person?

If you are in a substantive post and will be working within the same team for a long time, then it is reasonable to conclude that many of your WBAs will be signed off by the same person. However, it is best practice to find a variety of assessors to give you feedback as it shows that you are seeking input from multiple team members and reduces the possibility of selection bias.

How many CBDs do I need to do per year?

If you are collecting CBDs for a training portfolio, there may be a minimum requirement for the number of assessments you should do. For example, foundation trainees are required to do a minimum of 6 CBDs per year (2 per placement). If you are a non-training doctor then your appraisal will not require a specific number of mini-CEX assessments in order to ‘pass’ though you should aim to do them regularly out of training anyway.

You should keep records of old case discussions at the end of the year as they can be used again at revalidation, interviews, and as a record of your career highlights in the future. Just make sure they do not include any patient-identifiable information.

Where do I put my CBD in my MAG?

The MAG form (Medical Appraisal Guide) is the document that non-training doctors in England use for their medical appraisals.

If you are preparing for an appraisal, you may want to use evidence of your case discussions in your MAG to demonstrate your ongoing commitment to the principles outlined in the GMC’s Good Medical Practice document.

Your CBD can be uploaded into the CPD section of the portfolio (section 7 of the MAG).

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Section 7 of the MAG looks like this:

You can upload your CBD in any format that works best for you. It can be summarised directly on the MAG document, uploaded as a photo, screenshot, or scan of the hand-completed mini-CEX, or uploaded as a word document, or PDF. It doesn’t really matter how you upload your CPD so long as you can provide some evidence that you’ve done some, and learned from it.

Your appraiser may want to discuss the case to hear about what you learned from the experience and how your practice changed so be prepared to answer questions about it (it helps if you include some memory-jogging material in the summary!).

Template & Worked Example

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