CLINICAL DEBRIEFTutor Notes

Revised 2016

2

ContentsIntroduction 3

Aims of Clinical Debrief 4

ILOs 4

Clinical Reasoning definition 5

Why is Clinical Reasoning important 6

Preparation for practiceClinical Supervision 6

First meeting 7

Subsequent meetings 7

The final meeting 8

Trigger material to generate discussions 9

RALPHIE 10

RALPHIE - Core competencies and skills 10

Dr R Farrington amp Dr Lisa CollinsCommunity Based Medical Education Team

Acknowledgements Dr K Wilson amp Dr P Fisher

Role-play for history taking and presentation skills 12

Activities to use when students present their cases13

Presentation skills 14

Using cases presented - margin hypothesis generation 14

OSCE examination preparation 15

Using current events 15

Situational Judgement Test 16

Longitudinal Care 16

GP Videos 16

Troubleshooting guide for difficult groups 17

Documentation of learning activities 18

2

ContentsIntroduction 3

Aims of Clinical Debrief 4

ILOs 4

Clinical Reasoning definition 5

Why is Clinical Reasoning important 6

Preparation for practiceClinical Supervision 6

First meeting 7

Subsequent meetings 7

The final meeting 8

Trigger material to generate discussions 9

RALPHIE 10

RALPHIE - Core competencies and skills 10

Dr R Farrington amp Dr Lisa CollinsCommunity Based Medical Education Team

Acknowledgements Dr K Wilson amp Dr P Fisher

Role-play for history taking and presentation skills 12

Activities to use when students present their cases13

Presentation skills 14

Using cases presented - margin hypothesis generation 14

OSCE examination preparation 15

Using current events 15

Situational Judgement Test 16

Longitudinal Care 16

GP Videos 16

Troubleshooting guide for difficult groups 17

Documentation of learning activities 18

3

IntroductionClinical Debrief is a chance for students to present and learn from real cases The expecta-tion is that you will facilitate discussion provide immediate feedback and offer clinical sup-port to your group This is achieved by asking open questions encouraging reflection and debate Questioning and challenging students helps them to recognise their own learning needs You may provide some clarification to help the group organise their thinking so stimulating a deeper understanding of the cases and issues they raise but the aim is not to give a tutorial

General practitioners sometimes worry they donrsquot have sufficient expertise in areas of medicine the students wish to discuss Be reassured that third year students may have read about a topic recently but you will have more experience of prioritising investigations differential diagnoses managing risk making mature clinical decisions and involving the patient Your role is not to ldquoteachrdquo the medical students about individual topics such as ECG interpretation or chest X ray findings but to stimulate them to find out more Tutors do not ldquofailrdquo if they admit their knowledge is lacking and explore steps to address their own educational needs in fact this can be an example of good role modelling Ask students to bring in a presentation on this topic the following week if needed (do remember to make time for them to deliver it)

The abilities of groups will evolve over the academic year and their progression through the course will change both your and their expectations from the sessions

Session overview

Group size 5-9 students

Stage Year 3

Frequency Weekly x 24 weeks (12 per semester)

Duration 225 hrs (mandatory 15min break) Morning or afternoon

Attendance 100 expected Absence must be explained

Group Changeover At start of semester

Evaluation By tutor and students on eForms at the end of 12 weeks

Suggested equipment

BNF

Marker pens

Post-it notes

Sticky tape

Attendance sheet (with photos)

4

Aims of Clinical DebriefClinical Supervision

Support development of clinical reasoning skills

Preparation for practice

Intended Learning OutcomesConstruct clinical reasoning skills to prioritise differential diagnoses investigations and management options with attention to cognitive biases

Develop and apply authentic communication skills to use with peers colleagues and patients Recognise the impact of diversity on clinical interactions and shared deci-sion-making

Develop skills to learn through discussion and analysis of individualsrsquo and peersrsquo real clinical experiences Consider the emotional impact of these experiences and identify strategies for building resilience

Make a clear presentation to peers and senior colleagues of a clinical situation or condi-tion in medical language appropriate to the context of the communication

Demonstrate the ability to evaluate a patientrsquos history in order to determine the health care and social needs of that individual patient

Describe ways in which lsquothe patient journeyrsquo longitudinal care and attention to patient safety impacts on health

Critically appraise ethical issues portrayed in lay and medical media and apply a recog-nized ethical framework to reflect on how they might change practice

Understand and make early preparations for undergraduate assessment including the national Situational Judgement Test and Prescribing Safety Assessment

Appraise and appreciate how the integration of primary and secondary care can im-prove patient care in preparation for Year 4 GP placements

Clinical SupervisionAs a GP tutor we need to nurture a non-judgemental and supportive environment where students feel able to reveal and discuss difficult clinical experiences These are issues they may not feel comfortable discussing elsewhere They raise topics such as emotional diffi-culty clinical and ethical uncertainty and professional vulnerability By helping students to explore recreate and re-interpret the story you will challenge any assumptions they have and help them to

Nurture insight and critical thinking

Build resilience and wellbeing

Create collaborative relationships

Enhance patient safety and quality of patient care

5

Your role is to support not rescue It is important to explore whether the issues raised are personal welfare or issues of professionalism If you feel they need escalating please see the clinical supervision resources pack

Clinical Reasoning definitionOne of the essential tasks of an undergraduate medical programme is to enable students to make safe clinical decisions The process by which clinicians develop this ability referred to in the literature as Clinical Reasoning (CR) can be defined as

ldquothe process by which clinicians collect cues process the information come to an understanding of a patient problem or situation plan and implement interven-tions evaluate outcomes and reflect on and learn from the processrdquo 1

Hoffman 2007 Kraischsk amp Anthony 2001 Laurie et al 2001

Using students own case encounters Clinical Debrief tutors help students to develop the skills to take a history with a purpose thinking about what information they should be gathering what might be causing the patientrsquos symptoms and what else they need to ask to include or exclude likely diagnoses Students need to think not just WHAT are the most likely differentials but WHY are they the most likely

Clinical reasoning skills help students to

Widen the range of differentials using models

Justify and prioritise investigations and management options

Enable shared decision making with patients and colleagues

Become aware of their biases

Methods used for integrating clinical reasoning into teaching

Stop ndash start

Hypothesis generation

Socratic questioningWhat else What if Why

There are many different skills used in the clinical reasoning process (see HYMS pocket guide on the CBME website httpsitesbmhmanchesteracukcbmeProgInfCDresourc-esHndbkrsrcs ) Prompt students to think about these skills and the questions they can ask when taking a history or interrogating a colleague about a history

What did the patient tell you in their What diseasesconditions are most opening statement likely for the age of this patientRemember to clarify clarify clarify What diseases are most likely for the gender of this patient

What are you thinking at this point in the What are the 3 most likely differentialpatientrsquos history What else do you need to diagnoses Why Can you justify theseyou to ask to rule in or out some diagnoses

4

Aims of Clinical DebriefClinical Supervision

Support development of clinical reasoning skills

Preparation for practice

Intended Learning OutcomesConstruct clinical reasoning skills to prioritise differential diagnoses investigations and management options with attention to cognitive biases

Develop and apply authentic communication skills to use with peers colleagues and patients Recognise the impact of diversity on clinical interactions and shared deci-sion-making

Develop skills to learn through discussion and analysis of individualsrsquo and peersrsquo real clinical experiences Consider the emotional impact of these experiences and identify strategies for building resilience

Make a clear presentation to peers and senior colleagues of a clinical situation or condi-tion in medical language appropriate to the context of the communication

Demonstrate the ability to evaluate a patientrsquos history in order to determine the health care and social needs of that individual patient

Describe ways in which lsquothe patient journeyrsquo longitudinal care and attention to patient safety impacts on health

Critically appraise ethical issues portrayed in lay and medical media and apply a recog-nized ethical framework to reflect on how they might change practice

Understand and make early preparations for undergraduate assessment including the national Situational Judgement Test and Prescribing Safety Assessment

Appraise and appreciate how the integration of primary and secondary care can im-prove patient care in preparation for Year 4 GP placements

Clinical SupervisionAs a GP tutor we need to nurture a non-judgemental and supportive environment where students feel able to reveal and discuss difficult clinical experiences These are issues they may not feel comfortable discussing elsewhere They raise topics such as emotional diffi-culty clinical and ethical uncertainty and professional vulnerability By helping students to explore recreate and re-interpret the story you will challenge any assumptions they have and help them to

Nurture insight and critical thinking

Build resilience and wellbeing

Create collaborative relationships

Enhance patient safety and quality of patient care

5

Your role is to support not rescue It is important to explore whether the issues raised are personal welfare or issues of professionalism If you feel they need escalating please see the clinical supervision resources pack

Clinical Reasoning definitionOne of the essential tasks of an undergraduate medical programme is to enable students to make safe clinical decisions The process by which clinicians develop this ability referred to in the literature as Clinical Reasoning (CR) can be defined as

ldquothe process by which clinicians collect cues process the information come to an understanding of a patient problem or situation plan and implement interven-tions evaluate outcomes and reflect on and learn from the processrdquo 1

Hoffman 2007 Kraischsk amp Anthony 2001 Laurie et al 2001

Using students own case encounters Clinical Debrief tutors help students to develop the skills to take a history with a purpose thinking about what information they should be gathering what might be causing the patientrsquos symptoms and what else they need to ask to include or exclude likely diagnoses Students need to think not just WHAT are the most likely differentials but WHY are they the most likely

Clinical reasoning skills help students to

Widen the range of differentials using models

Justify and prioritise investigations and management options

Enable shared decision making with patients and colleagues

Become aware of their biases

Methods used for integrating clinical reasoning into teaching

Stop ndash start

Hypothesis generation

Socratic questioningWhat else What if Why

There are many different skills used in the clinical reasoning process (see HYMS pocket guide on the CBME website httpsitesbmhmanchesteracukcbmeProgInfCDresourc-esHndbkrsrcs ) Prompt students to think about these skills and the questions they can ask when taking a history or interrogating a colleague about a history

What did the patient tell you in their What diseasesconditions are most opening statement likely for the age of this patientRemember to clarify clarify clarify What diseases are most likely for the gender of this patient

What are you thinking at this point in the What are the 3 most likely differentialpatientrsquos history What else do you need to diagnoses Why Can you justify theseyou to ask to rule in or out some diagnoses

5

Your role is to support not rescue It is important to explore whether the issues raised are personal welfare or issues of professionalism If you feel they need escalating please see the clinical supervision resources pack

Clinical Reasoning definitionOne of the essential tasks of an undergraduate medical programme is to enable students to make safe clinical decisions The process by which clinicians develop this ability referred to in the literature as Clinical Reasoning (CR) can be defined as

ldquothe process by which clinicians collect cues process the information come to an understanding of a patient problem or situation plan and implement interven-tions evaluate outcomes and reflect on and learn from the processrdquo 1

Hoffman 2007 Kraischsk amp Anthony 2001 Laurie et al 2001

Using students own case encounters Clinical Debrief tutors help students to develop the skills to take a history with a purpose thinking about what information they should be gathering what might be causing the patientrsquos symptoms and what else they need to ask to include or exclude likely diagnoses Students need to think not just WHAT are the most likely differentials but WHY are they the most likely

Clinical reasoning skills help students to

Widen the range of differentials using models

Justify and prioritise investigations and management options

Enable shared decision making with patients and colleagues

Become aware of their biases

Methods used for integrating clinical reasoning into teaching

Stop ndash start

Hypothesis generation

Socratic questioningWhat else What if Why

There are many different skills used in the clinical reasoning process (see HYMS pocket guide on the CBME website httpsitesbmhmanchesteracukcbmeProgInfCDresourc-esHndbkrsrcs ) Prompt students to think about these skills and the questions they can ask when taking a history or interrogating a colleague about a history

What did the patient tell you in their What diseasesconditions are most opening statement likely for the age of this patientRemember to clarify clarify clarify What diseases are most likely for the gender of this patient

What are you thinking at this point in the What are the 3 most likely differentialpatientrsquos history What else do you need to diagnoses Why Can you justify theseyou to ask to rule in or out some diagnoses

6

Why is Clinical Reasoning importantPatient safety

67 of claims against GPs diagnostic error

15000 preventable deaths per year UK - 30 due to diagnostic error

Cognition involved in 75 of errors

Preparation for practiceWe are preparing our students for the increasing complexity of practice both for Year 4 and ultimately as F1 doctors Reflecting on cases helps students to make connections between what they have learnt in lectures and from books (education and experiences) and what they see in real life practice In addition to the cases students bring to the sessions you have a menu of resources for generating discussion helping students to identify their indi-vidual learning needs and build their competencies These resources include prescribing exercises role play practice for OSCE articles (lay and professional) games and videos of real GP consultations They can be found on the CBME webpages httpsitesbmhman-chesteracukcbmeProgInfCDresources

We have developed the concept of a longitudinal case as one of the many resources for tutors This provides a framework for exploring increasing complexity through the patient journey over the course of the 24 weeks

What are you thinking at this point in the patientrsquos history

What else do you need to ask to rule in or out some diagnoses

What are the three most likely differential diagnoses

Why Can you justify these

7

First meetingPreparation

Simple things like making sure you are aware of start time and location of the room can make life easier Make sure you have a flipchartwhiteboard and marker pens

Information on your group is on MedLea You are able to e-mail students in advance to encourage them to prepare cases to present You can print off an attendance register with photos making learning names easier

Copies of all the tutor resources are on the CBME websitehttpsitesbmhmanchesteracukcbmeProgInfCDresources

Find out the Themed Case Discussion topics for the week ndash the CD session is not a lsquocase openingrsquo discussion for this topic httpsitesbmhmanchesteracukcbmeProgInfCDre-sourcesTtrinstrctns

Introductions

Investing time at the first session getting to know your students is worthwhile They also need to know a bit about you

Ice-breakers might feel a bit contrived but often do give you an insight into what moti-vates a student and how they might interact in the group

Ground Rules

Year 3 students have iPads Students are aware of the code of conduct for their use You may want to negotiate how they will contribute to your sessions Likewise mobile phones

Confidentiality is key to small group work ndash ldquono such thing as a silly questionrdquo ldquowhat is said here stays hererdquo and other reassurances can help a group to openly discuss their gaps in knowledge and skills

Attendance is compulsory and late students may be marked as absent

Document your agreed rules so you can refer back to them if there are any problems

Subsequent meetingsOpenings

An active game can be a useful warm-up

A brief roundup of the week from each student helps include everyone Which activities (eg clinics ward rounds theatre) have they found helpful or interesting

Check for burning issues from the last session that need addressing at the start

The middle bits

Students present and discuss real patient histories examination findings experience and learning from patient encounters in hospital and community

Developing presentation skills is a key element

The group will be diverse in background skill and experience It is important to recog-

8

nize and use this to stimulate useful and interesting discussions

Your own clinical experiences and cases are useful

You may wish to use tables journal articles quizzes communication skills role-play and OSCE practice to reinforce the learning and vary the activities We have provided a se-lection of these to stimulate your ideas

Make opportunities for students to compare their understanding and performance with one another and to share resources

A short break midway will benefit tutor and student concentration and is strongly recom-mended

Endings

Reflect on the work covered by the group during the session and plan a theme for the next meeting Although students can present any kind of case this will help inform you which areas of medicine they have already covered This is particularly important early in the year when their knowledge base will be more limited

Ask individual students to commit to case presentations for the next session The tutor can outline any other preparation required by group for debate or discussion Docu-menting plansILOs either on paper or by shared e-mail is necessary for accountability and informs good teaching practice ILOs should be specific eg ldquowe would like to revise our knowledge of cardiac drugs and practice explaining them to the patientrdquo

The final meetingBrief feedback

Tutors must set time aside for a one-to-one meeting with each student This is used to highlight studentrsquos strengths and areas for improvement You will be one of the few tu-tors who meet the student repeatedly and reliably over the twelve-week period so you will have valuable insights to offer They must be recorded on eForms

One-to-one discussions can be done sooner if specific problems are identified

At your last meeting remind students to complete their feedback about the sessions on eForms

Ask students for feedback on how each session goesNegotiate how you might make changes to improve it

Remember to be flexible as the year progresses and studentsrsquo needs change

This guide is intended as a menu of activities and ideas to give structure and context to student-led sessions Feedback is always welcome from tutors and

students on how sessions can be improved

9

Trigger material to generate discussions

Spend the majority of your time discussing real cases events and experiencesThere are occasions where additional pre-prepared material can enhance

the studentrsquos learning but the topics outlined are not intended to be used in place of case discussion

We do not suggest the resources are used as tutorials but as triggers to stimulate enquiry and discussion

Longitudinal Case ArticlesRole play amp

OSCE practice

Games VideosPrescribing amp Record keeping

10

RALPHIEWe have developed the acronym ldquoRALPHIErdquo to summarise the competencies and skills em-bedded within the ILOs for Clinical Debrief These competencies are not exclusive but are at the core of preparation for practice We hope that they will provide you with a framework for expanding discussion Sharing these competencies with your students may help them to develop their own learning needs and identify areas that they wish to explore in the con-text of the cases they have seen

Reasoning (clinical)

Application of skills

Longitudinal care

Patient centred care

Healthy people

Identity (personal and professional)

Ethical scenarios

You will find quality resources on the Clinical Debrief webpage under the competency headings httpsitesbmhmanchesteracukcbmeProgInfCDresources However we do encourage you to identify current affairs in the (medical) press for discussion

Documentation of learning activities covered in Clinical Debrief sessions will be aligned to these headings

RALPHIE - Core competencies and skillsReasoning (clinical)

Develop differential diagnoses

Have you checked for red flagsWhat diseasesconditions are most likely for a patient this agegender

Common things are common

Turning patient narrative into medical narrative

Margin hypothesis

Hypothetico-deductive model what are you thinking at this point in the history What else do you need to ask to rule inout some diagnoses

Pattern recognition are you squeezing to fit and ignoring any of the evidence that doesnrsquot fit

Application of skills (consultation and communication skills)

What did the patient tell you in their opening statement

Negotiating investigations and management plans with patients

How do we communicate risk to patients

Shared decision making with the patient

9

Trigger material to generate discussions

Spend the majority of your time discussing real cases events and experiencesThere are occasions where additional pre-prepared material can enhance

the studentrsquos learning but the topics outlined are not intended to be used in place of case discussion

We do not suggest the resources are used as tutorials but as triggers to stimulate enquiry and discussion

Longitudinal Case ArticlesRole play amp

OSCE practice

Games VideosPrescribing amp Record keeping

10

RALPHIEWe have developed the acronym ldquoRALPHIErdquo to summarise the competencies and skills em-bedded within the ILOs for Clinical Debrief These competencies are not exclusive but are at the core of preparation for practice We hope that they will provide you with a framework for expanding discussion Sharing these competencies with your students may help them to develop their own learning needs and identify areas that they wish to explore in the con-text of the cases they have seen

Reasoning (clinical)

Application of skills

Longitudinal care

Patient centred care

Healthy people

Identity (personal and professional)

Ethical scenarios

You will find quality resources on the Clinical Debrief webpage under the competency headings httpsitesbmhmanchesteracukcbmeProgInfCDresources However we do encourage you to identify current affairs in the (medical) press for discussion

Documentation of learning activities covered in Clinical Debrief sessions will be aligned to these headings

RALPHIE - Core competencies and skillsReasoning (clinical)

Develop differential diagnoses

Have you checked for red flagsWhat diseasesconditions are most likely for a patient this agegender

Common things are common

Turning patient narrative into medical narrative

Margin hypothesis

Hypothetico-deductive model what are you thinking at this point in the history What else do you need to ask to rule inout some diagnoses

Pattern recognition are you squeezing to fit and ignoring any of the evidence that doesnrsquot fit

Application of skills (consultation and communication skills)

What did the patient tell you in their opening statement

Negotiating investigations and management plans with patients

How do we communicate risk to patients

Shared decision making with the patient

10

RALPHIEWe have developed the acronym ldquoRALPHIErdquo to summarise the competencies and skills em-bedded within the ILOs for Clinical Debrief These competencies are not exclusive but are at the core of preparation for practice We hope that they will provide you with a framework for expanding discussion Sharing these competencies with your students may help them to develop their own learning needs and identify areas that they wish to explore in the con-text of the cases they have seen

Reasoning (clinical)

Application of skills

Longitudinal care

Patient centred care

Healthy people

Identity (personal and professional)

Ethical scenarios

You will find quality resources on the Clinical Debrief webpage under the competency headings httpsitesbmhmanchesteracukcbmeProgInfCDresources However we do encourage you to identify current affairs in the (medical) press for discussion

Documentation of learning activities covered in Clinical Debrief sessions will be aligned to these headings

RALPHIE - Core competencies and skillsReasoning (clinical)

Develop differential diagnoses

Have you checked for red flagsWhat diseasesconditions are most likely for a patient this agegender

Common things are common

Turning patient narrative into medical narrative

Margin hypothesis

Hypothetico-deductive model what are you thinking at this point in the history What else do you need to ask to rule inout some diagnoses

Pattern recognition are you squeezing to fit and ignoring any of the evidence that doesnrsquot fit

Application of skills (consultation and communication skills)

What did the patient tell you in their opening statement

Negotiating investigations and management plans with patients

How do we communicate risk to patients

Shared decision making with the patient

11

Longitudinal care

The ldquotherapeutic relationshiprdquo

Managing increasing complexity

Patient centred care

Supporting self-care

Shared decision making

Supporting patients with chronic disease

GP as care co-ordinator

How do we use time to manage uncertainty in primary care

Holistic care

The biopsychosocial mode

The impact of chronic disease on the patientrsquos family and carers

Develop a problems list (as opposed to a differential diagnosis) for a patient

How does diversity impact on access to healthcare

Healthy people

Public Health and Occupational Medicine

Brief interventions

Behavioural change cycle of change barriers to change

Health work and wellbeing

Managing your own mental health

Taking an occupational history

Health promotion and disease prevention

Identity (personal and professional)

Teaching and learning experiences that students have found challenging

Discuss any unprofessional or potentially dangerous behaviour students have observed

Share examples of good practice

Discuss and challenge personal beliefs and values

Managing patient complaints or errors

Ethical Scenarios

Ethical framework

Healthcare rationing

Ethics of a patientrsquos right to know

12

Is it ethical not to discuss common side effects of medication with patients

Role-play for history taking and presentation skillsAt the start of Year 3 students need to learn and practice how they present information that they obtain by history taking At the first session it is unlikely they will have brought a case to discuss so it can be useful to role-play There are some extra scenarios on the CBME web-pagehttpsitesbmhmanchesteracukcbmeProgInfCDresourcesHndbkrsrcs

Good examples of tutor prompts can be found by looking up Socratic questioning techniques

Student 1(doctor) Takes a history

Student 2(patient)

GroupTakes brief

notes

Scribes on flipchart

Presentshistory

Identify informationthey feel is usefulunclear missingunusual unexpected orthey had difficulty obtaining

Out of role Outline information

from history that was missed

In-role Feedback from patient perspective

Tutor prompt What else might you have asked

HowWhat would you

do differently next time How did you interpret the

non-verbal communicationGive examples of how rapport

was built with the patient

Tutor prompt Was there any jargon

the patient didnrsquot understand

12

Is it ethical not to discuss common side effects of medication with patients

Role-play for history taking and presentation skillsAt the start of Year 3 students need to learn and practice how they present information that they obtain by history taking At the first session it is unlikely they will have brought a case to discuss so it can be useful to role-play There are some extra scenarios on the CBME web-pagehttpsitesbmhmanchesteracukcbmeProgInfCDresourcesHndbkrsrcs

Good examples of tutor prompts can be found by looking up Socratic questioning techniques

Student 1(doctor) Takes a history

Student 2(patient)

GroupTakes brief

notes

Scribes on flipchart

Presentshistory

Identify informationthey feel is usefulunclear missingunusual unexpected orthey had difficulty obtaining

Out of role Outline information

from history that was missed

In-role Feedback from patient perspective

Tutor prompt What else might you have asked

HowWhat would you

do differently next time How did you interpret the

non-verbal communicationGive examples of how rapport

was built with the patient

Tutor prompt Was there any jargon

the patient didnrsquot understand

13

Activities to use when students present their cases

M

edic

atio

n

Ask t

he st

uden

ts ab

out e

ach

drug

the

patie

nt is

taki

ng

Use

a sim

ple

tabl

e to

hel

p th

em

orga

nise

thei

r tho

ught

s

Disc

uss c

ompl

ianc

e an

d ta

lkin

g to

pa

tient

s abo

ut ri

sk

Pres

enta

tion

skill

s

Ask s

tude

nts t

o wr

ite a

case

sum

mar

y of t

wo to

th

ree

sent

ence

s

Com

pare

the

sum

mar

y eac

h ha

s writ

ten

Diffe

rent

ial d

iagn

osis

Stop

the

pres

enta

tion

afte

r the

firs

t se

nten

ce an

d as

k for

diff

eren

tial d

iagn

oses

Just

ify an

d ra

nk o

ptio

ns

Cons

ider

furth

er q

uest

ions

for

eac

h

Sign

ifica

nt e

vent

ana

lysi

s

If a d

iagn

osis

was m

issed

or

som

ethi

ng w

ent w

rong

use

th

e ch

ance

to d

iscus

s SEA

s

Ethi

cs a

nd p

rofe

ssio

nalis

m

Disc

uss i

ssue

s suc

h as

do

not r

esus

citat

e or

ders

inv

olvi

ng re

lativ

es an

d ca

rers

in

decis

ions

adv

ance

d di

recti

ves

copi

ng w

ith

chal

leng

ing

patie

nt b

ehav

iour

Rais

ing

the

soci

al is

sues

How

will

this

affe

ct th

e pa

tient

rsquos jo

b

Driv

ing

Sex

life

Who

rsquos ro

le is

it to

di

scus

s thi

s H

ow T

ry ro

le p

layhellip

Mr X

is a

55 ye

ar o

ld jo

iner

who

pre

sent

ed

to ca

sual

ty w

ith a

thre

e ho

ur h

istor

y of

brea

thle

ssne

sshellip

He h

ad a

hist

ory o

f hyp

erte

nsio

n an

d wa

s ta

king

hellip

On e

xam

inat

ion

I fou

ndhellip

OSCE

pra

ctic

e

Ask t

he st

uden

ts to

role

pla

y exp

lain

ing

the

inve

stig

atio

ns t

he te

st re

sults

or t

he

med

icatio

n to

the

patie

nt

Orde

ring

test

s

Ask t

he st

uden

ts to

prio

ritise

test

s for

ea

ch o

f the

ir di

ffere

ntia

ls M

ake

sure

th

ey ju

stify

eac

h on

e

Exam

inat

ion

findi

ngs

Ask t

he st

uden

ts to

talk

thro

ugh

the

exam

inat

ion

findi

ngs t

hey

woul

d ex

pect

for e

ach

diffe

rent

ial

diag

nosis

Use

a sim

ple

tabl

e to

co

mpa

re fi

ndin

gs

14

Presentation skillsThis is a key element of the initial Clinical Debrief sessions The Calgary-Cambridge mod-el of history taking is taught from Year 1 and is integrated with more traditional models A summary is included in the resource pack and on wwwskillscascadecom Do not try to apply all the elements to a single consultation Use it as a guide and pick chunks that are relevant to the cases discussed

The communication skills teams use feedback sheets printed on yellow paper to help them stand out They are sometimes referred to as ldquoyellowsrdquo and there are copies in your pack for you to use

There are a number of frameworks for presenting cases This is one that students may find useful

ldquoSOAPrdquo technique

S = Subjective ndash what the patient said

O = Objective ndash what you found

A = Assessment ndash what you think is going on

P = Plan ndash investigations and management

Activity

1 Revisit existing knowledge of history taking

2 Ask for a summary of Calgary-Cambridge framework

3 Brainstorm ndash ldquowhat makes a good presentationrdquo

4 Practice with brief role-play scenario

5 Ask history-takers to write a two or three sentence summary to present

6 Give them a chance to rewrite after they have heard other studentsrsquo summaries

Using presented cases - margin hypothesis generationDifferential Diagnoses from the History

The group thinks of differential diagnoses as the history progresses by stopping the presentation at intervals Generating differentials even after the first line can be useful Continue with a STOP-START approach

Differentials are noted in the margins of notes and on the flipchart

The tutor asks the student to justify their choices and rank them in order of likelihood

Rankings are updated and differentials can be added or removed as new information becomes available from the student who is presenting

Thinking about Examination Findings

In later sessions students can also focus on examination findings What findings would

15

be expected for each of the differentials Or ask students to present their examination findings before the history and then debate differentials This is good to demonstrate how much we rely on the history rather than the physical findings in most instances

Thinking about selective use of Tests

Ask students to think during the presentation which test would most help them

Prioritise and justify choices They often see the more invasive tests in hospitals and may jump for these too early

Which test would they choose if they were only allowed to perform one

This exercise can also facilitate discussion about the concepts of specificity and sensitiv-ity

Thinking about Medication

Ask students to tell you about the patientrsquos medication drug class mechanism of action indications contraindications side effects and monitoring

You could try having the medications listed first and work out what this tells you about their patient

Ask the students to write out a prescription for their case ndash either on a hospital chart as if the patient has just been admitted or on a sample FP10 for community patients (examples on website httpsitesbmhmanchesteracukcbmeProgInfCDresourcesCDPrescrib-ing)

OSCE examination preparationStudents approaching their exams often ask for OSCE practice There are a number of ways of handling this Base administrators and hospital libraries have a copy of OSCES for PLAB and Medical Students which has been written by a Manchester tutor who has given permis-sion for it to be photocopied and used without worry about copyright The role plays avail-able under the longitudinal care also provide excellent OSCE practice

Alternatively encourage the students to think about what examiners are looking for and write a station themselves including the marksheet Students can play the patient and act as examiners for the station they have written Following the mock OSCE examination stu-dents present the station they wrote to the group by outlining the information provided in their station what they were testing for and things that went well or caused difficulty The group then shares pointers to improve overall performance

Another method is to bring in anonymised notes from a surgery you have held during the week Ask the students to pick a case randomly and you play the patient

Using current eventsNewspaper cuttings (the Metro is a great source) or journal articles may be useful source materials to trigger discussion They do not have to be scientific research articles If Le-gionnaires is in the news what do the students know about Legionnaires If a doctor is up before the GMC for self-prescribing discuss the ethical issues brought out A few example articles are provided in the resource folder but more importantly use current topical events in your discussions

14

Presentation skillsThis is a key element of the initial Clinical Debrief sessions The Calgary-Cambridge mod-el of history taking is taught from Year 1 and is integrated with more traditional models A summary is included in the resource pack and on wwwskillscascadecom Do not try to apply all the elements to a single consultation Use it as a guide and pick chunks that are relevant to the cases discussed

The communication skills teams use feedback sheets printed on yellow paper to help them stand out They are sometimes referred to as ldquoyellowsrdquo and there are copies in your pack for you to use

There are a number of frameworks for presenting cases This is one that students may find useful

ldquoSOAPrdquo technique

S = Subjective ndash what the patient said

O = Objective ndash what you found

A = Assessment ndash what you think is going on

P = Plan ndash investigations and management

Activity

1 Revisit existing knowledge of history taking

2 Ask for a summary of Calgary-Cambridge framework

3 Brainstorm ndash ldquowhat makes a good presentationrdquo

4 Practice with brief role-play scenario

5 Ask history-takers to write a two or three sentence summary to present

6 Give them a chance to rewrite after they have heard other studentsrsquo summaries

Using presented cases - margin hypothesis generationDifferential Diagnoses from the History

The group thinks of differential diagnoses as the history progresses by stopping the presentation at intervals Generating differentials even after the first line can be useful Continue with a STOP-START approach

Differentials are noted in the margins of notes and on the flipchart

The tutor asks the student to justify their choices and rank them in order of likelihood

Rankings are updated and differentials can be added or removed as new information becomes available from the student who is presenting

Thinking about Examination Findings

In later sessions students can also focus on examination findings What findings would

15

be expected for each of the differentials Or ask students to present their examination findings before the history and then debate differentials This is good to demonstrate how much we rely on the history rather than the physical findings in most instances

Thinking about selective use of Tests

Ask students to think during the presentation which test would most help them

Prioritise and justify choices They often see the more invasive tests in hospitals and may jump for these too early

Which test would they choose if they were only allowed to perform one

This exercise can also facilitate discussion about the concepts of specificity and sensitiv-ity

Thinking about Medication

Ask students to tell you about the patientrsquos medication drug class mechanism of action indications contraindications side effects and monitoring

You could try having the medications listed first and work out what this tells you about their patient

Ask the students to write out a prescription for their case ndash either on a hospital chart as if the patient has just been admitted or on a sample FP10 for community patients (examples on website httpsitesbmhmanchesteracukcbmeProgInfCDresourcesCDPrescrib-ing)

OSCE examination preparationStudents approaching their exams often ask for OSCE practice There are a number of ways of handling this Base administrators and hospital libraries have a copy of OSCES for PLAB and Medical Students which has been written by a Manchester tutor who has given permis-sion for it to be photocopied and used without worry about copyright The role plays avail-able under the longitudinal care also provide excellent OSCE practice

Alternatively encourage the students to think about what examiners are looking for and write a station themselves including the marksheet Students can play the patient and act as examiners for the station they have written Following the mock OSCE examination stu-dents present the station they wrote to the group by outlining the information provided in their station what they were testing for and things that went well or caused difficulty The group then shares pointers to improve overall performance

Another method is to bring in anonymised notes from a surgery you have held during the week Ask the students to pick a case randomly and you play the patient

Using current eventsNewspaper cuttings (the Metro is a great source) or journal articles may be useful source materials to trigger discussion They do not have to be scientific research articles If Le-gionnaires is in the news what do the students know about Legionnaires If a doctor is up before the GMC for self-prescribing discuss the ethical issues brought out A few example articles are provided in the resource folder but more importantly use current topical events in your discussions

15

be expected for each of the differentials Or ask students to present their examination findings before the history and then debate differentials This is good to demonstrate how much we rely on the history rather than the physical findings in most instances

Thinking about selective use of Tests

Ask students to think during the presentation which test would most help them

Prioritise and justify choices They often see the more invasive tests in hospitals and may jump for these too early

Which test would they choose if they were only allowed to perform one

This exercise can also facilitate discussion about the concepts of specificity and sensitiv-ity

Thinking about Medication

Ask students to tell you about the patientrsquos medication drug class mechanism of action indications contraindications side effects and monitoring

You could try having the medications listed first and work out what this tells you about their patient

Ask the students to write out a prescription for their case ndash either on a hospital chart as if the patient has just been admitted or on a sample FP10 for community patients (examples on website httpsitesbmhmanchesteracukcbmeProgInfCDresourcesCDPrescrib-ing)

OSCE examination preparationStudents approaching their exams often ask for OSCE practice There are a number of ways of handling this Base administrators and hospital libraries have a copy of OSCES for PLAB and Medical Students which has been written by a Manchester tutor who has given permis-sion for it to be photocopied and used without worry about copyright The role plays avail-able under the longitudinal care also provide excellent OSCE practice

Alternatively encourage the students to think about what examiners are looking for and write a station themselves including the marksheet Students can play the patient and act as examiners for the station they have written Following the mock OSCE examination stu-dents present the station they wrote to the group by outlining the information provided in their station what they were testing for and things that went well or caused difficulty The group then shares pointers to improve overall performance

Another method is to bring in anonymised notes from a surgery you have held during the week Ask the students to pick a case randomly and you play the patient

Using current eventsNewspaper cuttings (the Metro is a great source) or journal articles may be useful source materials to trigger discussion They do not have to be scientific research articles If Le-gionnaires is in the news what do the students know about Legionnaires If a doctor is up before the GMC for self-prescribing discuss the ethical issues brought out A few example articles are provided in the resource folder but more importantly use current topical events in your discussions

16

Situational Judgement TestCD is a good place to introduce the SJT a national assessment taken in Year 5 prior to foundation applications Examples can be found on the Foundation website httpwwwfoundationprogrammenhsukpagesmedical-studentsSJT-EPM

Longitudinal careWe have introduced the concept of a longitudinal case as one of the resources for explora-tion with your students over the 12 weeks There are broad themes introducing increasing complexity exploring the doctor-patient relationship over time and the impact of continu-ity on the consultation The cases are introduced as themes such as ldquoCommon things are commonrdquo for the first encounter We have written a roleplay using a history of fever but you could equally write your own using any presenting complaint For greater authenticity use your own experiences ldquoI saw a case ofhelliprdquo

Students may be stimulated in subsequent sessions to ask you what happened to your patient We have developed suggested areas for discussion using the RALPHIE competen-cies

GP videosDr Kurt Wilson has developed real GP consultation videos which have been anonymised The videos have ethical approval and consent from both patient and doctorYear 3 students are not currently in GP placements The videos may be useful to help pre-pare our students for practice in Year 4 and to help contextualise some of the issues raised from a primary care perspective For example it can sometimes be difficult to discuss ldquocom-mon things are commonrdquo when students are coming from a secondary care perspectiveThe videos are suggested to support specific themes within the longitudinal care heading but feel free to use them as you find useful to support the learning needs raised by your stu-dents The transcripts are available for the videos and are embedded in the video resource heading httpsitesbmhmanchesteracukcbmeProgInfCDresourcesCDVideos

Semester 1

Theme 1 Common things are commonTheme 2 Have you checked for red flagsTheme 3 Hypothetico-deductive modelTheme 4 Interpreting resultsTheme 5 Negotiating changeTheme 6 Communicating riskTheme 7 Patient centred consultingTheme 8 Pattern recognition

Semester 2

Theme 9 Integrated careTheme 10 Holistic careTheme 11 Longitudinal care Theme 12 Impact of chronic diseaseTheme 13 Ethical dilemmasTheme 14 Patient centred consultingTheme 15 Diversity

17

Troubleshooting guide for difficult groupsFortunately most students are hardworking and respectful of your time and preparation however sometimes sessions flow better if you have strategies to deal with specific situa-tions

Dominant behaviour

A student wants to be the centre of attention and is trying to impress you or other group members It may be because they think they know much more about a subject than the rest of the group and want to share their knowledge It is important to try to reduce their input without causing offence or obstructing group process

Sitting next to a potentially dominant group member can reduce the amount of eye-con-tact you have with them and increase your eye contact with other group members helping promote their interaction If more active intervention is necessary ask the dominant student to undertake a task for example scribing An overt conversation with the group about the process may be appropriate

Jokey or offensive behaviour

Groups can usually deal with these issues themselves as they will be heartily sick of it and speak up Sometimes they may need a prompt such as asking them to discuss group at-mosphere and behaviour

Reticent behaviour

Students may not want to involve themselves in discussion for various reasons including shyness having personal problems dominating their thoughts being tired or ill or feeling out of their depth Group exercises like lsquosnowballingrsquo or giving individual specific tasks such as scribing can help

Remember in difficult situations

Refer group back to ground rules

It can be necessary to speak to the student after the session about behaviour you have observed

Consider relaying observations to the base administrative staff CBME team or Dean

For personal problems or illness help and advice will offered by their Dean own GP or student counsellor

(The tutor should not address these issues as a doctor other than to identify them and ensure no immediate risk They can provide educational and general personal support to guide students to other sources of help and follow up to check there has been appropri-ate action)

Group members whose behaviour isDominant

lsquoJokeyrsquoOffensiveReticent

Late or absent

18

Documentation of Learning ActivitiesDocumentation of your plans and activities is important to reinforce learning and for ac-countability in use of the time We ask you do this electronically share it with your students and with the CD central academic team (so we can map the content of this course) This also helps clarify responsibilities for preparatory actions for the next week such as bringing cases Tutors will vary content according to needs of group

To summarise the session or record your learning objectives you may want to use Bloomrsquos Taxonomy (Knowledge Skills and Behaviour)

These sessions are tied to the MMS curriculum and a permanent record of activities is ex-pected as an overview Please record them in your DLA eForm regularly At the end of the 12 week period (when you ldquoSubmitrdquo your completed form) you will automatically be sent a copy of this

The CBME website has a wide range of CD resources available to youhttpsitesbmhmanchesteracukcbmeProgInfCDresources

You can also join the CD tutor community on PIAZZA

18

Documentation of Learning ActivitiesDocumentation of your plans and activities is important to reinforce learning and for ac-countability in use of the time We ask you do this electronically share it with your students and with the CD central academic team (so we can map the content of this course) This also helps clarify responsibilities for preparatory actions for the next week such as bringing cases Tutors will vary content according to needs of group

To summarise the session or record your learning objectives you may want to use Bloomrsquos Taxonomy (Knowledge Skills and Behaviour)

These sessions are tied to the MMS curriculum and a permanent record of activities is ex-pected as an overview Please record them in your DLA eForm regularly At the end of the 12 week period (when you ldquoSubmitrdquo your completed form) you will automatically be sent a copy of this

The CBME website has a wide range of CD resources available to youhttpsitesbmhmanchesteracukcbmeProgInfCDresources

You can also join the CD tutor community on PIAZZA

19