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Discussion tools

The CBD can record any conversation that reviews a trainee's practice or their thoughts about practice. From an office-based, time-protected tutorial to the short conversation that happens in the theatre coffee room, or even the corridor, CBD allows trainers to explore the thinking of their trainees, and to share understanding and professional thinking.

CBDs that look at information are addressing the knowledge base of the trainee. This may be asking trainees for the classification of shock. A trainer could take the discussion beyond the classification to look at how that knowledge relates to the understanding of the patient’s condition and the symptoms manifested by the patient. Application relates to the use of knowledge and understanding in practice and so the trainee may be asked to consider the possible treatment options for that patient. Analysis and synthesis are higher order levels of the thinking or cognitive function and CBDs that look at a situation reflectively, to break it down and consider what elements helped or hindered patient care, can be invaluable to trainees in reviewing and making sense of their experiences and in extending their critical thinking. At the evaluation level trainees may well be engaging in discussions that relate to service improvement and changes in practice at a group level rather than an individual one.

In the clips we see three CBDs focusing on the same case. The first looks at the knowledge base underpinning the case. The second looks at the clinical skills used by a CT2 - that is the application of knowledge and understanding. The third one looks at Reflection by the registrar involved in the case.

Overall Summary of case

A 23-year-old man had arrived in Accident and Emergency (A&E) after being involved in a road traffic accident (RTA). He had been riding a bike and had been hit from the left hand side by a car, had got up and was shaken but sore. He was brought to A&E by ambulance and triaged by A&E. He was seen three hours later by the A&E SHO and fast tracked to SAU by a surgical CT1 at handover time. The incoming CT2 flagged him up as a case that should be reviewed by the Registrar on call. The CT2 had seen the patient in SAU as he had been transferred. Suspicious of a splenic injury with the clinical findings, he had requested a CT scan. The CT scan was carried out and was not reported for several hours. The patient was stable and so there was no real urgency but was discussed in the corridor with the consultant on call who had been angered by the clinical scenario and requested that the report be made readily available. The ST3 was busy on call and asked the CT2 to chase the report. Finally the scan result was available at 6pm just as the patient deteriorated and the ST3/ST5 was called urgently as blood pressure was falling. The patient needed urgent review and theatre that evening for a splenectomy. The procedure was carried out by an ST5 with consultant supervision.

A conversation is triggered in the coffee room


CT1 – Splenic injury – knowledge based

All CBDs will look at the knowledge and understanding of a trainee in a given context. Some will stay at the lower level of Bloom’s taxonomy, especially with more junior trainees who are still at the level of learning about the relationship between knowledge and practice.

This CBD looks at the underlying knowledge base used by the CT1 trainee who first saw the patient in A&E. Note that the initial questions have a narrative function – 'Tell me your involvement,' 'Tell me again the mechanism of injury,' followed by questions that probe a little more deeply into understanding – 'Tell me why you made that judgement call,' and further into the application of knowledge – 'What were your instructions to the nursing staff?' The questions do not go beyond this level however and the remaining conversation focuses on knowledge, understanding and application – 'Tell me about the grades of shock,' and 'Do you know the grades of splenic trauma?'

Typically, formal discussions have often been 'viva-like' in their concentration on recall of information, with some application of that information perhaps. So a trainee who did know the grades of shock would be pushed beyond to the grades of splenic trauma or some other such paradigm. The knowledge itself may have become more complicated but the use of the knowledge was not necessarily developed.

This takes eight minutes.

CT2 – Splenic injury – clinical skills

Similarly, in this clip we see the trainer taking the CT2 through the events of that day, and reviewing his clinical skills. The focus here is less on his knowledge base and more on his knowledge and understanding of clinical signs and pattern recognition. By focusing on what the trainee did so well the trainer is reinforcing and conserving good clinical practice. She elicits clinical reasoning from the trainee which is a valuable skill to develop.

We now know that in order to learn effectively and to move from extensive knowledge through to excellent professional practice, we need to scaffold and support trainees in applying what they know to clinical contexts, to guide them to not just apply their learning but also to analyse it and their knowledge, to synthesise both and to evaluate patients according to experience, knowledge and practice.

This takes eight minutes.

Registrar – Splenic injury – Clinical Judgement and Professional Behaviour (Reflective practice)

Higher levels of the taxonomy are used in this clip. This CBD is used more as a reflective conversation. The Registrar has the insight to know that on the previous day his consultant on call was displeased with the way he managed a patient with a splenic injury and he requests to speak to another consultant about this.

In the 12 minute conversation which ensues, the consultant facilitates reflection on the event so that the registrar can re-run the events of the day, and examines them from a range of perspectives. In doing so the registrar is analysing his practice and knowledge, synthesising future ways of practising and evaluating not just what he did or did not do but also the service within which he is working. At the end of the case discussion an action plan is formed.

The structure used by the consultant is a very simple one devised for the TAIP course:

List events as they happened
Identify feelings, assumptions, or beliefs about the case
See similarities and differences with other practice
Action points to change practice.
(Notice that questions 2 and 3 are interchangeable.)

In the first part of the reflection the registrar ran thought the events of the afternoon with a degree of hindsight which made him begin to see things from alternative perspectives. He seems to be trying his best to view his actions from both his and from the consultant’s viewpoint.

His realisation about the issue central to the case came in the second section of the reflection when the consultant asked him whether he had been in this situation before. He saw that although he had seen splenectomies before he had not done one and that may well be the reason why he had not thought ahead to the next logical step a little earlier. Experience gives us an understanding of the natural narrative of a surgical disease or condition. Without that experience the registrar was slow to accelerate that narrative.

This learning point was reinforced in the third question when the trainee realised that recognising the injury is not the same as planning for and implementing the next steps in the process.

In the final section action points were discussed after the trainee had assessed his strengths and areas for development. Note the use of the consultant’s open questions 'What would be the deciding factor?' and 'What would have made you take the patient to theatre based on the imaging?' and 'How would you circumvent that?' to promote the registrar’s problem solving and evaluative thinking. However, the final action plan is prompted by the consultant and focuses on a change in behaviour in terms of presenting information to consultants and a teaching session with the radiologists looking at splenic injury. The registrar still requires direction from the consultant but the benefit of reflective CBDs is the opportunity to review and analyse actions. Some trainees will produce their own action plans; others may need help.

This takes just over 11 minutes.

A simple, regular occurrence can be used to develop trainee thinking and practice and generate service improvement and clinical governance input. The trainee produces three pieces of evidence for their portfolio.

A fractured NOF – CBD in Trauma meeting

This clip shows a simple, regular occurrence. A problem with incomplete clerking and handover results in a delay to the Trauma list. By using five minutes to look at the case, several learning points are made:

  • The trainee realises the impact of incomplete clerking and handover
  • The trainee considers alternative ways to clerk patients
  • There is reflection on the process of handover
  • Action to produce a handover document is agreed
  • Evidence is collected in the form of a CBD, the handover documentation produced and the presentation at Clinical Governance.

This takes just over seven minutes.