CLINICAL DEBRIEF Tutor Notes Revised 2016
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
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
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
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
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
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
19
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
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
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
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
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
19
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
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
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
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
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
19
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
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
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
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
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
19
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
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
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
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
19
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
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
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
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
19
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
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
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
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
19
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
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
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
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
19
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
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
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
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
19
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
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
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
19
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
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
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
19
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
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
19
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
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
19
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
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
19
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
19
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
19
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
19
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
19