Discussion tools

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

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

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

This takes eight minutes.

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

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

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

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

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

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

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

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

This takes just over 11 minutes.

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

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

This takes just over seven minutes.