Standardised Case-Based Discussion workshop - Melbourne Medical School Ottawa 2020
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Melbourne Medical School Standardised Case-Based Discussion workshop A/PROF. DAVID SMALLWOOD, DR RUTH SUTHERLAND, A/PROF JONATHON KNOTT Ottawa 2020 KUALA LUPUR CONVENTION CENTRE, MALAYSIA 29TH FEBRUARY – 4TH MARCH 2020
SCBD WORKSHOP TABLE OF CONTENTS HOW TO WRITE A SCBD ................................................................................................................................... 1 SCBD EXAMPLE: SHORTNESS OF BREATH ........................................................................................................ 14 Information for students 15 Additional information for examiners Error! Bookmark not defined. Expectations of a PCP3 student performance in this SCBD 16 SCBD marksheet 19 Section marking guide 20 Overall marking guide 21 Marking instructions for Examiners 22 SCBD WORKSHOP GROUP ACTIVITY ............................................................................................................... 23 ACKNOWLEDGEMENTS AND CONTACT DETAILS.............................................................................................. 24
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SCBD WORKSHOP SCBD EXAMPLE: SHORTNESS OF BREATH Case synopsis: Doreen Williams, aged 68 years, presents to her usual GP, Dr. Redmond, with a one-week history of shortness of breath on exertion. Her dyspnoea has slowly been getting worse over the past week. She has symptoms doing household chores and can no longer walk 3km on the flat to the dog park, which was previously easy for her. She is now feeling short of breath at rest. Doreen does not feel comfortable at night time and has tried using more pillows in bed, but she does not think this has helped her. She has felt hot and sweaty overnight but is not sure if she has had a fever or not. She has not noticed any ankle swelling. Doreen has had some left sided chest discomfort which started this morning. She has also had an irritating cough for the past few days, but no sore throat or runny nose. She is an ex-smoker. Topic Shortness of breath and chest pain Objectives of this station Students should ascertain a history of subacute dyspnoea and chest pain in a 68-year-old woman and elicit the underlying reason for this, indicate any relevant examination or investigations they would wish to undertake and formulate an appropriate management plan. Through the SCBD format, this station should: 1. Allow students to consider important aspects of history and examination in the diagnosis of an adult presenting with shortness of breath and chest pain 2. Allow students to determine the appropriate management steps 3. Allow students to determine the appropriate pace of assessment in the allocated time 4. Allow examiners to understand the clinical reasoning that students are utilising Station Writers Dr. Ruth Sutherland UNIVERSITY OF MELBOURNE 14
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Information for students
Patient Name: Doreen Williams
Patient Age: 68 years old
Gender: Female
Celebrex 200mg daily
Current Medications:
Avapro 150mg daily
Allergies: Nil known
Lives with husband, Bill.
Social history: Has two grown up children
Has a dog called Maxi
Smoking: Ex-smoker ceased 18 years ago
Alcohol: 1-2 standard drinks each weekend
Dr Redmond is a GP in suburban Melbourne, within 20 minutes of a tertiary teaching hospital.
UNIVERSITY OF MELBOURNE 15SCBD WORKSHOP Expectations of a PCP3 student performance in this SCBD Level of Students: Principles of Clinical Practice 3 (PCP3) Students in PCP3 have completed one year of biomedical science and two years of clinical training. This includes an initial year of adult medicine and a subsequent year of specialty health rotations (General Practice, Aged Care, Mental Health, Women’s Health and Children & Adolescent Health). Each rotation is of 6- 8 weeks duration. Students at this level are expected to be able to integrate knowledge gained throughout their medical course and apply it to a range of clinical scenarios. These students should be able to take a history and perform an examination at the level of an intern in their first rotation. They should be able to justify any investigations they feel are warranted. Treatment and management should be at the level expected of an intern on their first rotation. Discussion about the medical history Initially the student is expected to consider a broad range of differentials for this case. The differential diagnosis should include respiratory, cardiovascular, hematological and intra- abdominal causes. Taking into account the patient’s age and the information she provides in the video prompt an acceptable list of differentials would include: Pulmonary embolism, pneumonia, pleural effusion, metastatic disease in the lung or pleura, metastatic ascites, anaemia, heart failure, possible arrhythmia, COPD and anxiety. The student is expected to take a history that gathers sufficient information to further guide clinical reasoning about the potential diagnosis. The diagnoses not to be missed include pulmonary embolism, lung infection, heart failure and metastatic disease. The student is also expected to explore the patient’s history for associated features of a pulmonary embolus or an infection and explore possible risk factors for these conditions. An excellent performance would involve exploration and consideration of all potential emergency presentations for this case. An excellent performance would explore pulmonary embolism in detail, including past history of DVT/PE and family history of DVT/PE, symptoms of DVT. It would also involve detailed enquiry about associated features of pneumonia, including infectious contacts and recent travel) and cardiovascular disease. An excellent student will also look for symptoms of tumour recurrence (e.g. loss of weight, abdominal distension). A satisfactory performance would consider PE and some other relevant differential diagnoses. They would explore some aspects of risk for PE but not all. They would ask about some relevant associated features to explore for other causes, but this would be patchy. They may not consider tumour recurrence as a cause or may only ask about this in a very superficial manner. An unsatisfactory performance would not clearly reveal the important causes not to be missed i.e. pulmonary embolus, infection, metastatic disease. They may not consider PE as a cause or they may only consider PE and not include other important differential diagnoses. They would not gather all the relevant information about possible pulmonary embolus / lung infection/ metastases and would not be able to adequately justify why they are gathering this information. Discussion about the physical examination The student is expected to ask about the vital signs and focus upon cardiorespiratory examination. They should also examine for signs of recurrence of ovarian carcinoma or new metastatic disease (such as pleural effusions, abdominal distension or demonstrable ascites with percussion, palpation for hepatomegaly and masses). The differential diagnosis will not change significantly following the physical examination for this case, however, provided the student has asked about it, will most likely rule out heart failure and ascites. UNIVERSITY OF MELBOURNE 16
SCBD WORKSHOP After hearing the examination findings students should be considering pulmonary embolus, lung infection, metastatic lung/pleural disease and anaemia. An excellent performance will enquire in detail about the respiratory and cardiovascular examination findings. An abdominal examination will be performed to assess risk of cancer recurrence, specifically ascites. In particular, an excellent performance will include enquiry about the presence of a pleural rub, consolidation, and pleural effusion. Rib pain from metastasis is also possible so looking for rib tenderness might be mentioned. An excellent performance will also include those students who ask about calf DVT. A satisfactory performance will enquire about key parts of the respiratory and cardiovascular examination findings, but there may be some omissions and the student may not be very organized in their approach. Abdominal examination may not be requested or if requested, may not focus on ruling out recurrent metastatic disease or heart failure. An unsatisfactory performance will not be comprehensive or specific about the most relevant features so therefore will not explore the details of a focused respiratory examination and will not gather sufficient information to confidently rule out pulmonary embolus, lung infection or the other differential causes including cancer recurrence. Discussion about investigations The most important investigations that are expected to be requested include: The differential diagnoses prior to investigations should be pneumonia vs PE. Basic bloods should be done and a chest X-ray. However, some students might go straight to the CTPA or VQ scan. This will give the definitive diagnosis, but other basic tests should still be done to obtain a good mark. The student is expected to justify all investigations requested. It is acceptable for them to propose FBE and CRP, but they must provide a rationale for how it will inform their diagnosis. Baseline renal function is also important. If a student mentions arranging a CT abdomen/ pelvis, ask the student to justify this request. An excellent performance will include request of relevant investigations and justification of their investigation choices and why they will help rule in or out their differential diagnoses. Irrelevant investigations will not be included. A satisfactory performance will include request of most of the relevant investigations (e.g. VQ scan or CTPA and basic bloods) and students will be able to supply some justification for their choices but may not always be able to correctly synthesise all the new information to inform their differential diagnosis list. An unsatisfactory performance would not clearly prioritise the investigations expected and would not be able to justify all their choices. Completely irrelevant investigations may be ordered, or students may order too many investigations, some relevant and some not, but are not able to apply the results to inform their thinking. Discussion about management Students are expected to recognise this is an emergency presentation due to the patient’s oxygen saturations and rapidly progressive symptoms, which are not clearly explained by the physical examination. The patient must be referred to the emergency department for further investigation and management. Initial management will include oxygen, analgesia and anticoagulation. Students are expected to discuss the risks and contraindications of anticoagulation. Priorities for management include: Stabilization of the patient to ensure adequate oxygenation Analgesia Management of the PE with anti-coagulation- initially with Low Molecular Weight Heparin and consideration for oral anticoagulants although they may not be as efficacious as LMWH. Exploration for ovarian tumour recurrence as a cause for the PE An excellent performance will recognise that this presentation is an emergency situation that requires rapid definitive management and would comment on the need for effective communication with the patient. UNIVERSITY OF MELBOURNE 17
SCBD WORKSHOP Appropriate initial measures could include: oxygen; analgesia; and anti-coagulation. They would be able to discuss management of pulmonary embolism in the hospital setting in depth and would also consider further assessment for recurrence of cancer. A satisfactory performance will recognise that this presentation is an emergency situation that requires rapid definitive management and would comment on the need for effective communication with the patient. Appropriate initial measures could include: oxygen; analgesia; and anti-coagulation. Most principles of PE management will be included, but the student may fail to fully explore the possibility of ovarian tumour recurrence as a cause. An unsatisfactory performance will not recognise that this presentation needs urgent referral and definitive management and will not recognise the importance of effective communication. They would not be able to discuss optimal management of PE and may not explore for recurrence of cancer. Particular Points to look out for Students have been given clear instructions to manage the pace of the station. They should not be moved on to the next phase by the examiner. Students are allowed to return to any phase to obtain additional information and should not be penalised for this. It is expected that examiners will probe students to get a better understanding of what they are thinking. However, examiners should not prompt students. A probing question explores information already raised by the student. For example: “You mentioned a cardiovascular cause. Can you elaborate on your thinking?” A prompt raises new information not already mentioned by the student, so may lead them in a certain direction. Prompts should be avoided by examiners. For example: “Could this be a cardiovascular issue?” Other examples of appropriate phrases include the following: “How will that information change your diagnosis?” “How do the results of that test help you make a diagnosis or management plan? UNIVERSITY OF MELBOURNE 18
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SCBD marksheet
Please affix Student ID label here Please affix your Examiner label here
Section A - Medical History
1. After watching the interview between the GP and Doreen, please explain your main differential
diagnoses and justify your reasoning.
2. What further information on history would you like to know and how does this information refine your
thinking?
3. Taking this new information into account, what diagnoses are you considering at this stage? Why?
Please rate the student’s clinical reasoning regarding medical history
Not-Attempted Unsatisfactory Borderline Satisfactory Good Excellent
Section B - Physical Examination
1. What features would you seek on examination and how would these help to refine your diagnosis?
2. Taking this new information into account, what diagnoses are you considering at this stage? Why?
Please rate the student’s clinical reasoning regarding physical examination
Not-Attempted Unsatisfactory Borderline Satisfactory Good Excellent
Section C- Investigations
1. What investigations are required to determine the likely diagnosis and how will they help make a
diagnosis?
2. Taking this new information into account, what is your working diagnosis at this stage? Why?
Please rate the student’s clinical reasoning regarding investigations
Not-Attempted Unsatisfactory Borderline Satisfactory Good Excellent
Section D - Management
1. If I student has not discovered the diagnosis of pulmonary embolism, then say; “Doreen has been
diagnosed with pulmonary embolism”. What are your priorities for managing Doreen and why?
Please rate the student’s clinical reasoning regarding management
Not-Attempted Unsatisfactory Borderline Satisfactory Good Excellent
Section E - Overall Standard of Performance
Please rate the student’s clinical reasoning regarding overall performance
Not-Attempted Unsatisfactory Borderline Satisfactory Good Excellent
UNIVERSITY OF MELBOURNE 19SCBD WORKSHOP Section marking guide Please refer to the following descriptions to guide your rating of the student’s performance at each phase of the case-based discussion. While these descriptions aim to describe overall performance, they should also be used to guide your judgements about the student performance at each phase of the discussion as outlined on the mark sheet. Excellent performance As for Good Performance, but with greater consistency, clarity and fluency Good performance Considers relevant differentials, and progressively hones in on the appropriate diagnosis as further information is provided Requests mostly relevant features or findings, and can provide sound reasons for doing so i.e. clear hypothesis-led information-seeking? Interprets information provided soundly and applies most or all to refining their thinking Explains well how each new information influences their reasoning Suggests an appropriate and safe initial management plan Satisfactory performance Considers some relevant differentials, and show some capacity to move towards more likely diagnosis as further information is provided May not necessarily identify the most correct diagnosis, but much of their reasoning around the information and its interpretation is sound, and their final diagnosis is one of the acceptable differential diagnoses Requests several relevant features or findings, and can provide some relevant reasons for doing so Will occasionally request irrelevant information and/or offer unsound justifications Some evidence of a hypothesis-led information-seeking approach Is able to draw some relevant features from information provided, and shows evidence of using this to modify their reasoning in the appropriate direction Is able to provide a reasonable account of how the information informs their thinking Suggests a relevant and safe initial management plan which may be incomplete and/or incorrect in some of the details Borderline performance Use this category if the student’s performance varies across the descriptions for Satisfactory and Unsatisfactory, so that you are unclear which category best characterises their performance Unsatisfactory performance Unclear about relevant differentials and/or pursues unlikely differentials Further information does little to correct or coherently influence this e.g. remains stuck on initial hypothesis despite contradictory evidence or jumps to a new diagnosis with each piece of information May possibly name the appropriate diagnosis as a ‘lucky guess’ but can offer no reasonable account as to why this is likely, or request little or no relevant information which would support the diagnosis Requests for information are unsystematic or possibly random Cannot provide sound reasons for requesting the information; no evidence of hypothesis-led information- seeking Poor capacity to interpret information requested and/or apply it to clinical reasoning Suggests an inappropriate and/or unsafe initial management plan Not Attempted The student fails to commence the relevant section. UNIVERSITY OF MELBOURNE 20
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Overall marking guide
Excellent
The final diagnosis is correct and well justified
Clinical reasoning is coherent, focussed and sustained across the case, and substantially correct
The student needed minimal probing to draw out relevant reasoning
Good
The final diagnosis is one of the main differentials, with relevant reasons
Clinical reasoning is generally clear and relevant across the case, with some relatively minor errors
The student needed some probing to draw out relevant reasoning
Satisfactory
The final diagnosis is a less likely differential or one of the main differentials with limited justification
Clinical reasoning was generally patchy, displaying some relevant reasoning but also notable gaps and/or
errors
The student needed a moderate amount of probing to draw out relevant reasoning
Borderline
The student’s performance varies across the descriptions for Satisfactory and Unsatisfactory.
Unsatisfactory
Manifestly unclear about relevant differentials and pursues unlikely differential diagnoses
Further information does little to correct or coherently influence their reasoning, for example:
Suggests a clearly unsuitable and/or unsafe initial management plan
Likely to need considerable or almost constant probing to draw out relevant ideas or thinking
UNIVERSITY OF MELBOURNE 21SCBD WORKSHOP Marking instructions for Examiners Setup On the marksheet, select the station and group you have been allocated to and make sure the appropriate round is also selected. Attach your ID Label on the marksheet provided. Assessing the Student Ask the student for their Student ID label and attach to the marksheet inside the clipboard. Ask the student to confirm their name matches with the marksheet. Use the statements on the marking sheet to guide your discussion with the student. When providing further information requested by the student, please try to provide it as recorded in the examiner information sheets. There will be a warning bell after (10) TEN minutes and a final bell at (15) FIFTEEN minutes. Record the student’s interview performance as per examiner briefing. Score the student using the marking scheme provided. Select your recommendation regarding the student’s overall performance in the ‘Performance’ tab. if you have rated the student’s overall performance as either Borderline or Fail then please provide some notes supporting your decision. Do not allow the student to leave the station until the final (15) FIFTEEN-minute bell is rung. BEFORE LEAVING YOUR ROOM FOR A TEA OR LUNCH BREAK, PLEASE CHECK THAT YOU COMPLETED EVERY SECTION OF EACH STUDENT’S MARK SHEET. UNIVERSITY OF MELBOURNE 22
SCBD WORKSHOP SCBD WORKSHOP GROUP ACTIVITY Using the Standardised Case-Based Discussion in your context. What is the purpose of the SCBD in your context be? e.g. Formative or summative assessment? Who are your learners? Where in your program will the SCBD occur? Who are your assessors? How will you prepare your learners for the SCBD? How will you prepare your assessors for the SCBD? How will you set the standard? Development of a specific SCBD case What is the presenting symptom? What is your preferred diagnosis? What are the key differential diagnoses? What information will you provide upfront to students? What information do you expect a student to request? What key questions will you include on the mark-sheet? Use the SCBD template provided online to complete all components of the case. UNIVERSITY OF MELBOURNE 23
SCBD WORKSHOP ACKNOWLEDGEMENTS AND CONTACT DETAILS Assoc Prof David Smallwood Respiratory & General Physician Principal Fellow in Medical Education Melbourne Medical School University of Melbourne Director of General Medicine Austin Hospital Melbourne, Australia david.smallwood@austin.org.au Dr Ruth Sutherland General Practitioner Educational consultant for Dept Medical Education Melbourne Medical School University of Melbourne Medical educator with Murray City Country Coast GP Training Victoria, Australia ruth.sutherland@mccc.com.au Assoc Prof Jonathan Knott Clinical Sub-Dean Emergency Medicine Melbourne Medical School University of Melbourne Director of Emergency Research Royal Melbourne Hospital Melbourne, Australia jknott@unimelb.edu.au Dr Kate Reid Director of Evaluation and Quality Department of Medical Education Melbourne Medical School kjreid@unimelb.edu.au UNIVERSITY OF MELBOURNE 24
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