Clinical case analysis
Clinical case analysis (CCA) is an assessment format comprising review of clinical notes or case reports and oral questioning and discussion. CCA assessment tools include random case analysis (RCA) and case-based discussion (CBD).
Both RCA and CBD are powerful tools for identifying and addressing learning and supervision needs. They enable deep exploration of the application of a registrar’s clinical reasoning, management, and decision-making skills using real clinical cases that the registrar has managed. These assessment modalities evaluate what the registrar did during the clinical encounter. Feedback is immediate, which encourages learning and reflection.
In both assessments, the assessor proceeds with a structured discussion of a case, using targeted questions to elicit evidence of the registrar’s competency in specified curriculum areas, and to explore issues relating to the case, which may identify any clinical knowledge gaps.
The assessor also uses targeted questions to explore the selected case from four perspectives: the doctor, the patient, the problem and the system – asking how a case changes when any of these elements changes. By proposing hypothetical scenarios through ‘what if’ questions, unidentified learning needs may be uncovered.
It is recommended the first two CCA be undertaken prior to the supervisor mid-term appraisal and the remaining two completed in the second half of the term prior to the supervisor end- term appraisal. This will allow the registrar sufficient time to reflect on their performance and respond to feedback.
The registrar’s competency is rated in the following areas:
- ability to gather and interpret information
- diagnosis, decision making and clinical reasoning
- ability to develop an appropriate management plan
- ability to manage uncertainty
- understanding and application of population health initiatives
- general practice systems and regulatory requirements
- ability to identify and manage the seriously ill patient.
In a CBD, the registrar presents a recent clinical case to the assessor, providing clinical notes, relevant investigations or results, and details of referrals or preventive healthcare plans. The case must be one that the registrar has been primarily responsible for and that is of a medium level of complexity; for example, where clinical reasoning is complicated by uncertainty or where decision making requires multiple issues to be considered.
An assessor may request a case be presented that focuses on a specific area, particularly one in which the registrar has been identified as needing further support. As the assessor works through the case with the registrar, they may pose questions from varying perspectives to explore clinical reasoning further. The registrar may also highlight aspects of the chosen case for discussion, depending on their self-identified learning needs.
A CBD may be completed as part of an ECTV or in-practice teaching session by the supervisor, or in any other context that supports or enables the assessment, such as by video.
In some instances, simulated cases may be used for CBD. This will allow for discussion around clinical presentations that may be uncommon in a general practice to be discussed, such as domestic violence or drug and alcohol misuse. Simulated cases may also be used for assessing cultural competency with respect to Aboriginal and Torres Strait Islander peoples.
Random case analysis
For an RCA, the assessor randomly selects a case from the registrar’s consultation records to discuss. This method may uncover gaps in knowledge and skills that a registrar may not have identified or been actively avoiding when self-selecting cases for CBD.
An RCA is generally conducted through the lens of the five domains of general practice of the curriculum and syllabus, and explores the development of clinical reasoning by considering changes to four contextual influences: the doctor, the patient, the problem and the system. By proposing hypothetical scenarios through ‘what if’ questions, unidentified learning needs may be uncovered.