Definition and purpose

Case-based discussion (CBD) is an alternative term for chart stimulated recall, an assessment technique originally developed by the American Board of Emergency Medicine. It is designed to allow the assessor to probe the candidate’s clinical reasoning, decision making and application of medical knowledge in direct relation to patient care in real clinical situations. It is a validated and reliable tool for assessing the performance of candidates and identifying those in difficulty. The CBD tool has greater validity and reliability when aligned with specific constructs in discussing the patient (i.e. elements of history, examination, investigations, problem solving, management, referral and discharge planning).

Case-based discussion is designed to:

• improve clinical decision making, clinical knowledge and patient management
• improve clinical record keeping
• provide candidates with an opportunity to reflect on and discuss their approach to the patient and identify strategies to improve their practice
• enable assessors to share their professional knowledge and experience in a collegial way
• enable candidates to access experts in clinical decision making and understand the rationale for preferred management choices
• guide learning through structured feedback
• identify areas for development as part of the continuum of learning
• assist candidates in identifying strategies to improve their practice.

For more information, see the background paper, Norcini J, Burch V. Workplace-based assessment as an assessment tool: AMEE Guide No. 31. Medical Teacher. 2007; 29: 860-862 (PDF 1.9 MB).

What a CBD is

A case-based discussion (CBD) uses data recorded by the candidate on a real patient. It involves a comprehensive review of a patient’s clinical situation based on a discussion between the candidate and their trained assessor. The candidate is given feedback from the assessor across a range of areas relating to clinical record keeping, clinical assessment, management and clinical reasoning.

A CBD takes place face-to-face (or by other connection if the assessor is distant) over approximately 20–30 minutes in total.

This is usually split 50/50 for candidate reflection and discussion and assessor discussion and feedback, which should be an interaction between colleagues focusing on clinical reasoning, decision making and application of knowledge in direct relation to patient care.

What a CBD is not

A CBD is not a long case, a viva, a bedside presentation, a knowledge test or a mini-CEX.

The CBD process

General considerations

The same patient should not be used for two different assessments (e.g. mini-CEX and CBD).

• A CBD should be conducted away from the patient and respect patient confidentiality.
• A CBD generally takes place face-to-face, but could potentially be conducted by teleconference or other connection if the assessor is distant (research needed).
• A CBD should take about 20 minutes, plus 10 minutes of specific and constructive feedback.
• If the candidate has not had recent contact with patients in the discipline to be assessed, the assessor may select the patient and allow the candidate sufficient time to see the patient and write up case notes/records.
• An appropriate assessor should be selected.

The ideal assessor is:

• willing to devote undivided time
• a content expert
• able to articulate their own clinical reasoning (based on experience, evidence and best practice)
• skilled in adult learning principles and assessment
• a good communicator who is able to give effective constructive feedback
• aware of, and attuned to, the level of performance expected

Before conducting a summative CBD, the assessor should have completed this online program or similar so that they are fully prepared. WBA providers are expected to provide training in CBD which includes additional calibration exercises. The assessor must be familiar with the level of performance expected for the level of training of the candidate.

The sequence of activities

1. The candidate or the WBA program team will identify 2-4 cases:
   • The records should be those of patients they have seen and documented.
   • Patients should be those recently cared for by the candidate and may include longitudinal care patients.
   • Each case record should have sufficient breadth, depth and complexity to enable focus on clinical decision making.
2. The assessor prepares by exploring the general features of the case record (relevant areas:
3. The assessor considers the areas that will provide the most valuable discussion.
4. The assessor chooses a number of areas for further discussion based on the marking domains for evaluation.
5. The candidate gives a short summary of less than two minutes (not a case presentation).
6. The assessor asks questions, covering each domain and using guidelines from the assessment form.
7. The assessor and candidate engage in a feedback process, wherein:
   • The candidate is invited to reflect on their performance
   • The assessor gives their feedback, focusing on three or four key issues
   • The assessor encourages the candidate in self-assessment and reflection during feedback
   • The assessor invites the candidate to discuss how issues can be addressed
   • The assessor summarises and checks the candidate’s understanding
8. The assessor completes a CBD form and both the assessor, and the candidate sign it.
9. The assessor and the candidate together consider an action plan.

See also: Giving effective feedback.