A Case-based Discussion (CBD) aims to assess a pharmacist’s clinical decision-making skills and application of pharmaceutical knowledge for patients they have cared for. Essentially it involves a retrospective discussion of care they have provided with an experienced colleague questioning them about why they acted as they did and exploring the pharmacist’s knowledge of pharmacology, pharmacokinetics and evidence-based practice (including application of guidelines). Some cases may also allow a discussion of relevant legal and ethical issues. Case-based Discussions usually take around 20 minutes (with additional time for feedback).
Pharmacists can use any patient that they have contributed to the care of. Although a minimum number of contributions to care isn’t stipulated, the higher the number the greater the scope for discussion. Contributions to care need to extend beyond medicines reconciliation and / or counselling, since these activities can be observed and assessed during ACATs and Mini-CEXs. There is also no minimum period of time that the pharmacist needs to have cared for the patient – a complex patient that they have managed for just one day (e.g. on an admissions ward, on-call or covering a ward during a colleague’s absence) can be just a suitable as one that was followed up during a two week-long hospital admission.
Alternative scenarios for CBDs involve complex medicines information enquiries (i.e. level 2 or 3). If these are used, the pharmacist will discuss why they obtained particular background information from the enquirer, how they chose their reference sources / performed a literature search, synthesis of the information gathered and how they arrived at a final answer. The assessment can also involve reviewing documentation of the enquiry and any written communication sent to the enquirer.
Undertaking case-based discussions (CBDs) in the latter half of a rotation allows the pharmacist time to have developed their clinical knowledge in specific areas and therefore assesses (some of) what they have learnt during a rotation. However, conducting CBDs in the early part of a rotation allows them to be used as a diagnostic assessment to help identify priority areas of clinical knowledge to work on during the rotation.
Identifying TWO potential patients will allow the assessor to select the one they feel has the greater potential for discussion. However, the pharmacist may have identified a particularly challenging case that they would like to discuss with a more experienced colleague. Unlike the observational SLEs, pharmacists need to prepare for a CBD beforehand by providing the assessor with summary case details (including a copy of the prescription chart) and consolidating their clinical knowledge (as the depth of knowledge will be assessed).
The pharmacist should lead the discussion by being forthcoming with details such as:
Key case details – e.g. reason for admission, co-morbidities, medication history, other problems identified during the admission (e.g. electrolyte disturbances, adverse drug reactions). A day-by-day breakdown of the admission is not needed for every case; a summary of the key events (e.g. confirmation of a diagnosis) is often sufficient
High priority problems that they identified whilst caring for the patient and their input in resolving them, e.g. changes to the treatment regime advised, advice on therapeutic drug monitoring. Clinical decisions need to be justified clearly to the assessor
How the patient was monitored and the outcomes of such monitoring (e.g. results of a patient’s theophylline level and whether the patient’s therapy needed adjusting)
Relevant transfer of care issues that were addressed (if the patient has been discharged) or will need addressing before discharge
The assessor will then ask more in-depth questions to determine the level of the pharmacist’s therapeutic knowledge (pharmacology, pharmacokinetics, application of evidence-based medicine), decision-making skills and awareness of relevant legal and ethical frameworks. Depending on the level of detail provided about the case, the assessor may also need to ask for additional case details (e.g. allergies, lab test results).
There are no minimum numbers of each type of SLE that needs to be completed. Undertaking at least one case-based discussion (CBD) during each rotation will provide pharmacists with a decent variety of cases for their portfolio. As with other SLEs, if a pharmacist has performed poorly during a CBD, arranging an additional one to allow them an opportunity to address feedback would be beneficial.