The requirements
- In ST1, a minimum of 4 CbDs must be completed (a minimum of two for each 6 monthly Educational Supervisor Report (ESR)
- In ST2, a minimum of 4 CbDs must be completed (a minimum of two for each 6 monthly Educational Supervisor Report (ESR)
- In ST3 a minimum of 5 CATs must be completed (which can include CbDs)
It is expected that 2 or 3, but can be up to a maximum of 4 Capabilities and 2 Clinical Experience Groups be linked to each CbD by the registrar when preparing the case so that in-depth reflection and meaningful feedback is given for each. Separate assessments can be used if the assessment covers a larger number of either.
Ideally, by the end of training, the CbDs completed will cover the full range of the Capabilities providing triangulation of grades for each Capability across a range of different assessment methods. It is expected that all Capabilities will have been assessed using a formal assessment tool at least once in the three-year training period, but not all need to be done within a CbD.
While it is not mandatory to have a CbD for each Clinical Experience Group, a range of types of assessment and information will need to be provided in the Portfolio. This is to show exposure to, learning from, and competence in caring for, the range of Clinical Experience Groups across each training year. All Clinical Experience Groups should be covered by the range of assessments completed.
Before the assessment
The case should be one that has been managed independently by a GP registrar, (it is not appropriate to have received advice from another doctor for the consultation and then to be assessed on actions taken by that other doctor).
Before the assessment, the trainee should map the case to up to three Capability areas as these areas will be discussed during the assessment and it is these Capabilities the assessor will grade (an additional capability can be mapped later by the trainer if needed). The Capabilities should not necessarily be those that were covered well, as more useful learning can be achieved by choosing areas that were challenging.
The discussion and assessment
Protected time is needed for the assessment and the clinical entry should be shared with the supervisor before the assessment so they can familiarise themselves with the case. How long a CbD takes will depend on the complexity of the case, but the discussion (including assessor feedback) usually takes between 20-30 minutes.
Within primary care placements in ST1/2, assessors will be approved GP Clinical/Educational Supervisors who have met the GMC standards. CbDs can be carried out in secondary care by Clinical Supervisors (the named Clinical Supervisor should complete at least one CbD during each rotation), by doctors who are ST4 or above, or Specialist and Associate Specialist (SAS) doctors with equivalent experience who have met the GMC assessor requirements.
During the discussion, if the assessor feels any other Capabilities have been covered, these can be added to the assessment form. While the assessment is about what was done, for some more difficult capabilities it may be necessary to add hypothetical challenge to assess knowledge, for example regarding ethics or fitness to practice.
Recording the assessment on the Portfolio
The assessor will then complete the assessment form within the Portfolio. Each of the discussed Capability areas will be graded. The assessor will document their feedback on performance and their justification for their grades as well as their recommendations for further development.
Most assessors will have full access to the Portfolio but in non-primary care settings they may need a ticket code to enable the assessment form to be completed.
To use the ticketed feedback system, click on ‘generate a new ticket’ within the Portfolio, select the ‘CbD assessment form’ and complete the assessor’s details. An email will then be sent providing a login code for the assessor to use to complete the ticketed CbD assessment form.
Download the form
Example Case-based Discussion (CbD) questions
The following resource contains example questions against each Curriculum capability that can be asked as part of a Case-based Discussion. The questions should generate information related to each capability. These questions are suggestions and examples only - trainers and supervisors do not have to ask every question in each category.
Graded/Rating of GP Registrars
- When in primary care, GP registrars are rated against the expected standard required at the end of training.
- When in non-primary care, GP registrars are rated in comparison to other GP registrars at the same stage of training or comparable specialty registrars in the speciality/setting they are working in.
Example questions for supervisor/assessor to ask for each capability
- Was there any point in the consultation where you felt out of your depth? How did you define your limits? What did you then do?
- This case sounded difficult. How did you manage any external emotions or internal feelings or neutralise those to ensure they did not impact on the next patient you had to see? Our home/family life or physical/mental health can change our behaviour and performance at work. Can you tell me about how your non work life might have affected you, when you were caring for this patient? What strategies do you use to ensure that they do not impact your consultation?
- How did you feel after you looked after this patient? How did you care for yourself?
- Within this case, how did you balance your personal and professional demands, enabling both your work commitments to be met whist maintaining your own health and wellbeing?
- After the consultation, and on reflection, what were your thoughts on your performance (including your knowledge, skills and your approach to the patient e.g. g prescribing error or decision-making regarding phone or in person consultation. Could your performance have been improved? If so, how and what steps have you made any plans to tackle them? e.g. self-directed learning.
- Was there any significant learning highlighted by this consultation? (including complaints or performance issues raised). What were they? How did you proceed?
- Have you have received feedback in the interim between seeing the patient and the assessment today? How did this make you feel? How will this change your approach to patient care in the future?
- How did you value and support the team around you? Were there any needs of colleagues identified?
- Were there any legal or regulatory frameworks to consider with the care you provided?
- How did you promote patient safety?
- Did you have any concerns over what one of the previous health care professionals had done? What did you do about it?
- Did this case lead to a patient complaint? How did this make you feel? How did you manage/reflect on this?
- Were you aware of how to manage complaints within the GP practice or wider NHS? Are you aware of the need to declare complaints for your ARCP and future appraisal?
- Tell me about the ethical aspects of this case? What were they? How did you manage them?
- How did your own values, attitudes or ethics influence your behaviour in this case?
- How did you ensure you provided culturally sensitive healthcare?
- How did you ensure that you were non-judgemental when dealing with patients, carers and colleagues and respecting the rights and personal dignity of others?
- Within this case, how did you ensure fairness, respect and participation are valued both by the patient and/or their carer and other staff members? Did you need to take any additional steps to ensure the patient could make informed decisions?
- How have you applied the “Good Medical Practice” into your own clinical practice in this case?
- How did you ensure you didn’t discriminate (directly/indirectly) against the patient/staff member?
- How did you challenge attitudes that de-humanise or stereotype others and ensured you treated each person as an individual?
- What ethical principles did you use to inform your choice of treatment? How did you ensure the patient had an informed choice in terms of management?
- Was there a need to address confidentiality issues with the patient (e.g. in cases where the patient is a teenager)
- It is important to support and harness differences between people for the benefit of the organisation and patients alike. How did you ensure your care was inclusive?
- Did you need to address any professional duty of Candor within this case?
- What questions did you ask to establish what the patient expected to achieve when coming to the GP surgery? How did you separate these from what the patient thought about their health problems?
- Describe what you did or asked to balance the need to be focussed and keep to your consulting times with the need to allow patients to explain things in their way and feel heard.
- How did you adapt your language or communication to suit this patient to provide a personalised approach to care? e.g. a patient communicating in a second language, or with communication issues related to learning difficulties or cognitive impairment or if they were a child. Give examples of phrases you used.
- How did you adapt your language or communication to the mode of the consultation? [for example, telephone/face-to-face/text]
- Describe how you used the patient's health understanding to adapt your language and explanations.
- Describe how you adjusted your medically safe plans to suit the patient's agenda and desire for inclusion in decision making.
- How did you adjust your consultation to suit this patient given their background (educational and cultural) and beliefs (health and religious)?
- Describe how you used communication techniques or materials to improve patient understanding of the consultation. e.g. online resources
- How did you structure your consultation, for example did you apply a consultation model? If so, what did you use and how did this help your consultation? Did you deliberately flex from a model?
- How did you develop a professional relationship with the patient, to instil a long–term relationship, enhancing continuity of care?
- Tell me about the key findings in this case including duration of symptoms, their pattern or variability etc.
- How did you focus on getting this information in the limited time available?
- How did you ensure that you gathered enough information to make sure the patient was safe? How did you exclude red flags? (E.g. How did you carry out a suicidal risk assessment or exclude a brain tumour?)
- Describe how you kept a balance between keeping focussed and excluding worrying things? (for you and for the patient?)
- Had you gathered any further information about this case from others?
- What bits of information from the history, examination and investigations did you find helpful in this case? Why? How did you elicit these?
- What examinations and/or investigations did you do? Explain why you did all of these.
- You have described how you gathered your data, how was this adapted for this patient?
- How and why would you change the style of data gathering (consider the patient and their situation)
- How did you use pre-existing information (consultations, summary, letters, investigations) to help formulate your diagnosis/decision?
- How did you interpret your findings from your examinations and/or investigations? How did you act on any abnormal or unexpected findings/results?
- I see from the notes that there is no reference to examining… their "chest" for example. Why is it not there?
- Tell me about the abnormalities that you have found examining this person and that you found on investigation. Tell me about which bits of the examination were most useful. Can you explain why this was?
- What prior knowledge of the patient did you have which affected the outcome of your consultation(s)?
- Which examinations did you do in this case and why was each one carried out? To wWhat level of depth was the examination carried out? Was this appropriate for the clinical situation?
- When you examined this patient, how did you assess their x e.g. knee/ abdomen? What were you intending to gain from this examination? Do you think that your assessment (examination) allowed you to make a definitive assessment? what further assessment might you have done?
- You have explained that you found x when you examined the (part of body). Tell me what this implies to you. What further examination did you do? What was the order of your examination (and your reason for this)?
- You have described doing x examination and then going on to do y. Was it your preference or the patient's?
- How did you put the patient at ease and ensure no harm?
- What were the medico-legal aspects of your examination? Consider informed consent, mental capacity, best interests etc.)
- You have described doing an intimate examination. Tell me how you managed the patient's needs and care whilst also gaining the clinical information you needed.
- Did you offer/use a chaperone? Tell me more about your decision on this. Was it for your benefit or theirs? (protecting patients, protecting doctors)
- Were there any moments when the patient shared any verbal/non-verbal cues that they were not comfortable with the examination? How did you manage this?
- Patients do not always want to have the examinations that a doctor might want to carry out. How did you manage this difference?
- Describe how you managed any cultural and ethical issues that arose in this case.
- Were there any personal limitations by either yourself or the patient in undertaking the examination?
- You have suggested that the diagnosis might be x. How did you come to your final working diagnosis? Which features of the history and examination were instrumental in this?
- What was your differential diagnosis? What features made each one more or less likely?
- What is the natural history/pattern of this condition? How does that fit with your findings and your plans for the next steps?
- What are the most common causes locally of these symptoms? How does knowing this help you to care for this patient?
- Did you use any pattern recognition to identify diagnoses safely and reliably?
- Did you use any (or x specific) guidelines or frameworks (local or national) to help you with making the diagnosis? (Which ones?) How did this assist?
- When you got the result of the (names particular test) can you explain how it changed the diagnoses that you were considering?
- How did you approach defining your next steps?
- Did you use any decision aids (e.g. algorithms or risk calculators) to help guide a clinical decision? How did this help?
- How did it feel to independently make the decisions you made? How did you use others around you to support you with this case?
- Tell me about how you used time to help you when making decisions here? Were there some decisions that needed urgent (rapid and safe) decision making and others that could be deferred?
- How close to the limits of your competence were you in being able to make independent diagnoses/decisions in this case?
- What management options did you consider at the time? Tell me about some of the pros and cons of these options. Which did you choose? Did you consider any evidence in your choice?
- How did the patient's situation affect the management plan?
- How did you balance your management plan with the treatments requested or expectations of the patient, their carers or family?
- You have described a patient with several different problems. How did you choose which of these to prioritise? How did this affect your final management plan?
- How did you manage any symptoms that presented early or in an undifferentiated way?
- (If care was of an emergency nature) Tell me about the emergency that took place. How did you respond and what follow up did you arrange for the patient and their family? Did you liaise with any other services?
- You have described various medications that you have used. What made you prescribe x? How did you choose that? What does the evidence say about it? Do you know the costs? Why not y which is cheaper and as effective? What other drugs is the patient on? did you check for interactions?
- How did you ensure prescribing safety? What non-drug interventions did you suggest?
- Did you apply any local and national guidelines including drug and non-drug therapies when considering management options? Were there any considerations for prescribing legal frameworks?
- Was de-prescribing/reducing medication an option within the consultation? Did you involve or make a referral to anyone else? What was the added value of involving this other team or person? (Considerations here might include use of resources, (including time) but also patient safety, and/or recognition of limits to personal recognition of medical conditions) What did you put in the referral letter?
- Did you arrange any follow up/review to monitor the patients progress? Why do you want to see them again? (If not, in what ways could this patient have been followed up?)
- Recognising the balance between enhancing patient autonomy and continuity of care, how did you decide if you or another doctor/professional should review the patient?
- What were the advantages of using the way you have suggested? (What form of follow up did the patient suggest/ want, how did you incorporate this and keep the follow up plan safe?)
- What safety-net advice did you give? How did you ensure patient safety? Did you use any tools to help with your safety-netting e.g. online resources?
- What made this case medically complex? How did you resolve that?
- What were the areas of uncertainty? What strategies did you use to manage that uncertainty? (e.g. using time)
- There was a lot to coordinate in this consultation which added to the complexity of the case – from the acute to the chronic comorbidities to the existing medication prescribed and allergies. What strategies did you use to coordinate it all? How did you prioritise the management options?
- The advantages and disadvantages of different options were complex here. How did you explain these to the patient? How do you know that this worked for them?
- In the course of your work with this family (carer or patient network) can you describe any areas where your "medical" training differed from the "patient" perceptions of what should be done. How did you manage these differences? What did you do to address this area?
- Was there a difference of agendas? How did you tackle this? How did you manage to merge the agendas? How did you ensure a person-centred approach to consider all the issues that matter to the patient?
- How did you explain 'risk' to the patient? Did you involve them in the risk management? To what extent and how? How did that risk affect your management plan? How did you capture this discussion in the notes?
- Where multiple problems were presented in an Online/digital/electronic consultation were you able to recognise these and prioritise to manage these appropriately?
- Were there any limitations with using protocols within the decision making and management of complex multi-morbidity patient?
- How did you forge a partnership with the patient to help optimise the care? Were you able to facilitate continuity of care either personally or across teams?
- Did you involve anyone else in this case? Who? Why? How did they help? What skills did they bring that you don't have? (consider the wider workforce including Allied Health Professionals.)
- Did you involve any other organisations/agencies in this case? For what purpose?
- How do the roles, skills and diversity of other team members already involved (or soon to be) enhance the care of the patient?
- Some of your colleagues will have been working with this patient before your involvement. How did this affect your role in the wider team caring for this patient?
- Can you describe what this case tells you about how our team works, and the members interact?
- The working environment relies on a team-based approach with leadership within the team. What team interactions within this case enhanced patient care provided and the environment?
- How did you ensure you had effective communication with others involved in this case? (between professionals and teams in addition to carers)
- If many people/organisations are already involved in the case, what do you see as your role? Do so many professionals need to be involved? Did you do anything to ensure coordination of the overall care to promote more effective team working?
- Has appropriate follow-up with correct team (primary/non-primary care) been arranged if required? (and continuity of care considered if appropriate) What information did you provide with your referral? How did you make sure that this was as useful as possible to the team you referred to?
- Was there any potential problems or conflict that arises at the interface between different healthcare professionals, services and organisations with this case? How could this be mitigated? Reflecting on this case, could there be any improvement in the team working/interaction between people involved in the care?
- How did you use clinical guidelines to inform your decision making?
- How did you identify clinical guidelines for this case e.g. website, local resources Is this your normal practice?
- Infection risk and transmission of infection is an important part of quality healthcare. Was this considered in this case? Can you describe any steps taken to reduce any risks in this case?
- Within this case did you choose to use your professional judgement and challenge the protocol/activity and not follow a guideline?
- What learning needs did you identify and how are you going to take this forward?
- If you identified personal learning needs, have you added these to your PDP? How did you decide this? What will you do to ensure these learning needs are met?
- Based on learning from this case/activity are there any behaviours that you plan to change?
- Having had time to reflect on this case/activity have you identified any improvements that could be made regarding your performance?
- Have you used external standards to evaluate your performance in this case/activity? How did you identify these standards?
- Did you share any learning from this experience with anyone? Who did you share this with and why did you decide to do this?
- Was there a need to provide feedback to a colleague regarding this case/activity? How did you go about doing this?
- Did you identify any need for team-based quality improvement activity from your reflections? How did you proceed with this?
- Was there any opportunity to teach others as result of this case/activity e.g teaching practice team, GP registrars, medical students? How did you go about doing this?
- How did you use the computer in the consultation (including previous consultations results, letters and on-line resources.)?
- Describe how you balanced your need to record the consultation on the computer with the need to maintaining rapport with the patient.
- Is the computer record entry (or notes if paper system) satisfactory and contemporaneous? Have any important positive or negative findings been left out? Have they captured the patient's narrative? Are they concise yet appropriately thorough and understandable?
- Did you use appropriate SNOMED CT, Read, ICD-10 coding for diagnosis, examination and treatment in line with local expectations or guidance?
- How did you use the practice computer system to communicate with others? (e.g. electronic referrals, messaging, email)
- What steps did you take to keep this consultation to time, whilst ensuring appropriate record keeping. Was the consultation entry added in a timely manner?
- How effective and helpful is the future management plan you have written for your colleagues?
- Did you use any online information or resources to help? If so, what, why and how did this help?
- Describe the ways in which delegation and good time management improved your care of this patient. e.g. by booking patient with the in-house physiotherapist or clinical pharmacist
- Do you have any suggestions about how your management of this case would have been better if the guidance or organisation in the GP practice was different? What suggestions for change can you make based on this experience?
- How did the overall workload of the practice affect how you managed this patient and your day?
- The days can feel under pressure at times, how have you responded to this service pressure personally, and within the organisation? Have you taken any proactive and supportive steps?
- How do you ensure that you manage referrals/results/communication about patients in a timely way? Describe what strategies you have put in place to manage this?
- How did you coordinate patient care, bridging the different NHS systems, working as a generalist? Were there any external influences e.g., health inequalities, population health and environmental factors?
- How have you demonstrated effective time management, hand-over skills, prioritisation, delegation and leadership skills to ensure that the patient and colleagues are not unreasonably inconvenienced or come to harm?
- Tell me about the overarching structure of the UK healthcare system and how your consultation fits into this and the range of services available.
- The NHS is a rapidly evolving system which requires changes in the organisation. How can you positively respond to these changes?
- How do the actions you take affect the primary care organisation? [e.g. gatekeeper to services, appropriate follow up – following those that require it, but not unnecessarily blocking appointments for others, enabling access to all]
- Was there a time where you felt it was important for either yourself or colleagues to have freedom to speak up, including duty of candour/whistleblowing? What steps did you take?
- What was the patient's agenda (ideas, concerns and expectations)? How did you elicit their agenda? Why did they present now? What feelings did you explore? How did you work collaboratively to enhance patient care?
- Did you identify any ongoing problems which might have affected this particular presenting complaint?
- What effect did the symptoms have on the patient's work, family or carers and other parts of their life? (i.e. consider the difference between illness and disease)
- How did the symptoms affect him/herthe patient psychosocially? What phrases did you use to elicit these?
- What did you discover about the patient's culture and background? How did you use this to help advise the patient and their family about the next steps in their care?
- Did you explore the impact it had on other family members, carers or close friends? What did you find? How did you support them?
- What other teams or organisations have become involved in this person's care? How does this involvement link to the patient's needs?
- How have you involved the patient (and their carers or family?) in planning their own care?
- How did the patient feel about your choice of treatment? Did this influence your final decision?
- Did you use any health promotion strategies? How did you encourage the patient to e.g. stop smoking/lose weight/go back to work/other rehabilitation and recovery? Can you describe how this fitted into the rest of the discussions you had with this patient?
- How did you tailor your health promotion approach to this patient? Were there any differences in health beliefs between you and the patient (or their carers / family)? How did you address this difference whilst remaining compassionate, non- judgemental and continuing a productive relationship?
- How did the patients value and previous experience of health and illness affect their use of the healthcare system?
- Safeguarding is everyone's responsibility. Were there any safeguarding concerns? How did you elicit within the assessment if there was any evidence of abuse, neglect or other forms of harm? What action did you take including any referrals?
- This patient appeared vulnerable, how did you elicit risks of abuse, neglect or other forms of harm? What phrases did you use?
- What do you see is your role as a GP (or non-primary care speciality)? E.g. patient advocate, family practitioner, generalist and "gate keeper". How has this influenced the care provided in this case?
- Can you tell me about the cost of investigation, treatment and/or referral/care here? How did you consider these when making your decisions?
- What local health resources are available that you encouraged the patient to access? (e.g. particular clinics that the hospital offers or weight loss/exercise classes)
- How have you adjusted the care to fit the resources we have here?
- Are there any limitations of local healthcare resources that impact on this patient's care?
- You have described the care you and this GP practice/non-primary care setting have given this patient; how would it be different in a neighbouring area which has a different population (and if in hospital, potentially different role either more or less specialist than current setting)?
- Tell me about the implications of your treatment/investigations/referral on the individual patient and on society? Tell me more about these conflicting pressures.
- How did you balance the needs of this patient against the needs of the whole local patient population and more widely (e.g. when making referrals)?
- What characteristics of our local community impact on this patient's care (epidemiological/social/economic/ethnic)?
- Were you able to take any proactive steps to tackle health inequalities and improve local resource equity?
- You have prescribed a range of different medications. Tell me more about them concentrating on their costs and the evidence base for their use in this setting? Did you consider the environmental, financial and social impact of this prescribing (and any existing polypharmacy)? E.g. anti-cholinergic burden and CFC free inhalers, antimicrobial stewardship.
- Did you follow any protocols to guide your management? Did you feel there were times when it was appropriate to use them flexibly, incorporating the patient's preference or potentially deliberately noting the guideline but being able to provide reasoning for not following it on this occasion? Were you aware of the cost to the environment of this choice and did this influence your choice?
- Did you consider environmental as well as evidence-based research in advising lifestyle changes? E.g. plant-based diet, wider lifestyle medicine, changing epidemiology caused by planetary health
- Within this episode of care, were you able to demonstrate a small change towards sustainability? Does making a small change matter?
- Did this case make you think of any greater social/health care changes/provision we need to consider for our local population? What would we need to do to make this happen?
These questions were originally developed by Dr. Ramesh Mehay, Programme Director Bradford VTS (updated April 2010) for the Bradford VTS website (www.bradfordvts.co.uk). They have been further adapted and updated with permission by the RCGP WPBA Core Group (latest update January 2025).