Random Case Analysis for the Trainer

Aims
Broadly speaking these are to encourage self-audit & self-criticism rather than to criticise. To help
the trainee think about what he is doing & its consequences. To think of what he is not doing &
perhaps should be.

The difficulty with RCA is that any number of avenues can be followed up. The trainer has to be on
his toes to spot problem areas of which the trainee may be unaware. The trainer may discuss "the
case" or branch out into more general areas e.g. practice organisation, management of chronic
disease, protocols, ethics & confidentiality, records.

Where one goes depends on the way the trainee has dealt with the case, whether the trainee is
early/late in the attachment, first or final six months in practice, and depends on previous
knowledge of trainee's strengths & weaknesses.

Approaches to using the method of RCA

Type of case (3 groups)
1. Trivial illness (presenter feels little to discuss). Why has patient come. (What is the real
problem)? Should patient be able to manage it herself? How was it managed? What
opportunities were available for patient education?
2. Comfortable cases (didn't I do well).
3. Problem cases (presenter looking for help).

Dissecting the case

(see Priority Objectives occ. paper 30)
1. Problem definition (patients knowledge, anxieties & expectations; possibilities; probabilities;
selective history taking, examination & investigation; coping with uncertainty).
2. Management (choosing a plan with patients help; use of time; prescribing; use of other
members of team; referral; follow up).
3. Prevention (case finding, health education).

The skills of trainer (did these assist the learning?)

 giving information (explanation & knowledge)
 questioning (open & closed to clarify & assesss)
 listening & using silence
 reinforcing (positive encouragement and negative discouragement)
 reacting (challenging, giving feedback & moving discussion on)
 summarising (main ideas so far & links with other areas).

SOURCE
"Random case analysis" Jim Cox 1978

Dr Ramesh Mehay, Programme Director (Bradford), www.bradfordvts.co.uk

 Random Case Analysis for the Trainer

Using Random Case Analysis to assess performance: probing questions

1. Management
 I see that you prescribed drug for this patient: what were your thoughts regarding
this choice of medication?
 Were there other drugs which you considered and ruled out?
 What factors influenced this decision?

2. Diagnostic
 What specific features led you to the diagnosis of ...?
 Were there any other conditions you ruled out? How?

3. Investigative
 What approach did you choose for investigation?
 Were there other investigations which you considered and deferred or ruled out?
 What were your thoughts regarding these choices?

4. Patient Factors
 Was there anything unique about this patient which influenced your decision-
making?

5. Practice
 Is there anything unique to the practice which influenced the way you managed this
patient?

6. Follow-up
 What influenced your choice of follow-up time?

SOURCE :
Jennett: Chart stimulated recall. Educ Gen Pract, 1995, 6, 30-34

Dr Ramesh Mehay, Programme Director (Bradford), www.bradfordvts.co.uk

 Random Case Analysis for the Trainer

Development of an assessment instrument for teaching in random case analysis

Summary
This article describes the development by a trainer group of an instrument for assessing teaching
skills. It comments on the benefits of developing and using the instrument and some of the problems
encountered. Finally, it suggests ways in which the instrument can be further modified and
improved.

Aims
Most of our training group were either new or intending trainers. The group realised that further
development of training skills amongst trainers was an ideal topic to be addressed. All trainers in the
group recognised the benefits of using videos to improve trainee consultations and it was felt that
there was scope for using video taped teaching sessions to develop training skills.

Random case analysis (RCA)

RCA was felt to be the teaching method most suitable for video taping. Cases presented usually took
a shorter time than a topic-based seminar. RCA was performed routinely by all trainers in the group,
but it was felt that our skills could be improved. It was also felt that the unpredictability of problems
raised by RCA was advantageous as this feature tests the versatility of the trainer.

Teaching skills
The group initially reviewed a piece of work entitled "Principles and Conditions for Adult Learning"(l).
This article discussed characteristics of learning and conditions which facilitated learning. Secondly
the group spent time discussing the necessary components of a good tutorial. Thirdly, the group
explored their experiences of good and bad teaching trying to define why a particular teaching
session was either effective or ineffective. Ultimately four key areas were identified.
These were:
A. Process
B. Ambience
C. Teaching skills
D. Feedback

Structure and development of the instrument

Each trainer volunteered to look at one of the key areas identified above. The group had recognised
that there were similarities between doctor/patient consultations and trainer/trainee teaching
sessions. Members of the group had some experience in using the consultation assessment
instrument developed by Dr. James Cox (2) and it was felt that this format could be adapted to
assess RCA teaching sessions. The consultation assessment instrument uses different characteristics
defined by good and bad behaviour separated by six-point bipolar scales. Using similar principles
each trainer developed a number of stems with good and bad characteristics within their key area.
These were fed back to and modified by the group. This led to a production of an instrument that
was initially workable but had an excessive number of stems. Videos of RCA sessions between the
respective trainers and trainees were examined using the instrument and discussed by the group.
This allowed for checking the relevance to teaching of each stem. Wording of stems was gradually
modified mainly to clarify interpretation of a characteristic and thereby improving the instruments
reliability. A number of stems were culled either because there was overlap with other stems or the
characteristic was not thought to be relevant.

Dr Ramesh Mehay, Programme Director (Bradford), www.bradfordvts.co.uk

 Random Case Analysis for the Trainer

The trainer group invited an educationalist and the local course organiser to meetings and their
input was particularly helpful.

Once the instrument was finalised each trainer provided further video tapes allowing formative
assessment of their own teaching skills by the rest of the group.

Positive benefits
The group recognised that development of the instrument had a number of benefits.
 The project gave the group a clear direction throughout the development period.
 Discussions had helped our understanding of the necessary skills involved in teaching and
assessment.
 All trainers felt that their teaching skills had improved particularly in feedback and
summarising (Dl and D2).
The group recognised that the instrument would be of continued benefit to the development of
training skills through formative trainer assessment.

Weaknesses
Use of the instrument showed some variability in the responses of the assessors (ie. other members
of the group) which led to concerns about the reliability of the instrument. Certain stems cropped up
frequently for causing this problem and the usual difficulty we had was in the exact interpretation of
the stem (eg A2, Cl and C6). The stems involved were all thought to be extremely relevant to
teaching and we were therefore reluctant to drop them from the instrument. Only rarely would
differences in opinion extend across more than l or 2 points on each stem This variation could limit
the use of such an instrument to formative assessment only.
Concern was also expressed that this method may not be sensitive enough to identify some of the
more subtle non-verbal communication between a trainer and trainee.

The future
The group intends to use the instrument on a regular basis to maintain and further develop teaching
skills. We hope that other trainer groups will try and use the instrument and feedback to us their
experiences and suggestions for modifications.
The Group has not to-date sought a collective trainee view on the instrument outside the
involvement of our personal trainees. Clearly the effectiveness of teaching is an important area and
with increased use trainees views should be sought.

References
1. Learning. J J Guilbert. Educational Handbook for Health Personnel. 6th Edition. World Health
Organisation 1992 3.23-3.27.
2. An Instrument for Assessment of Video Tapes of Genera1 Practitioners Performance. J. Cox
and H. Mulholland. BMJ 17th April, 1993 Volume 306 1043-1046.

Dr Ramesh Mehay, Programme Director (Bradford), www.bradfordvts.co.uk

 Random Case Analysis for the Trainer

Assessment Of Trainer's Performance- Random Case Analysis

A. PROCESS
1. Case selection is random Case selection is influenced by
the trainer or trainee.
2. The Trainer/trainee dominates The discussion are balanced
discussions.
3. Lack of respect for trainee's Shows respect for trainee's
knowledge, values, feelings. knowledge. values, feelings.

B. AMBIENCE
1. No interruptions Frequent interruptions.

2. Setting is uncomfortable and Setting is comfortable and

tense. relaxed.
3. Poor use of eye contact Uses eye contact appropriately.

C. EVALUATION OF TEACHING SKILLS

1. Overuse of closed or rhetorical Uses open/reflective questions.
questions. Tends to be didactic. Encourages learner to discover
own solution.
2. Appears rushed, pressure to Unhurried, appropriate use of
complete task. silence, prepared to listen.
3. Responds to verbal/non verbal Ignores cues, sticks rigidly to
cues. Flexible agenda. agenda.
4. The trainer uses a The trainer colludes in avoiding
challenging/probing approach. difficult issues.
5. Tends to be Attempts to build confidence.
destructive/supportive.
6. The trainer shows appropriate The trainer rails to show
recognition of trainee's needs. appropriate recognition of the
trainee’s needs.
7. Trainer does not recognise Trainer recognises opportunity for
teaching opportunity. teaching.

D. FEEDBACK

1 The teacher does not provide The teacher provides constructive

constructive feedback. feedback.
2. No summary. The teacher is able to summarise.

3. Areas or strengths and The areas of strengths and

weaknesses not shared. weaknesses have been successfully
shared.
4. Opportunities for further Opportunities for further study not
development are identified. identified.

Dr Ramesh Mehay, Programme Director (Bradford), www.bradfordvts.co.uk