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 eg 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)
- 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?
- Comfortable cases (didn’t I do well).
- Problem cases (presenter looking for help).
Dissecting the case
(see Priority Objectives occ. paper 30)
- Problem definition (patients knowledge, anxieties & expectations; possibilities; probabilities; selective history taking, examination & investigation; coping with uncertainty).
- Management (choosing a plan with patients help; use of time; prescribing; use of other members of team; referral; follow up).
- 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).
Adapted from “Random case analysis” Jim Cox 1978