Clinical case review for general practitioners

After graduation, cases keep coming, but the preceptor disappears. The general practitioner treats everything, decides alone most of the time and rarely finds out how the case they referred ended. A systematic review that linked time in practice and quality of care found that 32 of the 62 evaluations analyzed (52%) reported lower performance with more years in practice across all measured outcomes (Choudhry et al., 2005).

NEXO is a daily medical diagnosis game: one clinical case a day, six progressive clues, and ICD-10 proximity feedback across five levels.

This text shows how the general practitioner can review clinical cases in a planned way: what research on continuing education says, how peer groups work, how to use data from their own practice, where SUS teleconsultation fits in and how to build a routine that fits into the week.

Key points

• Accumulated experience without review can age: years in practice do not guarantee up-to-date care.
• Continuing education improves physician performance, and the most interactive formats, repeated and linked to practice problems, tend to work better.
• Small groups of physicians who discuss cases from their own practice are a studied and well-accepted format in family medicine.
• Feedback with data from one's own practice, compared to a clear goal, improves conduct on average.
• In SUS, teleconsultation allows discussing clinical doubts with another professional.

Summary

• Why review cases after graduation
• What research says about continuing education
• Peer case review
• Feedback with data from one's own practice
• Teleconsultation: discussing the case with another professional
• How to build a case review routine
• Frequently asked questions
• Checklist for reviewing cases in practice

Why review cases after graduation

In medical school and residency, case review comes ready-made: someone chooses the case, checks the reasoning and corrects the error. In the general practitioner's practice, this feedback must be built.

Experience and quality do not always go together

The review by Choudhry and colleagues gathered studies that linked years in practice or physician age to knowledge and quality of care (Choudhry et al., 2005). Besides the 32 evaluations with decline in all outcomes, 13 (21%) showed decline in part of the outcomes and 13 (21%) showed no association (Choudhry et al., 2005). The authors conclude that physicians with more time in practice may be at risk of providing lower-quality care and may need improvement interventions (Choudhry et al., 2005).

The editorial reading is simple: experience helps recognize patterns, but the knowledge behind them changes. Reviewing cases is a way to check whether the pattern you recognize is still what current evidence supports.

Your own impression is an imperfect guide

Knowing where you are weak seems easy, but self-assessment often gets it wrong. The text on how to track your study progress summarizes studies on physicians' self-assessment and shows why it is worth looking at data, and not just at the feeling. In the study by Armson and colleagues with family physicians, knowledge gain was not related to the needs the physicians themselves had declared (Armson et al., 2020).

What changes compared to the student

The student reviews cases to learn the disease. The general practitioner reviews cases to keep reasoning sharp across a wide range of complaints, update conduct and find their own blind spots. The text on case-based learning explains teaching formats with cases; here the focus is how to fit these formats into the life of someone who already sees patients.

What research says about continuing education

Continuing medical education is the general name for everything a physician does to stay up to date after training: courses, congresses, reading, discussion groups and review of their own practice.

Courses and events help, with a modest effect

A Cochrane review gathered 215 studies with more than 28,167 health professionals on continuing education meetings and workshops (Forsetlund et al., 2021). Compared with no intervention, these activities probably slightly improve professional practice and, to a lesser degree, patient outcomes (Forsetlund et al., 2021). The authors were uncertain about the advantage of the interactive format over the lecture, because the certainty of the evidence in this comparison was very low (Forsetlund et al., 2021).

The format matters

A synthesis of 8 systematic reviews published since 2003 concluded that continuing medical education improves physician performance and patient health outcomes, with a more consistent effect on performance (Cervero and Gaines, 2015). The reviews support more interactive activities, with more than one method, multiple exposures, longer duration and a focus on outcomes that physicians themselves consider important (Cervero and Gaines, 2015).

Testing yourself also works for those who have already graduated

The testing effect, which the text on reviewing by playing explains for students, also appeared in family physicians. In a study with 112 physicians from a practice-based learning program, those who took a pre-test before the module got more of the repeated questions right on the final test than those who read a review article, with 65.9% versus 58.7% (Armson et al., 2020). When the module was studied individually, the pre-test group reported having made 80.0% of the practice changes they committed to, versus 45.0% in the other group (Armson et al., 2020).

Summary of findings

Format	What the studies show
Meetings and workshops	Probable small improvement in practice (Forsetlund et al., 2021)
Interactive, repeated and long activities	Associated with more positive results (Cervero and Gaines, 2015)
Pre-test with feedback	More correct answers on repeated questions (Armson et al., 2020)
Small practice-based groups	Feasible and well-accepted format, with evidence still being built (Zaher and Ratnapalan, 2012)
Audit and feedback	Average improvement in the desired conduct (Ivers et al., 2026)

Table source: summaries of the studies cited in each row.

Peer case review

Discussing cases with colleagues is the format closest to the old discussion with the preceptor, with one difference: everyone there sees patients and everyone has doubts.

Small practice-based groups

A systematic review on practice-based small group learning programs, with family physicians, included 13 articles (Zaher and Ratnapalan, 2012). The authors describe two formats: a self-directed one, with discussion of difficult or challenging cases brought by the participants, and another focused on specific practice problems, in which patient cases serve as a starting point for a topic (Zaher and Ratnapalan, 2012). Both were well accepted, and the review concludes that the format is promising, but calls for studies on practice change (Zaher and Ratnapalan, 2012).

Doubt as a starting point

In the experience called Practice Inquiry, primary care physicians outside academic centers began meeting at their own services to present dilemma cases, exchange experience and review evidence (Sommers et al., 2007). In 2006, 98 professionals at 11 services held regular meetings, and, among the 118 presentations in the seven oldest groups, the most common dilemmas were about the physician-patient relationship and treatment (Sommers et al., 2007). The authors noted that two tasks received less attention: integrating evidence with experience and following up the outcome of the cases (Sommers et al., 2007).

A script for the case meeting

Practical suggestion from the Editorial for a small group, of three to six colleagues, in a one-hour meeting:

1. Choosing the case. The presenter brings a case that generated doubt, surprise or discomfort, without identifying the patient.
2. Short presentation. Data in the order in which they arrived, without revealing the outcome.
3. Group reasoning. Each colleague states their main hypothesis and the data that supports it before hearing the discussion.
4. Evidence. Someone brings the guideline or the study that answers the central doubt.
5. Outcome and lesson. Whoever presented the case tells how it ended, and the group writes one sentence about what changes in practice.
6. Return to the case. At the next meeting, someone tells whether the change happened.

Steps 4 and 6 cover exactly the two tasks that came in second place in the Practice Inquiry experience (Sommers et al., 2007).

Patient confidentiality

Cases discussed outside the medical record must go without a name, initials, exact dates, identifiable images or any detail that allows the person to be recognized. Follow the confidentiality rules of your service and your professional council.

Feedback with data from your own practice

Reviewing cases one by one shows the reasoning; looking at the numbers from your practice shows the patterns. Audit and feedback measures clinical performance over a period and returns the data to the doctor or the team (Ivers et al., 2026).

What the Cochrane review found

The update of the Cochrane review included 292 studies, and in 81% of them those receiving the feedback were doctors (Ivers et al., 2026). In the meta-analyses, audit and feedback increased the desired practice by 6.2 percentage points on average, with moderate certainty (Ivers et al., 2026). The effect was greater when baseline performance was lower and when there were more associated interventions (Ivers et al., 2026).

What makes feedback more useful

In the authors' analyses, the effect was greater with individual data instead of team data, with comparison to the best colleagues or to a target, with a reference colleague known to the person receiving the feedback, with an interactive format, with support for engagement and with action goals for improvement (Ivers et al., 2026). Contrary to expectations, repeating the feedback was associated with a smaller effect (Ivers et al., 2026).

A simple audit for the office

Practical suggestion from the Editorial: choose just one question, such as requests for a test in a common complaint or the follow-up of a chronic condition. Set aside a sample of visits from the last month, compare with the guideline you follow and note where your conduct diverged. Then review two or three of those cases calmly, as in the peer meeting.

Teleconsultation: discussing the case with another professional

When there is no colleague nearby, SUS offers teleconsultation.

What the regulation defines

Ordinance GM/MS No. 3,691 of 2024 established the Strategic Action SUS Digital Telessaúde and defines teleconsultation as a consultation between health professionals, mediated by digital technologies, to clarify doubts about clinical procedures, health actions and questions of the work process (Ministério da Saúde, Portaria GM/MS nº 3.691/2024). It can be synchronous, with simultaneous interaction, or asynchronous, through messages exchanged at different times (Ministério da Saúde, Portaria GM/MS nº 3.691/2024).

A Brazilian experience

TelessaúdeRS, from the Federal University of Rio Grande do Sul, was created in 2010 to support primary care teams, with a focus on the flow between primary and specialized care (Harzheim et al., 2016). According to the article, the program had made more than 50 thousand clinical consultations since 2010 (Harzheim et al., 2016).

How teleconsultation fits into case review

Practical suggestion: keep the question you asked and the answer you received. After a few weeks, reread the set. Doubts that repeat point to topics that are worth a longer study or a peer meeting. To find out how to access the service in your region, contact the primary care coordination of your municipality.

How to set up a case review routine

Each format covers one part of the review. The combination below is a suggestion from the Editorial, based on the characteristics that the synthesis by Cervero and Gaines associated with more positive results: interaction, more than one method and several exposures over time (Cervero e Gaines, 2015).

Frequency	Activity	Suggested time
Every day	One short case, to keep diagnostic reasoning in volume	5 to 10 minutes
Every week	Note the cases that raised doubts and the teleconsultations made	15 minutes
Every month	Case meeting with colleagues or review of two cases calmly	1 hour
Every quarter	A small audit of one question from your practice	2 hours

Table source: suggestion from the Editorial; the formats are described in the sections above.

Record the errors, not only the successes

The case you got right teaches little. The one you got wrong, or almost got wrong, shows where the gap is. The method of the error notebook helps separate error of knowledge, of reasoning and of attention, and it is also useful for those who are already graduated.

Training on NEXO

On NEXO, each case arrives in up to six clues, one at a time, and you give your guess by the name of the diagnosis or by the ICD-10 code. With each wrong guess, the game shows the proximity in five levels, from different chapter to Exact ICD, and opens the next clue. For the generalist, it is a way to keep diagnostic reasoning in volume, with complaints from various areas.

The Daily brings one case per day, the same for everyone, and the Archive gathers the previous daily cases. Multimedia brings image, audio and other exams, and Continents changes the underlying epidemiology. Adrenaline adds time. How each mode is unlocked is on the NEXO economy page.

Save, discuss and take part

The Anki button creates the card straight from NEXO and opens it in the Anki app, searches the cards you already have and, when the case has an image, takes the image to the card. The Group tab of the ranking, which gathers invited colleagues, lets you compare with your discussion group on which clue each one got it right. Generalist or specialist physicians with active registration can review cases in their area through NEXO Curator. If you coordinate a residency, a league or a medical school, get to know NEXO Closer; researchers in continuing medical education can propose studies through NEXO Researcher, and those who produce medical content can get to know NEXO Creators.

Frequently asked questions

How can the generalist physician review clinical cases?

By combining formats: short cases in daily life, case meetings with colleagues, teleconsultation when a doubt arises and small audits of your own practice. The synthesis of reviews on continuing education associates interactive, repeated activities with more than one method with more positive results (Cervero and Gaines, 2015).

Does continuing medical education work?

It works, with a more consistent effect on the physician's performance than on patient outcomes (Cervero and Gaines, 2015). For meetings and workshops, the Cochrane review speaks of probable small improvement in practice (Forsetlund et al., 2021).

Does experience replace case review?

Experience helps, but the systematic review on years of practice found more assessments with decline than with improvement in performance over time (Choudhry et al., 2005). Reviewing cases is a way to keep knowledge up to date.

What is a practice-based case discussion group?

It is a small group of physicians who meet to discuss difficult cases from their own practice or to apply a topic to cases from their own service, with unidentified patients. A review on this format in family medicine considered it promising (Zaher and Ratnapalan, 2012).

What is teleconsultation in the SUS?

It is consultation between health professionals, mediated by digital technologies, to clarify clinical doubts, health actions and the work process, synchronously or asynchronously (Ministry of Health, Ordinance GM/MS No. 3,691/2024).

How does NEXO help the graduated physician?

NEXO offers one case per day in the Daily, in up to six clues, with the proximity of the guess in ICD-10, which helps keep diagnostic reasoning in volume. To get to know the game, read what NEXO is.

Checklist for reviewing cases in practice

1. Write down the cases that raised doubts during the week.
2. Choose one case per month to review calmly.
3. State your hypothesis before seeing the outcome or the colleague's opinion.
4. Look for the evidence that answers the central doubt.
5. Write one sentence about what changes in your practice.
6. Check later whether the change happened.
7. Use teleconsultation when the doubt appears during the appointment.
8. Do a small audit of one question from your practice every quarter.
9. Test yourself before studying a new topic.
10. Keep short cases in daily life for reasoning in volume.

Want to keep your diagnostic reasoning sharp between one shift and another? Play the case of the day on NEXO.

References

1. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005. https://pubmed.ncbi.nlm.nih.gov/15710959/
2. Forsetlund L, O'Brien MA, Forsén L, et al. Continuing education meetings and workshops: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2021. https://pubmed.ncbi.nlm.nih.gov/34523128/
3. Cervero RM, Gaines JK. The impact of CME on physician performance and patient health outcomes: an updated synthesis of systematic reviews. J Contin Educ Health Prof. 2015. https://pubmed.ncbi.nlm.nih.gov/26115113/
4. Armson H, Roder S, Wakefield J, Eva KW. Toward Practice-Based Continuing Education Protocols: Using Testing to Help Physicians Update Their Knowledge. J Contin Educ Health Prof. 2020. https://pubmed.ncbi.nlm.nih.gov/33284176/
5. Zaher E, Ratnapalan S. Practice-based small group learning programs: systematic review. Can Fam Physician. 2012. https://pubmed.ncbi.nlm.nih.gov/22859626/
6. Sommers LS, Morgan L, Johnson L, Yatabe K. Practice inquiry: clinical uncertainty as a focus for small-group learning and practice improvement. J Gen Intern Med. 2007. https://pubmed.ncbi.nlm.nih.gov/17356994/
7. Ivers N, Yogasingam S, Lacroix M, et al. Audit and feedback: effects on professional practice. Cochrane Database Syst Rev. 2026. https://pubmed.ncbi.nlm.nih.gov/42325158/
8. Ministry of Health. Ordinance GM/MS No. 3,691, of May 23, 2024 (Strategic Action SUS Digital Telehealth). Official Gazette of the Union. https://www.in.gov.br/web/dou/-/portaria-gm/ms-n-3.691-de-23-de-maio-de-2024-562742406
9. Harzheim E, Gonçalves MR, Umpierre RN, et al. Telehealth in Rio Grande do Sul, Brazil: Bridging the Gaps. Telemed J E Health. 2016. https://pubmed.ncbi.nlm.nih.gov/27096384/