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Domain 1 Communication skills and the patient-doctor relationship
Domain 2 Applied professional knowledge and skills
Domain 3 Population health and the context of general practice
Domain 4 Professional and ethical role
Domain 5 Organisational and legal dimensions
Aboriginal and Torres Strait Islander health
Abuse and violence
Child and youth health
Ear, nose, throat and oral health
Education in general practice
Endocrine and metabolic health
Justice system health
Kidney and urinary health
Migrant, refugee and asylum seeker health
Military and veteran health
Occupational and environmental medicine
Older persons' health
Pregnancy and reproductive health
Research in general practice
Sexual health and gender diversity
This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.
Endocrine and metabolic health is a core component of Australian general practice. Endocrine disease represents the ninth largest cause of total disease burden in Australia.1 Diabetes is the fastest growing chronic disease in Australia and affects approximately 5% of the population,2 with Aboriginal and Torres Strait Islander Australians almost four times more likely than non-Indigenous Australians to have type 2 diabetes.3 It is believed that around 30% of Australians with diabetes are undiagnosed.4 Metabolic syndrome is a significant problem, affecting 20–30% of Australian adults.5 Sixty-seven per cent of Australians are overweight and obese.6
Osteoporosis affects more than one million Australians.7 Bone health is often overlooked by both general practitioners (GPs) and patients, meaning osteoporosis is often not diagnosed until a fracture occurs.7 It is considered underdiagnosed and undertreated, and the condition’s prevalence has continued to increase in Australia over time.8
GPs play an important role in paediatric conditions, for instance, in the early diagnosis, ongoing management and coordination of care for type 1 diabetes. GPs must be broadly aware of the various inborn errors of metabolism and refer patients on for genetic screening where appropriate.
The nature of endocrine disease means that clinical presentations can be non-specific and may initially present a diagnostic conundrum.9 Unnecessary testing carries a risk of incidental findings, which can result in a cascade of investigations, procedures and unnecessary stress for patients.10 GPs must therefore possess highly developed diagnostic skills, balancing the need to prevent both over-investigation and under-investigation. For instance, thyroid testing is increasing in Australia, despite evidence that some of those tests may be unnecessary,10 but uncommon endocrinological diseases such as Addison’s disease are often associated with delays in diagnosis due to their non-specific symptoms.11
Pharmaceutical and technological advancements in this area continue to improve health outcomes, demonstrated by the increasing pharmacological options for type 2 diabetes12 and the development of continuous glucose monitoring devices.13 Similarly, osteoporosis has seen remarkable progress in its pharmacological treatment over the years.14 GPs need to remain up to date with these ongoing developments.
Patient health behaviours are an essential component in the prevention and management of many endocrine and metabolic diseases. Lifestyle interventions to address obesity and insulin resistance are the mainstay in the management of metabolic syndrome,15 and an important part of the overall management of polycystic ovary syndrome16 and type 2 diabetes.17 Counselling offered by GPs on this has the potential to make a significant positive impact on patients.18
Many Australians encounter barriers that hamper the management of their endocrinological and metabolic conditions. Aboriginal and Torres Strait Islander peoples, for instance, are limited by factors such as experiences of discrimination and poor or inappropriate communication by healthcare professionals.19 Australians living in rural and remote areas generally have poorer access to services than their urban counterparts.20 GPs should try to mitigate these factors wherever possible.
GPs therefore play a fundamental role in endocrine and metabolic health, needing to be highly skilled in prevention, diagnosis and management across a variety of conditions to offer patients the best quality care.
This section lists the knowledge, skills and attitudes that are expected of a GP for this contextual unit. These are expressed as measurable learning outcomes, listed in the left column. These learning outcomes align to the core competency outcomes of the seven core units, which are listed in the column on the right.
This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.
Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.
You can do this either on your own or with a study partner or supervisor.
The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.
Note that these are examples only of questions that may be asked in your assessments.
Extension exercise: Create your own questions or develop a new case to further your learning.
Lena is a 35-year-old woman with type 1 diabetes who presents for a general review at the urging of her endocrinologist. Although she regularly visits her endocrinologist, she infrequently attends the GP practice. Lena is on insulin through an insulin pump and has an intrauterine device.
How would you address Lena’s infrequent attendance to the practice? How could you engage Lena?
How would your communication style change if Lena had an intellectual disability? What if she presented with a family member or other carer?
How would your communication change if you were working in a remote Aboriginal community?
What specific questions should you ask Lena at this appointment? What examination would you do?
What is the most relevant and important information you would look for in the letter from Lena’s endocrinologist?
Are there any mental health conditions you need to consider? If so, which ones and how would you screen for them?
What are the associated (non-diabetic) conditions that should be screened for in Lena because she has type 1 diabetes?
Which complications of diabetes does Lena need to be screened for and how often?
What if Lena were a child or adolescent? How would your screening for complications differ?
What guidelines or resources would you use in caring for Lena?
What if Lena told you she would like to become pregnant for the first time? What should you discuss with her?
What if Lena were an 85-year-old woman in an aged care home? How would that change your management?
What if Lena told you that she uses complementary therapies at the encouragement of a diabetes support group on Facebook? What questions would you ask and what advice would you give her about this?
How would your management change if you were in a remote Aboriginal or Torres Strait Islander community with no visiting dieticians or diabetes educators, and no way for the patient to see one elsewhere?
If Lena were making unhealthy lifestyle choices (eg smoking, unhealthy diet), what could you do to help her? What if she were an Aboriginal or Torres Strait Islander, what government initiatives could assist Lena to make lifestyle changes?
When you read the endocrinologist’s letter, you decide that their management plan is not appropriate for Lena given what you know about her. What would your next step be?
What strategies can you implement in your practice to encourage Lena to present to a GP more regularly? What are your medico-legal obligations in terms of contacting Lena? For example, regarding abnormal pathology investigations
If Lena reported having trouble with her insulin pump, what would your next step be?
If Lena presented to your clinic very unwell (with either hypoglycaemia or hyperglycaemia), how would you immediately manage this?
How would you manage the consultation if Lena had just arrived from overseas and had limited information with her about her condition?
What potentially life-threatening situations do you need to know about in Lena’s case and how would you manage them if they occurred in your general practice?
What advice would you give Lena in identifying and self-managing those conditions?
This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.
There are suggestions for activities to do:
Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.
Conduct an informal literature review on the management of type 2 diabetes in Aboriginal and Torres Strait Islander peoples.
Identify your local referral pathways for bariatric surgery.
Make a list of all the screening (for both complications and associated conditions) that should occur in patients with type 1 or type 2 diabetes, and write a plan on how often this should be done.
Identify the indications in Australia for vitamin D deficiency screening.
Do a role play where your supervisor is a patient with type 1 diabetes and take them through a ‘sick day plan’.
With your supervisor, do a case review of two or three of your patients with type 2 diabetes and discuss how they were managed.
Do an informal presentation to your supervisor on the major adrenal diseases and the role of the GP in these conditions.
Discuss the different types of thyroid imaging, and when it is appropriate to order them.
Discuss how you might sensitively approach the topic of weight and lifestyle risk factors (such as diet and exercise) with a patient or parent (of an overweight child).
Practise with your peers giving a new diagnosis of type 2 diabetes to a patient.
Discuss when you would order calcium levels on a patient and what you would do if they came back high or low.
Have each person draw a diagram (off the top of their head) of the relationship between parathyroid hormone, vitamin D and calcium. Then get together and explain these interactions to each other.
Discuss what your friend or family member understands about osteoporosis, with an emphasis on how to prevent it, then fill in the gaps in their knowledge.
Give a short talk (10–15 minutes) to a friend or family member in lay terminology on hypothyroidism and hyperthyroidism. Include the differences between the thyroid function tests (ie TSH, T4 and T3) and sub-clinical hypo/hyperthyroidism.
These are examples of topic areas for this unit that can be used to help guide your study.
Note that this is not a complete or exhaustive list, but rather a starting point for your learning.
The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.
Advice for GPs on how to investigate thyroid disease.
Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/metabolic-and-endocrine-health 27/11/2022
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