Domain 2 Applied professional knowledge and skills

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Instructions

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.

General practice is a complex and challenging specialty, requiring understanding of, and proficiency in, numerous overlapping concepts and skills. First and foremost, general practitioners (GPs) must practise patient-centred care, recognising the patient as a partner in their own healthcare and people as unique individuals rather than conditions to be treated.1

Key to whole-person care is considering the multiple dimensions of the patient in an integrated way, underpinned by the patient–doctor relationship. Whole-person care recognises patients as individuals, acknowledges the humanity of the doctor, views health as more than just the absence of disease, employs a range of treatment modalities and places importance on the therapeutic relationship.2

The nature of general practice means that GPs must be particularly skilled in verbal and non-verbal communication.3 A good GP can adapt their communication and consultation styles to the person in front of them. This has the flow-on effect of ensuring the realisation of the patient’s agenda, improving concordance with treatment and improving health outcomes.4 This also allows for effective history taking, which is fundamental and offers the most valuable information in most presentations. It is also important for GPs to acknowledge the significance of practising culturally sensitive care, and to recognise the importance of providing safe spaces within their clinics, particularly for their Aboriginal and Torres Strait Islander and culturally and linguistically diverse patients.

General practice involves seeing the broadest range of conditions across any specialty, requiring GPs to possess a significant breadth of knowledge. A GP must have good working knowledge of 167 problems to cover 85% of the conditions they will see most frequently.5 Uncertainty, unpredictability and undifferentiated presentations are common challenges of general practice,6 so GPs must feel comfortable dealing with uncertainty, have an approach to managing it and communicate this appropriately to their patients.6 GPs should have finely honed investigative skills for the wide variety of conditions they see in day-to-day practice. This necessitates traversing the fine balance between ordering investigations in such a way that important pathologies are not missed, while avoiding over-investigation. A growing body of evidence suggests that over-testing is a significant problem, with many potential adverse consequences.7 GPs must be able to interpret the results of investigations in the broader context of the patient.

GPs need a holistic approach to management that is orientated to empowering patients to make their own health management decisions. This requires understanding the various pharmacological and non-pharmacological therapeutic options for an extensive range of conditions and being able to effectively communicate these to the patient. GPs must also have a keen understanding of pharmacokinetics, being able to safely prescribe for patients, some of whom might be on multiple medications, and appropriately counsel patients on this. A good GP knows how to integrate pharmacological and non-pharmacological options for a patient in a way that is adapted to their unique needs and is evidence based. GPs manage patients who are seriously unwell, in the community and in hospital settings, and GPs will be called on to stabilise these patients. These patients might or might not then require transfer to another clinician and/or facility for further care. GPs must be able to engage collaboratively with a wide variety of healthcare providers, knowing when to refer, communicating well, ensuring follow up and working successfully within a team.
References
  1. Australian Commission on Safety and Quality in Health Care. Patient-centred care: Improving quality and safety through partnerships with patients and consumers. Sydney: ACSQHC, 2011 [Accessed 8 November 2021].
  2. Thomas H, Best M, Mitchell G. Whole-person care in general practice: The nature of whole-person care. Aust J Gen Pract 2020;49(1/2):54–60. doi: 10.31128/AJGP-05-19-49501.
  3. Warnecke E. The art of communication. Aust Fam Physician 2014;43(3):156–58.
  4. Denness C. What are consultation models for? InnovAit 2013;6(9):592–99. doi: 10.1177/1755738013475436.
  5. Cooke G, Valenti L, Glasziou P, Britt H. Common general practice presentations and publication frequency. Aust Fam Physician 2013;42(1/2):65–68.
  6. Morgan S, Coleman J. We live in testing times: Teaching rational test ordering in general practice. Aust Fam Physician 2014;43(5):273–76.
  7. O'Riordan M, Aktürk Z, Ortiz JM, et al. Dealing with uncertainty in general practice: An essential skill for the general practitioner. Qual Prim Care 2011;19(3):175–81.

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP. These are expressed as core competencies that are required of a GP across all clinical consultations, interactions and contexts. These core competencies are further detailed as measurable core competency outcomes.

Applied knowledge and skills
Core competencies Core competency outcomes
  The GP is able to:
  1. GPs diagnose and manage the full range of health conditions across the lifespan
  1. take a comprehensive and clearly documented history in a timely, ordered and respectful manner
  2. perform a relevant and respectful physical examination
  3. identify and manage significantly ill patients appropriately
  4. formulate a list of relevant differential diagnoses
  5. receive consent and undertake relevant procedures
  6. offer relevant screening and investigations
  7. interpret investigation results within the context of the patient’s life/situation
  8. demonstrate clinical reasoning in the diagnosis and management of the patient
  9. prescribe and monitor medication safely and appropriately
  10. acknowledge clinical uncertainty and respond appropriately to it

Aboriginal and Torres Strait Islander health
  1. undertake screening for early identification of health issues in Aboriginal and Torres Strait Islander communities
  2. manage health conditions in a timely manner, including responding effectively to the complex needs of patients with multi-morbidity
Rural health 
  1. develop knowledge and skills appropriate to the practice location
  1. GPs are innovative and informed by evidence
  1. identify and critically analyse quality evidence-based resources
  2. stay informed (and consider the use) of innovative approaches to chronic and complex health issues
  1. GPs collaborate and coordinate care
  1. ascertain the appropriate care model
  2. minimise fragmentation of care
  3. demonstrate leadership in emergency situations
  4. establish professional networks to maintain quality care

Aboriginal and Torres Strait Islander health
  1. ensure care is relevant to Aboriginal and Torres Strait Islander peoples’ social, cultural, economic and other unique needs
  2. work in respectful partnership with Aboriginal and Torres Strait Islander healthcare professionals
Rural health
  1. establish interprofessional networks to ensure quality local healthcare delivery

Instructions

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.

  1. Rational test ordering can be difficult at times. Ask yourself, ‘How will this investigation change my management of this patient?’ If it won’t, you should not order it. It is also important to remember that you are solely responsible for the investigations you order, so do not order an investigation if you are unable to understand the results.
  2. John D Rockefeller Jnr once said that the secret to success is to ‘Do common things uncommonly well’. As noted in the area of practice section of this unit, BEACH data suggest that nearly 50% of general practice consultations involve the same 30 presentations. It therefore serves a GP well to achieve a mastery of those presentations, so copy a list of them, read widely on the conditions, and embrace opportunities to manage these conditions when patients present with them.
  3. It is important to develop a personal approach to managing uncertainty. Always check your practice against relevant guidelines (where applicable), seek assistance from your supervisor or a peer if you are unsure about ordering investigations, communicate your thought processes thoroughly to your patient to help them feel they are an active partner in the process of their management, safety net appropriately and remember that time is often the best investigation, as watchful waiting can often be safely implemented.
  4. Sometimes patients’ agendas and/or desires do not match with appropriate evidence-based practice. Never prescribe medications or order investigations when you feel uncomfortable to do so, and when they do not align with established and safe evidence-based care. If you are unsure, politely but firmly explain to the patient that you must defer the issue to seek further advice, and discuss with your supervisor, a non-GP specialist or medical defence organisation, where relevant.
  5. Safety netting is crucial in all clinical presentations. This means explaining to a patient what your thought processes are, such as what you think the diagnosis is, what you want to rule out and how you will do that, and how you’re going to manage them in the first instance. This gives your patient an understanding of what is happening. Then let them know when they should return to you and under what circumstances they should present to hospital, and why. And, of course, document these conversations appropriately.

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

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.

Domain 2 Applied professional knowledge and skills

Ferhana is a 46-year-old woman who recently emigrated to Australia from Afghanistan. She presents with undifferentiated abdominal pain that has been present for the past four weeks. Her medical history includes hyperlipidaemia. She is on no medications. She works as a cook and lives with her adult daughter, son-in-law and grandchild.

Questions for you to consider Clinical exam assessment area Domains

If Ferhana’s English skills were minimal, how would you approach communication in the consultation? What resources are available to you and Ferhana to assist with this? What might you advise her with respect to her future appointments?

Given the nature of the presentation, you would like to ask Ferhana about her sexual history and you sense that this is a sensitive topic to explore with her. How would you go about it?

What are some non-verbal communication skills that would help to enhance your consultation with Ferhana?

  1. Communication and consultation skills
1,2,5

What history and examination findings would help you work through the list of differential diagnoses for this condition?

Are there any point-of-care tests you should do?

  1. Clinical information gathering and interpretation
2

What are the serious pathologies that must be excluded in this case (through history, examination and/or further investigations)?

What are the possible investigations that can be done, and in what circumstances would it be appropriate to order them?

Based on the information in the clinical scenario alone, what are the statistically most likely causes for Ferhana’s pain?

What guidelines might assist you in making these decisions?

  1. Making a diagnosis, decision making and reasoning
2

How would you manage Ferhana if the cause of her pain was not apparent at the initial consultation? What non-pharmacological and pharmacological options would you consider?

How might your management for Ferhana change if you were in a remote location without a hospital, and imaging centres a long distance away?

  1. Clinical management and therapeutic reasoning
2

What resources could you offer Ferhana to manage her hyperlipidaemia?

What screening should you consider for Ferhana? If you were unsure, where would you find this information?

If Ferhana’s daughter came to the consultation, what would you advise her to support her mother’s health in general?

What social factors contribute to Ferhana’s overall health?

What if she were an Aboriginal or Torres Strait Islander? What government initiatives could be used to assist in managing Ferhana’s health?

  1. Preventive and population health
1,2,3

If Ferhana’s daughter or son-in-law called you after the consultation to ask for information on her health, what should you say?

If Ferhana requested Schedule 8 medications to manage her pain, what would be your next step?

What if a patient asked you to do investigations that are not clinically appropriate? How would you respond?

If Ferhana disclosed to you some information that you found personally distressing, what should you do to ensure your own mental health and wellbeing? Who could you speak to? What supports and resources exist for doctors in this area?

  1. Professionalism
4

Ferhana requests a medical certificate for work for the previous two weeks. How would you approach this request? If you were unsure, where could you find information on your medico-legal responsibilities with respect to this?

If you were going to be away when you expect her investigation results to come back, how would you ensure these results are appropriately followed up?

  1. General practice systems and regulatory requirements
5

If Ferhana would like a long-acting reversible contraceptive (LARC), what are her options? If you are not accredited to insert LARCs yourself, how could you learn how to do this?

  1. Procedural skills
2

How would you approach this consultation if Ferhana had just arrived in Australia and had no documentation about her medical history?

If the cause of her pain was not clear from the initial investigations, how would you manage this situation?

  1. Managing uncertainty
2

What clinical signs and symptoms would point to Ferhana being significantly unwell?

If you find that she is significantly unwell, what would be the next appropriate steps in management? If there was a language barrier, how would you make sure the next steps are as smooth as possible for Ferhana?

  1. Identifying and managing the significantly ill patient
2

Instructions

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:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Make a list of all red flags you should ask about when taking a patient’s history for each of the common presentations (eg headache, back pain, fatigue, cough, chest pain, abdominal pain, child with fever).

  • Where can you find information on this? Did you miss any?
  • Do the red flags change based on certain features of a patient (eg age)? How can you make sure you don’t forget to ask these red flag questions during a consultation?

Identify the GP-rebateable indications for ordering an MRI in adults and children.

  • Did any of them surprise you?
  • What should you do if you feel somebody requires an MRI for a condition not on that list?
  • If you worked remotely and MRI access was difficult, how would this change your approach to ordering?

Research the investigation and management approach for fatigue in general practice.

  • What does the evidence say? Are there guidelines on this?
  • How does this change your practice?
  • How do patient features (eg age, gender, cultural diversity) change your approach to this presentation?
With a supervisor

Discuss with your supervisor a case you had of a seriously ill patient (child or adult).

  • How did you identify that they were ill?
  • Did your supervisor agree with your management approach? How do they approach similar situations?
  • What resources are there to help you with this?
  • How would your approach change if you were in a rural or remote setting?

Ask your supervisor to demonstrate common general practice procedural skills that you are not confident in (eg injections; removal of foreign bodies from noses, ears, eyes and skin; epistaxis management).

  • Do they have any handy tips? How else might you learn more about these skills?
  • Ask your supervisor to watch/coach you as you perform these skills on a patient and give you feedback on how you went.

Ask your supervisor how they manage uncertainty in day-to-day practice.

  • What did you learn? How can you implement this in your own practice?

Identify guidelines that appear to contradict other guidelines on the same topic and discuss this with your supervisor.

  • How do you approach this uncertainty? When should you act outside guidelines? Discuss examples with your supervisor.
In a small group

With your peers, practise how you would counsel a patient who asks for a screening test that is not straightforward, such as prostate-specific antigen (PSA) testing.

  • What guidelines did you base your recommendations on? Are they recent and Australian based?
  • Did you learn any phrases or communication tips you can use in your own practice?
With your peers, practise doing a focused examination for each of the major symptoms and conditions (eg cough, dizziness, chronic renal disease, liver disease).
  • How did you go?
  • How does each examination change when the patient is a child?
  • What findings would you expect for each condition?
  • What resource/s can you use to improve your examination skills?

Discuss how you would go about prescribing a new medication. Have each member of the group find a resource that provides information about new medications.

  • Make a list of sites where you can find information about medications.
  • What if the resources each of you have found offer slightly different information?
With a friend or family member

Explain to a friend or family member the actions of some common medications prescribed in general practice (eg anti-hypertensives, statins, SSRIs/SNRIs, asthma/COPD puffers), and their most important side effects. Ideally, do this activity with people of varying ages and education levels and don’t choose a medication that your friend or family member is taking, so as not to create unintended confusion between them and their treating doctor/s.

  • How did you go? Did they clearly understand your explanations? Did they have questions?
  • What resources can you use in daily practice to help you explain medications to your patients?

Explain to a friend or family member what safety netting involves and how you would safety net some of the most common presentations (eg unwell child, headache, chest pain).

  • Was your friend or family member clear about what you said? Did they have any questions?
  • Compare what you said to a documented list – did you miss anything?

Instructions

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.

  • Identify and manage significant medical conditions, including:
    • recognise and manage the seriously ill patient
    • consider the possibility of serious illness inherent in many common presentations
    • ensure evidence-based practice.
  • Demonstrate skills in history-taking, physical examination, undertaking procedures and clinical decision-making relevant to the presenting problem, particularly undifferentiated problems.
  • Demonstrate acceptance and management of uncertainty in presentations which, despite appropriate clinical method, remain undifferentiated. This includes being able to negotiate a management plan (including safety netting) with patients that is consistent with the doctor’s and patient’s needs.
  • Use and promote best practice through:
    • judicious use of investigations, including:
      • following criteria for MRI and/or CT investigation of common conditions (eg headache)
      • referral for relevant radiology and pathology for common conditions (eg back pain, fatigue)
    • counselling about risks and benefits of screening (eg prostate-specific antigen (PSA) testing)
    • counselling about investigations, including risks and benefits, sensitivity and specificity, other factors (eg potential insurance implications), and referral for prenatal, antenatal or other genetic screening
    • interpreting investigation results in the context of the patient, including:
      • individuals with hepatitis B: significance of low normal platelets and low-level elevation of transaminases
      • ideal ferritin targets in individuals with haemochromatosis
      • acceptable creatinine levels in individuals with chronic renal impairment
    • safe and rational prescribing, including monitoring of medications where relevant
    • counselling patients on the risks, benefits and implications of genomic testing.
  • Competently manage common problems and develop management strategies that:
    • are holistic and consider the patient and their sociocultural context
    • include assessment of response to treatment
    • include education and empowerment of patients
    • consider appropriateness of harm minimisation strategies
    • include lifestyle or non-pharmacological therapies
    • include counselling regarding medication, if appropriate.
  • Engage in collaboration of care with other health providers, including:
    • using hospital and community-based expertise, resources and networks effectively
    • making valid and timely decisions about referral and follow up
    • using electronic and written communications 
    • ensuring effective handover and appropriate referrals
    • promoting continuity of care
    • working effectively with other team members, both external and internal to the practice, including Aboriginal health workers, cultural mentors, cultural educators, advisors and others in the general practice team (eg colleagues, practice manager, practice nurse, administrative staff, allied health colleagues).
  • Be aware of the pharmacokinetics of medications, including:
    • potential for iatrogenic harm
    • side effects and important adverse reactions
    • allergic reactions
    • drug interactions
    • contraindications
    • therapeutic drug levels and drug screening.

Instructions

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.

Journal articles
A summary of how to evaluate new medications and decide if and when to prescribe. How to tell which guidance is reliable and relevant. General approaches and practical strategies for rational test ordering. A summary of the main issues in appropriate prescribing. Practical management strategies for patients with medically unexplained symptoms.
Textbooks
A practical resource with helpful diagnostic strategies.
  • Murtagh J. Murtagh’s diagnostic strategies. 1st edn. Sydney: McGraw Hill, 2016. (Available from the RACGP library.)
Practical information and instruction on ways to deal with everyday ailments.
  • Murtagh J. Murtagh’s practice tips, 8th edn. Sydney: McGraw Hill, 2019. (Available from the RACGP library.)
Online resources
Practical suggestions for managing clinical uncertainty. Links to resources on common presentations with the latest information on how to approach them. An excellent concise summary on how to recognise the seriously ill baby. A guide to pathology testing and rational ordering of pathology tests.
Learning activities
A guide to evaluating research evidence and educational materials.
  • The Royal Australian College of General Practitioners. gplearning:
    • Australian Journal of General Practice clinical challenge – June 2018: Evidence-based medicine.
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/domain-2 23/05/2022