How the Profile is structured

The Profile is structured to give an overarching and integrated representation of a capable GP as well as the detail required to provide direction for educational practice (Figure 1). It is intended to represent contemporary general practice and to align with current medical educational scholarship. Its structure and nomenclature differ from that of the current curriculum and syllabus, which was revised prior to the completion of the Profile. It is intended that future revisions will see an alignment between these guiding instruments.

The Profile describes the competency and scope of practice of an Australian GP at four levels, starting broadly and becoming increasingly detailed:

• high-level roles of a GP
• broad capabilities required for each role
• specific competencies that enable each capability
• detailed indicative knowledge, skills and attitudes that the learner needs to acquire to achieve each competency.

The competencies and their component knowledge, skills and attitudes are grouped across four milestones of training to indicate by when each competency should be achieved. This grouping links development of competency to increasing scope of practice and informs learning, training and assessment for these milestones.

The milestones of training used in the Profile are:

1. Entry – Commencement of training in the general practice setting under direct supervision
2. Foundation – Transition to indirect supervision
3. Consolidation – Transition to ad hoc supervision
4. Fellowship – Certification for independent practice.

The Profile is structured around four roles of a GP’s work, each with an associated ‘orientation’. These roles are informed by the new structure of the AMC prevocational capability framework,¹ and have been refined to reflect the work of a GP.

In practice, GPs do not carry out the four roles separately but undertake them in an integrated way. There is inevitable crossover between the roles and their linked capabilities and competencies.

The four roles and their orientations are:

1. Clinician – Patient orientation

This role encompasses a GP’s clinical responsibility and accountability to patients. It includes a broad range of knowledge, skills and attitudes, such as considering cultural safety, communication, clinical problem-solving, consultation management, management of acute, undifferentiated and chronic conditions, and provision of preventive, holistic and person-centred care across the lifespan through a collaborative team-based approach.

2. Health advocate and leader – Community orientation

This role encompasses a GP’s accountability to their local and broader communities for the provision of sustainable care and rational use of community resources. It includes identifying and addressing public health risks and social determinants of health inequity, as well as advocating for improved access to care for both individuals and specific groups.

3. Ethical professional – Profession orientation

This role encompasses the GP’s fundamental duty-of-care responsibilities, their legal responsibilities and professional and ethical conduct. Professional conduct incorporates the responsibilities of therapeutic relationships, the important role of mentorship and support to peers and colleagues, and the need for insight, self-reflection and self care to maintain quality provision of care.

4. Scholar and scientist – Practice orientation

This role describes the GP’s responsibility to engage in ongoing reflective practice and learning to improve practice quality and safety and the quality of care delivered to patients. This role also incorporates teaching of colleagues and peers, engaging in research, understanding the scientific method, applying critical analysis and integrating evidence-based medicine into consultations.

In the Profile, the term ‘capability’ is used to describe the high-level abilities required of a GP. It is based on the conception of performance, capability and competencies presented in the AMC consultation paper, Competence-based medical education.² Capabilities can be defined as ‘The ability to use competencies in new, uncertain, complex and changing circumstances, to formulate and solve problems in familiar and unfamiliar settings and adapt, change and/or improve performance’.^3,4,5

The Profile describes 15 capabilities that are divided across the four roles of a GP (Table 1).

Table 1. The roles and capabilities of the Progressive capability profile of the general practitioner

Role	Capabilities
1. Clinician – Patient orientation	Deliver culturally safe care. Provide person-centred and comprehensive care, using a biopsychosocial approach. Manage consultations and communicate effectively with patients, families and carers. Collaborate and coordinate care (within healthcare teams and with other professional stakeholders). Across the lifespan and appropriate to context: Identify and manage uncertainty and acute and undifferentiated presentations. Manage individuals with chronic and complex conditions, providing continuity of care. Promote health and deliver preventive care.
2. Health advocate and leader – Community orientation	Rationally use the healthcare system and advocate for care access. Identify and address contributors to health inequity.
3. Ethical professional – Profession orientation	Maintain legal and duty of care responsibilities. Demonstrate professional and ethical conduct. Use self-reflection to deliver quality care and to enhance and maintain self-care practices.
4. Scholar and scientist – Practice orientation	Engage in reflective practice, ongoing learning, teaching and research. Integrate best available scientific evidence into practice. Display a commitment to practice quality and safety.

To achieve a capability, a doctor requires a range of competencies to enable that capability. A ‘competency’ has been defined as ‘An observable ability of a health professional, integrating … knowledge, skills, values, and attitudes. Since competencies are observable, they can be measured and assessed … Competencies can be assembled like building blocks to facilitate progressive development’.⁶

Each competency is further described by indicative knowledge, skills and attitudes that contribute to that competency.

Work-based learning theory and competency-based education identify competency as having three components: codified knowledge, skills and attitudes.^7,8,9,10 This differentiation is helpful because different modes of education and assessment are required for each.

• Codified knowledge refers to knowledge that can be gained from reading, lectures and online modules. Knowledge can be assessed by written exams.
• Gaining skills requires doing, either in practice or in simulation. Skills can be assessed by observing the individual performing the skill.
• Gaining attitudes requires interaction with peers and role models. Attitudes can be assessed by observing performance in practice.

Knowledge and skills can also be assessed by observation of performance.

The knowledge, skills and attitudes for each competency form the fourth level of the Profile’s structure, providing more detailed guidance for learning, teaching and assessment.

The knowledge, skills and attitudes detailed in the Profile are not intended to be exhaustive, but rather are provided as a guide. They have been titled as ‘Know’, ‘Do’ and ‘Be’. In some cases, these categories are combined where they cannot reasonably be separated.

The Profile uses four milestones in a doctor’s training journey from entry to general practice through to independent practice as a Fellowed GP. The milestones are linked to points of privileging and increasing scope of practice. The competencies required to enable the capabilities of a GP are distributed across these milestones to indicate by which stage of training the competency should be achieved.

The milestones of training used in the Profile are:

1. Entry – Commencement of training in the general practice setting under direct supervision
2. Foundation – Transition to indirect supervision
3. Consolidation – Transition to ad hoc supervision
4. Fellowship – Certification for independent practice.

1. Entry milestone

The Entry milestone is defined as the point when a doctor is ready to commence vocational training in a general practice setting under direct supervision.

Privilege

The doctor is deemed suitable to commence training in the general practice setting.

Scope of practice

The doctor is considered safe and competent to practise under supervision in the hospital setting.¹¹ In the general practice setting, the doctor must practise under direct supervision, with the supervisor having oversight of every case and carrying predominant responsibility for each patient. The rationale for this is that clinical care in the context of general practice is very different to hospital-based clinical care. Supervisory oversight includes mechanisms such as observing consultations, reviewing a consultation before the patient leaves, or reviewing consultation notes with the registrar at the end of each session. This level of oversight should continue until the doctor has been judged to have the competencies set out at the Foundation milestone.

Competencies

The competencies defined at this milestone are intended to incorporate the knowledge, skills and attitudes required at the point at which a doctor commences work as a general practice trainee in a general practice setting. These are currently assessed by the processes for selection to general practice training.

2. Foundation milestone

The Foundation milestone is defined as the point at which a doctor has demonstrated the required competencies to transition to indirect supervision with reliable access to supervisory support and close oversight of their practice.

Privilege

The doctor is deemed capable of attending general practice patients under close indirect supervision.

Scope of practice

The doctor is considered safe and competent to provide general practice care to patients, taking primary responsibility for management decisions. They are expected to adhere to guidelines on when to escalate the care of a patient to a supervisor. The supervisor monitors the doctor’s performance closely and is reliably available for support as required. The supervisor is responsible for ensuring that mechanisms are in place to monitor the doctor’s quality and safety of practice. This close supervision and support is required until the doctor attains the competencies of the Consolidation milestone.

Competencies

The competencies defined at the Foundation milestone are those necessary to be competent to practise safely without direct supervision. The doctor will need to have demonstrated the foundational clinical knowledge, skills and attitudes to assess common general practice presentations. They will also need insight into the limits of their knowledge and skills and their ability to access help when required; these competencies are fundamental for both patient and doctor safety.^12,13,14

Assessment of these is largely the responsibility of the supervisor and their team.

3. Consolidation milestone

The Consolidation milestone is defined as the point at which a doctor has demonstrated the required competencies to work largely independently in the general practice setting. They still require mentorship and occasional supervisory support.

Privilege

The doctor is deemed capable of working largely independently, but with access to support and supervision as needed.

Scope of practice

The doctor is considered safe and competent to manage a broad range of general practice presentations. The supervisor continues to ensure there are mechanisms in place to monitor whether the doctor is providing quality care, and remains available to provide mentoring, support and advice as requested by the doctor.

Competencies

The competencies defined at the Consolidation milestone are close to those required for independent practice. These enable the doctor to be capable of undertaking assessment and management of a large range of general practice presentations with a high degree of self-sufficiency.

At this milestone a doctor will have demonstrated a breadth of knowledge, skills and attitudes, including being culturally safe, communicating in an appropriate and effective manner, identifying and managing common acute and chronic conditions that present in primary care, understanding duty of care and professional responsibilities, working effectively in a team, having good strategies to support ongoing learning and improvements in quality of care, and having an understanding of organisational processes and legal requirements.

4. Fellowship  milestone

The Fellowship milestone is defined as the point at which a doctor transitions to independent practice, having achieved the competencies required to work as an RACGP Fellowed GP.

Privilege

At this milestone, the doctor is deemed capable to practise safely as an unsupervised GP anywhere in Australia.

Scope of practice

The doctor is certified as suitable for vocational registration and the full scope of practice of a fully qualified GP in Australia. This means having the competencies for independent safe practice in the context in which they currently practice and the ability to adapt and build on these for safe practice in other contexts across the scope of general practice in Australia.

Competencies

Transition to this point requires a doctor to have refined and built on the competencies of the Consolidation milestone. They will have the competencies to work as a GP independent of supervision.^15,16

The doctor will have well established organisational and consultation management skills and the knowledge and skills to manage complex general practice presentations and situations. They can safely manage uncertainty and undifferentiated conditions. They are developing leadership and mentoring skills. They can engage in community health initiatives, navigate the health system and practice structures. They are committed to addressing health inequity and are responsible in the use of healthcare resources.

Doctors at this milestone use best available evidence to deliver quality, person-centred and comprehensive care. They work effectively in healthcare teams, displaying professionalism and ethical practice, and providing support to colleagues. They engage in reflective practice with a commitment to ongoing learning and quality improvement and participate in ongoing professional development.

The Profile assigns each competency to a milestone of training. In this way, the progressive achievement of a capability is depicted through the progressive attainment of its associated competencies

Competency development often happens in a sequential way, where gaining one competency depends on the earlier acquisition of a more foundational competency. Where this is clearly the case, the link between competencies across milestones is indicated by the numbering system (where the first part of the number represents the capability, the second is the milestone, and the third is the competency within the milestone), as shown in the following example:

Capability 1. Deliver culturally safe care
Entry:	Competency 1.1.1 – Identify own cultural bias and cultural lens
Foundation:	Competency 1.2.1 – Explain how own cultural lens may impact consultations
Consolidation:	Competency 1.3.1 – Work effectively with Aboriginal and Torres Strait Islander health practitioners/workers and liaison officers, and with Aboriginal and Torres Strait Islander peoples
Fellowship:	Competency 1.4.1 – Integrate cultural perspectives, beliefs and impacts of historical events into provision of culturally safe care to Aboriginal and Torres Strait Islander peoples

However, not all competencies continue to be built upon at subsequent milestones. Once a competency is attained, it is expected that it will be maintained.

The relationships between capabilities and competencies and the dependencies between competencies provide a structure for learners, educators and assessors. However, these relationships and dependencies are not absolute. Any capability will also depend on competencies described under other capabilities, and any competency will be related to many other competencies. This reflects the interrelationship and integration of capabilities necessary in the daily practice of a GP.