THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate sexual health history, including risk factors and symptoms.

The competent candidate should:

• Use open-ended questions initially to explore the patient’s concerns, followed by targeted questions to clarify specific symptoms.
• Establish onset, duration, and progression of symptoms (discharge, dysuria, pelvic discomfort).
• Ask about previous STI testing and history of infections.
• Assess sexual history, including:
  • Number of partners in the past year.
  • Condom use and contraceptive practices.
  • Partner’s STI history (if known).
  • Recent sexual practices (oral, vaginal, anal sex) to guide testing.
• Identify red flag symptoms, such as severe pelvic pain, fever, abnormal vaginal bleeding, or systemic symptoms, which could indicate pelvic inflammatory disease (PID).
• Explore vaccination status (HPV, Hepatitis B) and cervical screening history.
• Address psychosocial concerns, including relationship impact, stigma, and partner notification.

Task 2: Discuss your differential diagnosis with the patient.

The competent candidate should:

• Explain that there are multiple potential causes of her symptoms, and testing is required for confirmation.
• Discuss most likely differentials:
  • Chlamydia/Gonorrhoea: Common STIs presenting with discharge, dysuria, and pelvic discomfort.
  • Bacterial vaginosis (BV): Discharge with a fishy odour, often without pain or inflammation.
  • Candidiasis (Thrush): Itchy, thick, white vaginal discharge, usually without dysuria.
  • Pelvic Inflammatory Disease (PID): If infection has spread to the upper reproductive tract, presenting with lower abdominal pain, fever, and tenderness on examination.
  • Urinary Tract Infection (UTI): Dysuria and urgency without significant vaginal discharge.
• Reassure the patient that most STIs are treatable and preventable.

Task 3: Explain the investigations you will request and why.

The competent candidate should:

• Justify initial investigations, including:
  • First-pass urine PCR for chlamydia/gonorrhoea.
  • High vaginal/cervical swabs for microscopy, culture, and sensitivity (to test for bacterial vaginosis, trichomoniasis, or gonorrhoea).
  • Serology for HIV, syphilis, and hepatitis B/C, in line with national STI screening recommendations.
  • Pregnancy test (if indicated).
  • Urinalysis and urine culture, if a UTI is suspected.
• Explain that STI results may take a few days, and empiric treatment might be offered based on symptoms.
• Provide clear follow-up plans for discussing results and arranging partner notification.

Task 4: Provide an initial management plan, including treatment, follow-up, and partner notification.

The competent candidate should:

• Develop a management plan based on likely diagnosis:
  • If chlamydia is suspected: Empiric treatment with azithromycin 1g orally (single dose) or doxycycline 100mg BD for 7 days.
  • If gonorrhoea is suspected: Ceftriaxone 500mg IM + azithromycin 1g orally.
  • If bacterial vaginosis: Metronidazole 400mg BD for 7 days.
  • If candidiasis: Clotrimazole pessary or fluconazole 150mg PO (single dose).
  • If PID suspected: Empiric broad-spectrum antibiotics (ceftriaxone, doxycycline, metronidazole).
• Advise partner notification, explaining that partners should be tested and treated even if asymptomatic.
• Provide safe sex education, including consistent condom use, regular STI screening, and vaccination.
• Arrange a follow-up appointment for test results and ensure treatment completion.

SUMMARY OF A COMPETENT ANSWER

• Takes a structured sexual health history, addressing symptoms, risk factors, and psychosocial concerns.
• Provides a clear and logical differential diagnosis, explaining common STIs and other causes of discharge.
• Orders appropriate investigations, ensuring PCR, serology, and microscopy are conducted.
• Develops a safe, patient-centred management plan, including empiric antibiotic treatment, partner notification, and follow-up.
• Uses empathetic and reassuring communication, addressing stigma, partner concerns, and fertility fears.

PITFALLS

• Failure to take a comprehensive sexual history, missing key risk factors or STI exposures.
• Not considering alternative diagnoses, such as BV, PID, or candidiasis, leading to mismanagement.
• Omitting partner notification discussion, increasing risk of reinfection and transmission.
• Delaying treatment unnecessarily, when empiric antibiotics may be warranted.
• Lack of clear safety-netting, leaving the patient uncertain about when to return for review.

REFERENCES

• RACGP Guidelines – Sexual Health and STI Screening
• GP Exams – STIs (Sexually Transmitted Infections)

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare, and the full impact of their illness experience on their lives.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets relevant sexual and medical history, including risk factors.
2.2 Selects and justifies appropriate investigations for STIs.

3. Diagnosis, Decision-Making and Reasoning

3.1 Forms a logical differential diagnosis based on symptoms and risk factors.
3.5 Identifies red flag symptoms requiring urgent referral.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based, patient-centred management plan.
4.3 Provides structured follow-up, partner notification, and public health reporting.

5. Preventive and Population Health

5.2 Addresses STI prevention, contraception, and vaccination (e.g., HPV, hepatitis B).

6. Professionalism

6.1 Maintains confidentiality and professional integrity.

7. General Practice Systems and Regulatory Requirements

7.1 Orders appropriate tests in accordance with national STI screening guidelines.

9. Managing Uncertainty

9.2 Develops a structured approach to a patient with an unclear diagnosis.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages serious STI-related complications.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD