CCE-CBD-143

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What further information would you like to gather to complete Michael’s cardiovascular risk assessment?

• Prompt: Explore personal and family history in more detail
• Prompt: Assess psychosocial factors, diet, exercise, alcohol use
• Prompt: Discuss medication adherence and any side effects
• Prompt: Evaluate readiness to change lifestyle habits

Q2. How would you assess and communicate Michael’s absolute cardiovascular risk?

• Prompt: Explain how the Australian absolute cardiovascular risk calculator works
• Prompt: Interpret his 5-year risk category (high-risk >15%)
• Prompt: Use shared decision-making to discuss risk reduction strategies

Q3. What preventive interventions would you recommend for Michael today?

• Prompt: Address pharmacological options (statins, antihypertensives, aspirin)
• Prompt: Lifestyle advice (smoking cessation, weight loss, diet, physical activity)
• Prompt: Referrals (dietitian, exercise physiologist, smoking cessation services)
• Prompt: Discuss follow-up schedule and monitoring

Q4. How would you manage the challenges of providing preventive care in a rural setting?

• Prompt: Address limited access to allied health and specialist services
• Prompt: Explore telehealth options
• Prompt: Leverage community resources
• Prompt: Promote self-management support strategies

Q5. How would you ensure Michael’s ongoing engagement in preventive health?

• Prompt: Build rapport and address his concerns about family history
• Prompt: Use motivational interviewing techniques
• Prompt: Set achievable goals and track progress
• Prompt: Encourage regular review appointments

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What further information would you like to gather to complete Michael’s cardiovascular risk assessment?

Answer:

To complete Michael’s cardiovascular risk assessment, I would gather more comprehensive information across several domains:

1. Personal and Family History:

• Clarify age of onset and severity of cardiovascular events in family members (father and brother).
• Confirm history of other cardiovascular conditions (e.g., stroke, peripheral vascular disease).
• Enquire about any symptoms suggestive of angina or intermittent claudication.

2. Lifestyle Factors:

• Smoking: Explore his readiness to quit, previous attempts, and barriers to cessation.
• Diet: Assess his intake of saturated fats, salt, fruit, and vegetables.
• Physical activity: Clarify type, frequency, and intensity of current exercise.
• Alcohol intake: Quantify and assess patterns of drinking (binge vs. regular).

3. Psychosocial Factors:

• Evaluate levels of stress and anxiety, particularly related to his family history.
• Assess support systems: Is his partner supportive of lifestyle changes?
• Work-life balance: As a truck driver, explore long sedentary hours, access to healthy food, and opportunities for exercise.

4. Current Medications and Adherence:

• Confirm compliance with ramipril and explore any side effects.
• Assess understanding of his hypertension diagnosis and medication rationale.

5. Screening for Other Risk Factors:

• Discuss erectile dysfunction, which can be an early marker of vascular disease.
• Explore sleep history for symptoms of obstructive sleep apnoea, common in overweight patients.

6. Readiness for Change:

• Use motivational interviewing to assess his willingness to engage in lifestyle changes.
• Identify potential facilitators and barriers to intervention.

7. Vaccination Status and Preventive Health:

• Confirm tetanus booster status and consider pneumococcal vaccination, particularly given his smoking history.

By gathering this additional data, I can better stratify his risk and tailor preventive strategies in line with RACGP Red Book recommendations.

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Q2: How would you assess and communicate Michael’s absolute cardiovascular risk?

Answer:

Assessment:

• I would use the Australian Absolute Cardiovascular Disease Risk Calculator, which factors in age, gender, systolic BP, total cholesterol/HDL ratio, smoking status, diabetes status, and family history.
• For Michael:
  • Age: 54
  • Systolic BP: 148 mmHg
  • Smoker
  • Total cholesterol: 6.5 mmol/L
  • HDL: 0.9 mmol/L
  • No diabetes (but pre-diabetes HbA1c 5.9%)
• His calculated 5-year absolute cardiovascular risk would likely exceed 15%, categorising him as high risk.

Communication:

• I would use clear, non-technical language and visual aids, such as the risk chart, to explain his current risk and potential risk reduction.
• For example:
  “Based on your risk factors, your chance of having a heart attack or stroke in the next 5 years is about 1 in 5. But we can significantly reduce this risk by making some changes.”

Shared Decision-Making:

• Engage Michael by asking about his concerns and priorities.
• Emphasise that risk is modifiable and that he has control over many factors.

Discuss Next Steps:

• Lifestyle changes
• Medications (statins, blood pressure optimisation)
• Ongoing monitoring and support

The goal is to empower him, ensuring he understands both the risks and benefits of interventions.

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Q3: What preventive interventions would you recommend for Michael today?

Answer:

1. Lifestyle Modifications:

• Smoking Cessation: Strongly advise quitting, offer NRT and referral to Quitline.
• Dietary Changes: Recommend Mediterranean-style diet, reduce saturated fats and salt.
• Physical Activity: Encourage at least 150 minutes/week of moderate-intensity exercise.
• Weight Management: Set realistic goals, e.g., 5-10% weight loss over 6 months.

2. Pharmacological Management:

• Statin Therapy: Initiate atorvastatin 40 mg daily, based on high absolute risk and elevated LDL.
• Antihypertensive Therapy: Review ramipril dose, consider titrating up or adding a second agent (e.g., amlodipine).
• Consider Low-dose Aspirin: Discuss risks and benefits, though guidelines advise caution in primary prevention unless clear indication.

3. Screening and Referrals:

• Refer to dietitian for individualised meal planning.
• Refer to exercise physiologist for structured program.
• Consider sleep study for obstructive sleep apnoea if clinically indicated.

4. Preventive Screening:

• Arrange ECG and consider coronary artery calcium scoring if available.
• Monitor HbA1c for progression towards diabetes.

5. Follow-Up:

• Review in 4 weeks for BP, lipid panel, and lifestyle progress.
• Regular 3-monthly reviews.

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Q4: How would you manage the challenges of providing preventive care in a rural setting?

Answer:

1. Access to Services:

• Leverage telehealth for dietitian and exercise physiologist consultations.
• Utilise local community programs or exercise groups.

2. Resource Limitations:

• Use online educational resources and mobile health apps for self-management.
• Partner with Primary Health Networks for funding/subsidised services.

3. Health Literacy and Engagement:

• Use simple language and culturally appropriate resources.
• Involve family in education and care planning.

4. Coordination of Care:

• Maintain accurate records in electronic health systems.
• Provide integrated care via regular GP management plans and team care arrangements.

5. Advocacy:

• Encourage local initiatives to promote healthy lifestyles.

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Q5: How would you ensure Michael’s ongoing engagement in preventive health?

Answer:

1. Rapport and Trust:

• Acknowledge his concerns about family history.
• Provide consistent support and empathy.

2. Motivational Interviewing:

• Explore ambivalence, focus on why change matters to him.
• Identify intrinsic motivators (e.g., family, future health).

3. Goal Setting:

• Establish SMART goals (e.g., reduce smoking by half in 1 month).
• Track progress using simple charts or apps.

4. Regular Follow-Up:

• Book reviews in advance.
• Use reminder systems for appointments and screening.

5. Celebrate Successes:

• Reinforce positive changes.
• Highlight improvements (e.g., weight loss, BP control).

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive cardiovascular risk assessment, including lifestyle and psychosocial factors
• Accurate communication of absolute risk and shared decision-making
• Evidence-based lifestyle and pharmacological interventions
• Practical strategies to address rural healthcare challenges
• Patient-centred engagement using motivational interviewing and goal setting

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PITFALLS

• Failure to use the absolute risk calculator
• Overlooking psychosocial factors or readiness for change
• Providing generic advice without tailoring to rural context
• Neglecting follow-up and continuity of care
• Using complex medical jargon instead of patient-friendly language

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REFERENCES

• RACGP Guidelines on Red Book
• Australian Cardiovascular Risk Calculator
• National Vascular Disease Prevention Alliance Guidelines

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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 information about health needs, considering the patient’s context and life stage.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses about health needs.
3.2 Demonstrates diagnostic reasoning and clinical judgment.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements patient-centred management plans.
4.2 Applies evidence-based medicine and shared decision-making.

5. Preventive and Population Health

5.1 Provides evidence-based advice, education, and intervention for health improvement.
5.2 Uses population health data to inform practice.

6. Professionalism

6.1 Adheres to ethical and professional standards, including confidentiality and respect.

7. General Practice Systems and Regulatory Requirements

7.1 Uses health information systems for quality improvement.
7.2 Adheres to preventive care guidelines in Australian general practice.

9. Managing Uncertainty

9.1 Manages uncertainty in preventive health and screening decisions.

12. Rural Health Context (RH)

RH1.1 Demonstrates understanding of rural health needs, including access and preventive health challenges.

Competency at Fellowship Level

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