CCE-CBD-077

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the key risk factors identified in Peter’s case, and how would you address them?

• Prompt: Explore cardiovascular risk, smoking, alcohol, obesity, family history
• Prompt: Use motivational interviewing to explore readiness for change

Q2. What preventive screening and immunisations would you recommend for Peter?

• Prompt: Age-appropriate screening (e.g., bowel cancer, prostate health if appropriate)
• Prompt: Immunisations for adults (influenza, pneumococcal, shingles)

Q3. How would you manage Peter’s cardiovascular risk in this consultation?

• Prompt: Absolute cardiovascular risk assessment
• Prompt: Lifestyle modifications and pharmacotherapy options

Q4. How would you approach Peter’s alcohol use?

• Prompt: Brief intervention techniques
• Prompt: Harm minimisation and referral options

Q5. How would you follow up and coordinate Peter’s care?

• Prompt: GPMP/TCA referral
• Prompt: Allied health engagement and regular reviews
• Prompt: Medicare item numbers and practice nurse involvement

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are the key risk factors identified in Peter’s case, and how would you address them?

The competent candidate should:

• Identify key risk factors, including smoking (20 cigarettes/day), obesity (BMI 32 kg/m²), excessive alcohol use (5-6 standard drinks nightly), poor diet, sedentary lifestyle, family history of IHD and Type 2 diabetes, and elevated BP (145/95 mmHg).
• Discuss absolute cardiovascular risk assessment using the Australian CVD Risk Calculator. Peter’s risk is likely high due to multiple risk factors.
• Engage Peter in a discussion around the importance of lifestyle modifications, using motivational interviewing to explore readiness to change, barriers, and personal motivators.
• Provide brief interventions for smoking cessation, including Nicotine Replacement Therapy (NRT) options and referral to Quitline.
• Address alcohol use with AUDIT-C screening, followed by brief intervention strategies and harm minimisation, highlighting NHMRC guidelines on alcohol consumption limits.
• Encourage dietary changes, referring Peter to a dietitian for tailored advice on weight reduction and healthy eating.
• Recommend increasing physical activity, aiming for 150-300 minutes per week of moderate-intensity exercise, and consider referral to an exercise physiologist.
• Explain the role of pharmacotherapy, such as antihypertensives or lipid-lowering therapy, if required based on risk calculation.
• Offer follow-up appointments to monitor progress and adjust the management plan.

Q2: What preventive screening and immunisations would you recommend for Peter?

The competent candidate should:

• Recommend National Bowel Cancer Screening Program (NBCSP) with a FOBT given Peter is over 50 and has never participated.
• Discuss Prostate Specific Antigen (PSA) testing after explaining pros and cons in line with RACGP Red Book guidelines and shared decision-making.
• Recommend cardiovascular screening, including fasting lipids and HbA1c/fasting glucose.
• Address vaccination status:
  • Offer Influenza vaccine (annually).
  • Recommend Pneumococcal vaccination (Prevenar 13 then Pneumovax 23) as per Australian Immunisation Handbook.
  • Discuss Shingles vaccination (Shingrix) for adults ≥50 years.
  • Confirm COVID-19 booster status and offer if appropriate.

Q3: How would you manage Peter’s cardiovascular risk in this consultation?

The competent candidate should:

• Perform an absolute cardiovascular risk assessment, which is likely high given multiple risk factors.
• Explain the risk score to Peter in simple terms, using visual aids if necessary.
• Recommend lifestyle interventions as first-line management: smoking cessation, alcohol reduction, dietary changes, and exercise.
• Discuss the potential need for pharmacological treatment:
  • Antihypertensives for BP ≥140/90 if lifestyle changes insufficient after 3 months.
  • Statin therapy for primary prevention if risk ≥10%, as per NVDPA guidelines.
• Order baseline ECG and urinalysis (ACR) for renal risk assessment.
• Create a GPMP to structure care and allow chronic disease management planning.
• Plan for 3-monthly follow-ups to assess BP, lipids, and medication adherence.

Q4: How would you approach Peter’s alcohol use?

The competent candidate should:

• Acknowledge Peter’s disclosure respectfully, ensuring a non-judgmental tone.
• Assess using AUDIT-C, with likely hazardous drinking.
• Provide brief intervention using the FRAMES model (Feedback, Responsibility, Advice, Menu of options, Empathy, Self-efficacy).
• Educate on safe alcohol limits (≤10 standard drinks per week; no more than 4 drinks per occasion as per NHMRC).
• Discuss health risks (liver disease, hypertension, cancer risk).
• Explore motivators for change and barriers (e.g., stress, social drinking).
• Offer referral to an alcohol counsellor, Drug and Alcohol services, or psychologist for behavioural interventions.
• Schedule follow-up to monitor progress and review drinking behaviour.

Q5: How would you follow up and coordinate Peter’s care?

The competent candidate should:

• Arrange regular follow-ups (every 3 months initially) to review cardiovascular risk, BP, smoking cessation, alcohol use, and weight.
• Implement a GPMP and TCA to coordinate care with:
  • Dietitian for weight management and healthy eating.
  • Exercise physiologist to tailor an exercise program.
  • Psychologist for support with behaviour change and alcohol reduction if needed.
• Involve the practice nurse in lifestyle education, vaccination, and monitoring BP and weight.
• Discuss Medicare item numbers for chronic disease management.
• Provide written materials and direct to reputable websites (e.g., Heart Foundation, Quitline, NDSS).
• Ensure continuity of care and document discussions, assessments, and agreed management plans.

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SUMMARY OF A COMPETENT ANSWER

• Identifies multiple modifiable risk factors, including smoking, alcohol, obesity, hypertension, and family history.
• Performs absolute cardiovascular risk assessment and explains results clearly.
• Implements age-appropriate preventive screening and vaccination per Australian guidelines.
• Uses motivational interviewing and brief interventions for smoking and alcohol cessation.
• Establishes a structured management and follow-up plan, including allied health referrals and Medicare-supported care plans.

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PITFALLS

• Failing to perform an absolute cardiovascular risk assessment or explain it to the patient.
• Missing preventive screening opportunities, such as colorectal cancer screening.
• Not addressing ambivalence or resistance to lifestyle changes.
• Inadequate exploration of alcohol use, missing dependence risks.
• Failure to involve multidisciplinary team or initiate GPMP/TCA for coordinated care.

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REFERENCES

• RACGP Guidelines (Red Book)
• Australian Cardiovascular Disease Risk Calculator
• NHMRC Guidelines for Alcohol
• Australian Immunisation Handbook

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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 Elicits an appropriate history informed by the patient’s context.

3. Diagnosis, Decision-Making and Reasoning

3.2 Demonstrates diagnostic reasoning with consideration of differentials.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a management plan with appropriate treatments and referrals.
4.2 Explains therapeutic options and engages in shared decision making.

5. Preventive and Population Health

5.1 Provides advice on preventive activities including screening, immunisation and lifestyle modification.

6. Professionalism

6.1 Demonstrates ethical practice and professional responsibility.

7. General Practice Systems and Regulatory Requirements

7.1 Uses appropriate systems to facilitate continuity of care and clinical handover.

9. Managing Uncertainty

9.1 Recognises and manages clinical uncertainty.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises potentially serious conditions requiring further investigation or intervention.

Competency at Fellowship Level

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