CCE-CBD-079.1

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: How would you approach John’s concerns in today’s consultation?

Approach to John’s concerns involves empathetic communication, validation of his feelings, and exploration of his ideas, concerns, and expectations (ICE framework).

• Establish Rapport: Greet John warmly, acknowledge his concerns, and provide reassurance that this is a safe space to discuss his health.
• Explore Concerns (ICE Framework):
  • Ideas: “What do you think might be going on with your health?”
  • Concerns: “What is worrying you the most?”
  • Expectations: “What are you hoping we can do today?”
• Acknowledge and Validate Feelings:
  • Reflect his emotions: “It’s understandable to feel worried after losing loved ones.”
  • Normalise his reaction without dismissing it.
• Clarify the Health Inquiry:
  • Emphasise the difference between routine screening and unnecessary testing.
  • Address anxiety-driven health-seeking behaviour gently.
• Reassure with Clinical Findings:
  • Share that his examination is reassuring and no red flags are present.
• Set a Collaborative Plan:
  • Offer structured, evidence-based investigations.
  • Discuss a follow-up plan to build continuity and trust.
• Address Health Anxiety Directly (if appropriate):
  • Introduce the concept that health anxiety might be contributing to his distress.
  • Suggest exploring strategies or referrals for anxiety management.

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Q2: What are the potential harms of ordering unnecessary tests or scans?

Harms of unnecessary testing include overdiagnosis, psychological distress, physical risks, and economic costs.

• Overdiagnosis:
  • Detection of incidental findings (incidentalomas) that are benign but may lead to further unnecessary investigations and procedures.
• False Positives/Negatives:
  • False positives can lead to invasive tests, causing harm and anxiety.
  • False negatives may give false reassurance, delaying appropriate medical care later.
• Radiation Exposure:
  • Imaging modalities like CT scans expose patients to radiation, increasing long-term cancer risk.
• Psychological Impact:
  • More tests may reinforce anxiety, creating a cycle of dependency on medical testing rather than addressing underlying fears.
• Economic Costs:
  • Both to the healthcare system and to the individual (if not covered by Medicare).
• Clinical Guidelines:
  • RACGP’s Red Book recommends targeted screening based on risk, not comprehensive “check-ups” without indication.
• Shared Decision-Making:
  • Involve John in the decision-making process, explaining why evidence-based, targeted approaches are safer and more beneficial.

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Q3: What are the appropriate investigations and preventive health measures for John’s age and risk factors?

For a 39-year-old male with a family history of premature cardiovascular disease, the following are recommended:

• Cardiovascular Risk Assessment:
  • Absolute CVD risk calculator.
  • BP measurement (already done), lipid profile, fasting glucose/HbA1c.
• Weight and Lifestyle:
  • BMI (29 kg/m² – overweight).
  • Diet, exercise, smoking, and alcohol history.
• Cancer Screening:
  • Bowel Cancer Screening: Eligible due to family history. Offer FOBT or refer for colonoscopy if high-risk.
  • Skin Check: Given Australian sun exposure risks.
  • Prostate Screening: Discuss PSA testing—shared decision-making following RACGP guidelines.
• Mental Health Screening:
  • Use GAD-7 or Health Anxiety Inventory to screen for health anxiety.
• Vaccinations:
  • Confirm influenza and COVID-19 vaccinations are current.
  • Consider pneumococcal and shingles vaccines if applicable in future reviews.
• Health Promotion:
  • Smoking cessation if applicable (John is a non-smoker).
  • Alcohol consumption within national guidelines.
  • Encourage exercise—at least 150 minutes of moderate activity per week.

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Q4: How would you manage John’s health anxiety moving forward?

Management of health anxiety involves recognition, education, and structured follow-up.

• Acknowledge Anxiety:
  • Empathically explain that his symptoms may be linked to health anxiety, not physical illness.
• Psychoeducation:
  • Educate about health anxiety—explain the brain’s response to fear and how it can create physical sensations and reinforce worry.
• Psychological Therapies:
  • Recommend CBT (Cognitive Behavioural Therapy), which is first-line treatment.
  • Discuss referral to a psychologist via Mental Health Treatment Plan (MHTP).
• Lifestyle Modifications:
  • Encourage regular physical activity, stress management (e.g., mindfulness, meditation).
• Limit Testing:
  • Set boundaries around investigations to avoid reinforcing anxiety.
• Structured Follow-up:
  • Regular reviews (e.g., monthly), offering reassurance and a consistent therapeutic relationship.
• Medication (if appropriate):
  • Consider SSRI if anxiety is severe and impairing function, in collaboration with mental health services.

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Q5: What role does continuity of care and GP systems play in managing patients with health anxiety?

Continuity of care is essential in building trust, reducing unnecessary interventions, and improving outcomes.

• Consistent GP Relationship:
  • Encourages patient trust, reducing the need for repetitive histories and unnecessary tests.
• GP Management Plans (GPMPs):
  • Useful for chronic disease management and mental health conditions, ensuring structured care.
• Referral Pathways:
  • Efficient use of referrals to psychology and allied health services under Medicare.
• Practice Systems:
  • Implement recall systems for preventive care and regular follow-ups.
• Documentation:
  • Comprehensive, accurate documentation of consultations helps maintain consistency of care.
• Team-Based Approach:
  • Involve practice nurses, mental health nurses, and allied health professionals in care planning.

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SUMMARY OF A COMPETENT ANSWER

• Uses empathetic communication to validate and explore the patient’s concerns.
• Explains the risks of overdiagnosis and unnecessary testing clearly and supportively.
• Focuses on evidence-based investigations and preventive health relevant to the patient’s risk profile.
• Addresses health anxiety through education, psychological referral, and structured care.
• Promotes continuity of care and the importance of a therapeutic relationship with a regular GP.

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PITFALLS

• Ordering unnecessary tests to appease the patient, reinforcing anxiety.
• Failing to address underlying health anxiety, focusing solely on physical health.
• Not involving the patient in shared decision-making, leading to mistrust.
• Inconsistent follow-up, reducing the efficacy of therapeutic interventions.
• Ignoring preventive health opportunities, such as cardiovascular risk reduction.

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REFERENCES

• RACGP Guidelines for Preventive Activities in General Practice (Red Book)
• Health Anxiety on Beyond Blue
• Cardiovascular Absolute Risk Calculator

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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.
2.2 Performs an appropriate physical examination.

3. Diagnosis, Decision-Making and Reasoning

3.1 Selects appropriate investigations.
3.2 Demonstrates diagnostic reasoning considering 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.

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.

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 intervention.

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Competency at Fellowship Level

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