EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you approach Sarah’s request for a neurologist referral?

• Prompt: How would you explore her concerns and expectations?
• Prompt: What clinical reasoning would you provide for or against the referral?

Q2. What red flags would indicate the need for urgent neuroimaging or referral?

• Prompt: What features of Sarah’s presentation are reassuring?
• Prompt: What additional symptoms or signs would change your management approach?

Q3. How would you manage Sarah’s headaches if no red flags are present?

• Prompt: What are the likely causes of her headaches?
• Prompt: What treatment strategies would you suggest?

Q4. Sarah is anxious about missing a serious diagnosis. How would you counsel her?

• Prompt: How would you provide reassurance while addressing her anxiety?
• Prompt: What follow-up strategies would be appropriate?

Q5. What preventive strategies can Sarah implement to manage her headaches and anxiety long-term?

• Prompt: What lifestyle modifications may be beneficial?
• Prompt: How can non-pharmacological treatments help?

---

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you approach Sarah’s request for a neurologist referral?

Sarah’s concern about a brain tumour should be acknowledged empathetically while exploring her ideas, concerns, and expectations.

Key Steps:

1. Elicit Her Concerns & Expectations
   • “Can you tell me what’s worrying you the most about your headaches?”
   • “What are you hoping to achieve with a neurology referral?”
2. Assess Clinical Need for Referral
   • Based on history and examination, her headaches are most consistent with tension-type headaches, exacerbated by stress and anxiety.
   • No red flags for a serious intracranial cause.
3. Explain Clinical Reasoning
   • “Your neurological exam is normal, and your symptoms are typical of tension headaches rather than a brain tumour.”
   • “An MRI or neurologist referral is not needed at this stage, but we can review if symptoms change.”
4. Provide Alternative Management
   • Focus on headache triggers, stress management, and lifestyle changes.
   • Offer a safety-net plan, ensuring she feels supported.

The key is to validate her concerns while ensuring evidence-based care.

---

Q2: What red flags would indicate the need for urgent neuroimaging or referral?

Features warranting urgent imaging or referral:

• New-onset headaches in patients >50 years.
• Rapidly worsening or persistent headaches (>3 months without improvement).
• Neurological deficits (e.g., focal weakness, vision loss).
• Morning headaches with vomiting (raised ICP).
• Headache with fever, stiff neck, or altered mental state.

Reassuring Features in Sarah’s Case:

• Normal neurological exam.
• No progressive worsening.
• **Symptoms suggest tension-type headaches rather than an intracranial lesion.

A watchful waiting approach with follow-up is reasonable in her case.

---

Q3: How would you manage Sarah’s headaches if no red flags are present?

1. Identify & Manage Triggers:

• Stress and anxiety reduction (CBT, mindfulness).
• Improving sleep hygiene.
• Reducing muscle tension (physiotherapy if needed).

2. Symptomatic Relief:

• Simple analgesia (paracetamol, ibuprofen) as needed.
• Avoid overuse of painkillers (risk of medication overuse headache).

3. Consider Preventive Therapy (if frequent headaches):

• Amitriptyline or nortriptyline for chronic tension-type headaches.

4. Follow-Up Plan:

• Review in 2–4 weeks.
• Escalate care if symptoms worsen or new symptoms develop.

---

Q4: Sarah is anxious about missing a serious diagnosis. How would you counsel her?

1. Acknowledge Her Fears
   • “It’s understandable to worry about something serious like a brain tumour.”
2. Explain Reassuring Features
   • “Your symptoms and exam findings are not concerning for a brain tumour.”
   • “Brain tumours typically cause progressive neurological symptoms, which you don’t have.”
3. Offer a Monitoring Plan
   • “We will monitor your symptoms and reassess if needed.”
4. Address Underlying Anxiety
   • Explore health anxiety concerns.
   • Consider psychological support if anxiety is affecting daily life.

Building trust and reassurance while maintaining clinical safety is key.

---

Q5: What preventive strategies can Sarah implement to manage her headaches and anxiety long-term?

1. Lifestyle Modifications:
   • Regular sleep schedule (reduce sleep deprivation triggers).
   • Balanced diet & hydration (avoid caffeine overuse).
   • Regular exercise (reduces stress-related headaches).
2. Psychological Strategies:
   • Cognitive behavioural therapy (CBT) for anxiety-related headaches.
   • Mindfulness meditation or relaxation techniques.
3. Medical Management (If Needed):
   • Optimise anxiety treatment (sertraline review, psychologist referral).
   • Trial headache prophylaxis (if headaches persist).
4. Follow-Up & Monitoring:
   • Review in 4–6 weeks to assess symptom progression.
   • Adjust management as needed.

Preventing headaches involves a multifaceted approach addressing physical, emotional, and lifestyle factors.

---

SUMMARY OF A COMPETENT ANSWER

• Explores patient’s concerns and expectations before addressing the request.
• Differentiates between benign and serious headache causes, ensuring red flags are excluded.
• Provides a clear clinical rationale for not referring, while offering supportive management strategies.
• Addresses underlying anxiety and fear of serious illness, with a structured safety-net plan.
• Emphasises preventive strategies, including stress management, sleep hygiene, and CBT.

PITFALLS

• Dismissing patient concerns too quickly, leading to dissatisfaction and loss of trust.
• Over-referring unnecessarily, increasing healthcare costs and patient anxiety.
• Failing to identify red flags, missing serious underlying pathology.
• Not addressing health anxiety, leading to recurrent presentations and over-investigation.
• Lack of follow-up planning, missing worsening or persistent symptoms.

REFERENCES

• RACGP – RACGP Guidelines for Preventive Activities in General Practice (Red Book)
• GP Exams – Clarify/discuss patient RFE/demand NOS

---

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 Elicits the patient’s concerns, expectations, and beliefs about their request.
1.2 Uses shared decision-making to explore appropriate management options.

2. Clinical Information Gathering and Interpretation

2.1 Takes a structured history to clarify the underlying issue behind the request.
2.2 Identifies any potential red flags requiring further assessment.

3. Diagnosis, Decision-Making and Reasoning

3.1 Determines the appropriateness of the patient’s request.
3.2 Balances patient autonomy with clinical safety and ethical considerations.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate response to the request, including alternative solutions if necessary.
4.2 Explains clinical reasoning to the patient in a way that is understandable and respectful.

5. Preventive and Population Health

5.1 Provides education on evidence-based management approaches relevant to the request.

6. Professionalism

6.1 Manages patient expectations with empathy while maintaining professional boundaries.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures compliance with medical guidelines and legal responsibilities.

9. Managing Uncertainty

9.1 Recognises when further assessment or specialist referral is warranted.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies when the request may indicate an underlying serious condition requiring further assessment.

Competency at Fellowship Level

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