CCE-CBD-147.1

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses for John’s leg symptoms?

A competent candidate should recognise that John’s intermittent claudication is characteristic of peripheral arterial disease but should also explore other potential causes.

• Peripheral Arterial Disease (PAD): Classic claudication symptoms, relieved by rest, exacerbated by activity, diminished peripheral pulses, and reduced ABI support this diagnosis.
• Spinal stenosis/neurogenic claudication: Similar presentation, but often associated with relief by sitting/flexion rather than simply stopping, may include lower back pain, altered reflexes, and neurological findings.
• Chronic venous insufficiency: Leg heaviness rather than pain; swelling, skin changes, and ulcers more common.
• Diabetic peripheral neuropathy: Presents with burning, tingling, and sensory deficits, typically not activity-related.
• Musculoskeletal causes: Osteoarthritis or muscle strain.
• Red flags: Acute limb ischaemia, critical limb-threatening ischaemia (rest pain, ulceration, gangrene) would necessitate urgent referral.

Q2: What investigations have you done, and are any further tests required?

The competent candidate should show structured reasoning for the use of investigations:

• Ankle-Brachial Index (ABI): Already done, confirms moderate PAD (ABI 0.6).
• Duplex Ultrasound: Already done, confirms significant stenosis in the superficial femoral arteries.
• Blood tests: Full blood count, renal function, lipid profile, HbA1c for cardiovascular risk stratification and diabetes control.
• Further imaging: CT Angiography or MR Angiography may be considered if surgical intervention is anticipated or for vascular surgery referral planning.
• Cardiovascular risk assessment: Absolute cardiovascular risk calculator (as per RACGP Red Book) to guide intensity of secondary prevention strategies.

Q3: Outline your management plan for John’s peripheral vascular disease.

A competent candidate would develop a comprehensive management plan:

• Lifestyle: Smoking cessation (reinforce benefits even after quitting), graduated walking program (30-45 min, 3-5 days/week), weight management, dietary advice focusing on cardiovascular health.
• Pharmacological: Antiplatelet therapy (aspirin 100 mg or clopidogrel if intolerant), statin therapy (intensify as needed), optimise antihypertensives (target <130/80 mmHg), tight glycaemic control.
• Procedural: Discuss potential revascularisation options (angioplasty, bypass surgery) if symptoms fail to improve or critical limb ischaemia develops.
• Rural context: Access to allied health services (podiatry, exercise physiologist), telehealth vascular surgeon consults, community nursing for foot care.

Q4: How would you explain the diagnosis and treatment options to John?

A competent candidate demonstrates effective communication skills:

• Explanation: Simple, non-medical language. “Your leg arteries have narrowed because of a build-up of fatty deposits over time, reducing blood flow when you walk.”
• Management options: Walking therapy can improve symptoms. Medications to protect the heart and improve circulation. Surgery is an option if these do not help.
• Prognosis: Slow disease progression is possible with treatment. Increased risk of heart attack or stroke—managing risk factors is essential.
• Addressing concerns: Validate his anxiety about surgery. Explain it’s not always required and decisions will be made together with a specialist.

Q5: What preventive measures and long-term monitoring would you implement?

A competent candidate integrates preventive and chronic disease management:

• Cardiovascular risk reduction: Aggressive management of blood pressure, lipids, and diabetes; aspirin/clopidogrel; statins.
• Lifestyle: Smoking cessation (ongoing reinforcement), physical activity, dietitian input.
• Screening for complications: Regular foot checks (neuropathy, ulcers), renal function monitoring if on ACE inhibitors.
• Vaccinations: Ensure influenza, pneumococcal, and COVID-19 vaccination are up to date.
• Follow-up: 3-6 monthly reviews depending on control, more frequent if deteriorating symptoms.
• Allied health and rural support: Involve diabetes educator, exercise physiologist, potential telehealth specialist review.

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SUMMARY OF A COMPETENT ANSWER

• Clear differentials, including neurogenic claudication, diabetic neuropathy.
• Appropriate investigations, including ABI, duplex, and consideration of advanced imaging.
• Comprehensive management, including lifestyle, medications, and potential interventions.
• Patient-centred communication, explaining diagnosis and management clearly.
• Preventive care and monitoring, cardiovascular risk reduction, and rural practice considerations.

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PITFALLS

• Missing critical diagnoses such as neurogenic claudication or venous disease.
• Failure to assess cardiovascular risk comprehensively.
• Overlooking lifestyle interventions, focusing only on medications or surgery.
• Inadequate communication, not addressing patient concerns about surgery.
• Neglecting rural access issues, including allied health referrals and telehealth opportunities.

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REFERENCES

• RACGP Red Book (9th edition)
• Therapeutic Guidelines on Cardiovascular
• Australian Absolute Cardiovascular Risk Calculator
• Murtagh’s General Practice, 8th Edition (2022)

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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.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses.
3.2 Demonstrates diagnostic reasoning and clinical judgement.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans.
4.2 Provides appropriate advice and support.

5. Preventive and Population Health

5.1 Provides advice and interventions to promote wellbeing.

6. Professionalism

6.1 Adheres to ethical and professional standards.

7. General Practice Systems and Regulatory Requirements

7.1 Uses health information systems appropriately.

9. Managing Uncertainty

9.1 Manages uncertainty in clinical decision-making.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and manages serious and life-threatening conditions.

12. Rural Health Context (RH)

RH1.1 Manages complex care within a rural and remote context.

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Competency at Fellowship Level

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