CCE-CBD-176

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you approach Karen’s concerns and gather relevant information?

• Prompt: Explore the psychosocial impact of her diabetes and disability
• Prompt: Clarify her understanding of her current health and future risks
• Prompt: Assess her ideas, concerns, and expectations (ICE framework)

Q2. What are the possible reasons for Karen’s functional limitations and how would you address uncertainty?

• Prompt: Discuss diabetic complications (neuropathy, hypoglycaemia unawareness)
• Prompt: Consider musculoskeletal factors (arthritis, falls risk)
• Prompt: Explain rationale for investigations and referrals (endocrinologist, diabetes educator, podiatrist)

Q3. What would your management plan be today?

• Prompt: Optimise diabetes control (insulin adjustment, CGM consideration)
• Prompt: Address falls prevention (podiatry, physiotherapy, home safety)
• Prompt: Discuss psychosocial supports and referral for NDIS

Q4. How would you address Karen’s preventive health needs?

• Prompt: Vaccinations (shingles, annual influenza, pneumococcal)
• Prompt: Regular eye and foot reviews
• Prompt: Cardiovascular risk reduction (BP, lipids, smoking cessation if relevant)

Q5. What are the key considerations in managing Karen’s long-term disability and ensuring coordinated care?

• Prompt: Advance care planning discussions if appropriate
• Prompt: NDIS eligibility and application process
• Prompt: Multidisciplinary care team involvement

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: How would you approach Karen’s concerns and gather relevant information?

Answer:

When approaching Karen’s concerns, it’s crucial to adopt a patient-centred communication style, ensuring empathy and understanding of her lived experience with chronic disease and disability.

Establish rapport and set an agenda:

• Greet Karen warmly, acknowledge her long journey with diabetes, and outline the purpose of today’s review.
• Confirm Karen’s key concerns: her functional limitations, fear of losing independence, frequent hypoglycaemic episodes, and quality of life issues.

Explore psychosocial impacts:

• Use open-ended questions to explore how diabetes is affecting her daily life (e.g., “How has this been impacting your ability to do the things you enjoy?”).
• Elicit her ICE framework:
  • Ideas: What does Karen think is happening? Does she link symptoms to her diabetes or something else?
  • Concerns: What is she worried about most? E.g., fear of falls, hypoglycaemia, loss of independence.
  • Expectations: What does she hope to achieve from this consultation? E.g., improving management, discussing NDIS options.

Assess functional status:

• Ask about activities of daily living (ADLs) and instrumental activities of daily living (IADLs), such as shopping, meal prep, and personal care.
• Discuss her falls risk, unsteadiness, and fear of leaving her home.

Review medical management issues:

• Ask about blood glucose monitoring practices and insulin administration routine.
• Confirm awareness of hypoglycaemia signs and self-management strategies.
• Explore her pain from neuropathy, impact on sleep, and whether medications are effective.

Screen for mental health concerns:

• Explore mood symptoms, including depression or anxiety, which are common in chronic disease.
• Consider using tools like the PHQ-9 or K10 if appropriate.

Summarise and clarify goals for the consultation:

• Reassure Karen that we will address her concerns and work on a holistic, team-based management plan.

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Q2: What are the possible reasons for Karen’s functional limitations and how would you address uncertainty?

Answer:

Karen’s functional limitations stem from a combination of factors, primarily related to her diabetes complications and musculoskeletal issues.

Differential diagnosis of her limitations:

• Peripheral neuropathy: causing sensory loss, balance issues, and increased falls risk.
• Hypoglycaemia unawareness: due to long-standing T1DM, leading to dangerous low blood sugars without symptoms.
• Musculoskeletal factors: Osteoarthritis in knees, limiting mobility and increasing fatigue.
• Psychosocial factors: Potential depression or social isolation impacting motivation and daily functioning.
• Medication side effects: Pregabalin may contribute to sedation or dizziness.

Addressing clinical uncertainty:

• Acknowledge the complex interplay of factors.
• Arrange for objective assessments:
  • Podiatry review for neuropathic changes and footwear assessment.
  • Physiotherapy for gait and balance training.
  • Consider endocrinology input for optimising glycaemic control.
• Introduce continuous glucose monitoring (CGM) as a way to better manage unpredictable blood glucose patterns.

Communicating uncertainty:

• Be transparent about the complexity of managing chronic diabetes with multiple comorbidities.
• Offer reassurance and safety-netting by maintaining close follow-up, especially during any medication or insulin regimen changes.

Collaborative decision-making:

• Engage Karen in shared decision-making and provide written action plans for hypoglycaemia management and falls prevention.

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Q3: What would your management plan be today?

Answer:

A multifaceted management plan addressing glycaemic control, functional ability, and psychosocial wellbeing is critical.

Optimising diabetes control:

• Refer to a diabetes educator for insulin regimen review; consider basal-bolus adjustments or insulin pump therapy.
• Strongly recommend CGM to reduce hypoglycaemic episodes and improve confidence.
• Reinforce self-monitoring of blood glucose and hypo recognition education.

Falls risk and mobility:

• Arrange physiotherapy for strength and balance training.
• Discuss home modifications and occupational therapy input (NDIS may fund).
• Podiatry review for footwear and pressure area management.

Pain management:

• Review pregabalin dose; explore alternatives or adjuncts (duloxetine, amitriptyline if appropriate).
• Assess impact on sleep and function; adjust accordingly.

Psychosocial support:

• Discuss NDIS application; provide medical reports to support eligibility.
• Offer referral to a social worker for NDIS navigation and community services.
• Explore mental health support, consider a GP Mental Health Care Plan.

Education and empowerment:

• Provide clear written instructions and resources.
• Encourage peer support groups (Diabetes Australia).

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Q4: How would you address Karen’s preventive health needs?

Answer:

Vaccinations:

• Recommend zoster vaccine (Shingrix) due to age and immunocompromised risk from diabetes.
• Confirm influenza and pneumococcal vaccines are up to date.

Cardiovascular risk management:

• Continue atorvastatin and ramipril for lipid and BP control.
• Regularly monitor BP and lipid targets (BP <130/80; LDL <2.0 mmol/L).
• Reinforce healthy diet and exercise advice (tailored to her mobility).

Foot care:

• Annual foot assessments, or more frequent due to neuropathy.
• Educate on daily self-exams and importance of foot hygiene.

Retinal screening:

• Ensure annual ophthalmology follow-up.

Renal monitoring:

• Regular eGFR and ACR testing; monitor for progression of diabetic nephropathy.

Advance care planning:

• Raise advance care directives gently, discussing future healthcare preferences if appropriate.

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Q5: What are the key considerations in managing Karen’s long-term disability and ensuring coordinated care?

Answer:

NDIS and Disability Support:

• Confirm she meets NDIS criteria (under 65, permanent and significant disability).
• Provide supporting medical documentation detailing the functional impact of her diabetes and neuropathy.
• Referral to an NDIS Local Area Coordinator (LAC) or advocate.

Multidisciplinary care team:

• Engage:
  • Endocrinologist for complex diabetes management.
  • Diabetes educator for insulin optimisation.
  • Podiatrist and physiotherapist for mobility and foot care.
  • Occupational therapist for functional aids and home safety.
  • Mental health support via psychologist or GP Mental Health Care Plan.

Care coordination:

• Develop a GP Management Plan (GPMP) and Team Care Arrangements (TCA).
• Schedule regular reviews to monitor progress and adjust care.
• Provide clear communication between services.

Future planning:

• Discuss advance care planning sensitively.
• Encourage Karen to involve family in decision-making.

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SUMMARY OF A COMPETENT ANSWER

• Patient-centred communication addressing Karen’s concerns and expectations.
• Thorough differential diagnosis exploring diabetic complications and musculoskeletal issues.
• Comprehensive management plan, including optimisation of diabetes control, pain management, and falls prevention.
• Preventive health measures including vaccinations, cardiovascular risk management, and regular screening.
• NDIS and disability support navigation, with a focus on multidisciplinary care and coordinated planning.

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PITFALLS

• Failing to explore psychosocial impacts, including mood and social support.
• Overlooking hypoglycaemia unawareness as a key contributor to functional decline.
• Inadequate preventive health planning, e.g., missing vaccinations or screening.
• Delaying NDIS referral or providing insufficient documentation for disability supports.
• Neglecting a multidisciplinary approach, resulting in fragmented care.

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REFERENCES

• RACGP Red Book
• Diabetes Australia on NDIS and Diabetes
• National Diabetes Services Scheme
• Australian Diabetes Society on Guidelines for the Management of Type 1 Diabetes
• RACGP Managing Diabetes in Older People

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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 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 and health determinants.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and tests hypotheses and makes evidence-based decisions.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements appropriate management plans.

5. Preventive and Population Health

5.1 Provides healthcare that anticipates and addresses social determinants of health.

6. Professionalism

6.1 Demonstrates ethical behaviour and professional integrity.

7. General Practice Systems and Regulatory Requirements

7.1 Uses quality and safety systems in practice.

8. Procedural Skills

8.1 Performs procedures safely and effectively.

9. Managing Uncertainty

9.1 Manages uncertainty in clinical practice.

10. Identifying and Managing the Patient with Significant Illness

10.1 Manages patients with chronic and complex health conditions.

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Competency at Fellowship Level

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