CCE-CE-008

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Task 1: Take an appropriate history, including pain severity, impact on function, previous treatments, and comorbidities.

The competent candidate should:

• Elicit details of the knee pain, including:
  • Onset, duration, and progression over time.
  • Pain character and severity (dull, aching, morning stiffness, activity-related worsening).
  • Functional impact—difficulty walking, climbing stairs, prolonged sitting.
  • Exacerbating and relieving factors (weather, rest, movement).
  • Night pain or rest pain (may suggest more severe disease).
• Assess for systemic symptoms: Fever, weight loss, or joint swelling (to exclude inflammatory arthritis).
• Explore previous treatments, including:
  • Use of paracetamol, NSAIDs, or topical treatments.
  • Physiotherapy or exercise programs.
  • Supportive aids (e.g., knee brace, walking stick).
• Identify risk factors and comorbidities, including:
  • Obesity, diabetes, osteopenia/osteoporosis, history of joint injuries.
  • Cardiovascular risk factors (important when considering NSAID use).
• Clarify patient’s concerns and expectations, including:
  • Fear of disability or dependence.
  • Willingness to try non-surgical options.
  • Interest in surgery or concerns about long-term pain management.

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Task 2: Explain the likely diagnosis of knee osteoarthritis, differentiating it from other causes of knee pain.

The competent candidate should:

• Explain osteoarthritis (OA) in simple terms:
  • A wear-and-tear condition affecting joint cartilage, leading to pain, stiffness, and reduced mobility.
• Differentiate OA from other causes:
  • Rheumatoid arthritis: Typically affects multiple joints, with prolonged morning stiffness and systemic symptoms.
  • Gout: Sudden onset, severe pain, and swelling, often in the first MTP joint.
  • Meniscal tear: Acute pain with locking or clicking.
• Explain the natural progression of OA:
  • Symptoms may fluctuate but can be managed effectively with lifestyle changes and treatment.
• Discuss imaging:
  • X-rays only if diagnosis is uncertain or for surgical planning.
  • MRI not routinely needed unless suspecting soft tissue pathology.

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Task 3: Discuss a multimodal management plan, incorporating lifestyle, physiotherapy, pharmacological, and potential surgical options.

The competent candidate should:

• First-line treatment: Non-pharmacological management
  • Physiotherapy referral for muscle strengthening, joint mobilisation.
  • Exercise therapy: Low-impact activities like swimming, cycling, strength training.
  • Weight loss (each kg lost reduces knee load by ~4 kg).
  • Use of walking aids (e.g., walking stick, supportive footwear, knee braces).
• Second-line treatment: Pharmacological options
  • Paracetamol first-line for mild pain.
  • NSAIDs (topical or oral) for flare-ups, but consider cardiovascular and GI risks.
  • Capsaicin cream may help.
  • Intra-articular steroid injections for short-term relief in moderate-severe OA.
• Third-line: Surgical options
  • Consider total knee replacement if pain is severe and function is significantly limited.
  • Arthroscopy generally not recommended for OA.
• Address patient expectations:
  • OA is a chronic condition but can be managed effectively without immediate surgery.

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Task 4: Address the patient’s concerns about pain relief and mobility.

The competent candidate should:

• Acknowledge the patient’s concerns about mobility loss and independence.
• Reassure that pain management is possible with a structured approach.
• Offer practical solutions:
  • Encouraging low-impact exercise, pacing activities, and maintaining joint movement.
  • Discussing joint protection strategies to reduce further deterioration.
• Address concerns about medication safety:
  • NSAIDs should be used cautiously with hypertension and osteopenia.
  • Regular monitoring and stepwise approach to pain management.
• Encourage ongoing engagement:
  • Plan for regular follow-ups to monitor symptoms and adjust treatment.

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SUMMARY OF A COMPETENT ANSWER

• Takes a thorough history of knee pain, including functional impact, previous treatments, and comorbidities.
• Provides a clear and structured explanation of osteoarthritis, differentiating it from inflammatory conditions.
• Develops a multimodal management plan, emphasising lifestyle, physiotherapy, and stepwise pain relief.
• Discusses surgical options appropriately, considering timing, risks, and alternatives.
• Addresses patient concerns empathetically and encourages proactive management strategies.

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PITFALLS

• Failing to assess the full impact on mobility and daily activities.
• Jumping to pharmacological treatment without emphasising non-drug strategies first.
• Not differentiating osteoarthritis from inflammatory arthritis, leading to misdiagnosis.
• Not discussing patient expectations and concerns about surgery.
• Using medical jargon rather than explaining OA in simple terms.

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REFERENCES

• RACGP Guidelines for Osteoarthritis Management
• GP Exams – Osteoarthritis

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MARKING

Each competency area is assessed on a 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 Communicates effectively and empathetically about chronic pain.
1.3 Engages the patient in shared decision-making regarding management options.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive history of knee pain and functional limitations.

3. Diagnosis, Decision-Making and Reasoning

3.1 Diagnoses osteoarthritis based on clinical presentation.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate non-surgical management plan.
4.3 Discusses pharmacological and surgical options when necessary.

5. Preventive and Population Health

5.1 Provides education on joint protection and long-term osteoarthritis management.

6. Professionalism

6.2 Provides patient-centred and empathetic care.

7. General Practice Systems and Regulatory Requirements

7.1 Engages with chronic disease management and referrals as appropriate.

9. Managing Uncertainty

9.1 Recognises when further investigations (e.g., X-ray, specialist referral) are needed.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies severe osteoarthritis requiring specialist review.

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Competency at Fellowship Level

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