CCE-CE-011

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history to assess the nature and severity of the patient’s symptoms and identify red flags.

The competent candidate should:

• Elicit a detailed history of symptoms, including onset, duration, frequency, and triggers of reflux symptoms.
• Differentiate GORD from other conditions, such as peptic ulcer disease, cardiac pathology, and functional dyspepsia.
• Ask about red flags requiring urgent referral:
  • Unintentional weight loss
  • Dysphagia or odynophagia
  • Persistent vomiting or haematemesis
  • Evidence of gastrointestinal bleeding (melaena)
  • Family history of gastric or oesophageal cancer
• Explore lifestyle and dietary habits, including alcohol intake, smoking, diet, and meal timing.
• Assess for risk factors in a rural setting, including limited access to investigations and specialist services.

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Task 2: Formulate a differential diagnosis and explain your reasoning to the patient.

The competent candidate should:

• Explain the most likely diagnosis: Gastro-oesophageal reflux disease (GORD), given the postprandial burning sensation, regurgitation, and symptom triggers.
• Provide a differential diagnosis, considering:
  • Peptic ulcer disease (pain relieved by food or antacids, nocturnal symptoms)
  • Functional dyspepsia (epigastric discomfort without acid regurgitation)
  • Cardiac causes (rule out angina with careful history-taking)
  • Eosinophilic oesophagitis (history of food impaction, allergies)
  • Malignancy (weight loss, progressive dysphagia, family history)
• Reassure the patient while explaining the importance of red flag symptoms.

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Task 3: Develop an appropriate initial management plan, including lifestyle advice, pharmacological treatment, and follow-up.

The competent candidate should:

• Recommend first-line lifestyle modifications, such as:
  • Avoiding trigger foods (spicy foods, alcohol, coffee)
  • Eating smaller meals and avoiding late-night eating
  • Sleeping with head elevation
  • Encouraging smoking cessation and alcohol reduction
• Initiate empirical treatment:
  • A trial of proton pump inhibitors (PPIs) for 4–8 weeks (e.g., omeprazole 20mg daily)
  • Consider H2-receptor antagonists if PPIs are not tolerated
  • Use antacids for symptomatic relief
• Arrange follow-up in 4–6 weeks to assess response and consider further investigation if symptoms persist.

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Task 4: Consider the rural context in planning investigations and specialist referral if needed.

The competent candidate should:

• Determine if endoscopy is needed, based on:
  • Persistent symptoms despite 8 weeks of PPI therapy
  • Presence of red flag symptoms
  • Long-standing reflux (>10 years) with risk of Barrett’s oesophagus
• Address access issues in a rural setting:
  • If endoscopy is required, consider referral to the nearest facility (90km away).
  • Use telehealth for specialist consultation where appropriate.
• Ensure continuity of care, particularly if referral or travel is required.

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SUMMARY OF A COMPETENT ANSWER

• Thorough history covering symptoms, red flags, lifestyle factors, and rural healthcare barriers.
• Appropriate differential diagnosis, ruling out peptic ulcer, cardiac causes, and malignancy.
• Clear explanation of diagnosis and management, ensuring patient understanding and engagement.
• Evidence-based treatment plan, including lifestyle advice, pharmacological therapy, and follow-up.
• Consideration of rural limitations, including access to investigations and referrals.

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PITFALLS

• Failing to recognise red flag symptoms requiring urgent investigation.
• Overlooking lifestyle factors that could be contributing to symptoms.
• Ignoring rural health barriers, such as access to endoscopy and specialist care.
• Not providing a stepwise management approach, including lifestyle and pharmacological interventions.
• Dismissing the patient’s concerns about malignancy due to family history.

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REFERENCES

• RACGP – GORD
• GP Exams – Oesophagus disease (GORD)

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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, and expectations.
1.5 Negotiates a shared management plan.

2. Clinical Information Gathering and Interpretation

2.1 Takes a focused history to differentiate GORD from other upper GI conditions.
2.2 Recognises red flags requiring further investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Formulates an appropriate differential diagnosis.
3.2 Justifies the working diagnosis of GORD based on clinical findings.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a stepwise management plan including lifestyle changes and pharmacological options.
4.3 Recognises when specialist referral is required.

5. Preventive and Population Health

5.1 Provides education on dietary and lifestyle modifications for symptom control.

6. Professionalism

6.1 Ensures patient-centred communication and shared decision-making.

7. General Practice Systems and Regulatory Requirements

7.1 Arranges appropriate investigations if required and ensures continuity of care.

9. Managing Uncertainty

9.2 Addresses potential atypical presentations and diagnostic uncertainty.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies when urgent referral for upper GI malignancy workup is warranted.

12. Rural Health Context (RH)

RH1.1 Adapts management to the limitations of a rural setting.
RH1.3 Plans for ongoing follow-up and access to specialist services despite geographical barriers.

Competency at Fellowship Level

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