CCE-CE-040

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, considering risk factors for osteoporosis and vitamin D deficiency.

The competent candidate should:

• Use open-ended questions to gather a detailed history, covering the fracture mechanism, risk factors, and relevant symptoms.
• Explore the nature of the fall, the force involved, and whether there were any pre-existing symptoms (e.g., back pain or previous minor fractures).
• Assess lifestyle factors contributing to osteoporosis risk, including physical activity levels, dietary calcium intake, sun exposure, and sunscreen use.
• Ask about past medical history, focusing on previous fractures, bone health, and medication use (e.g., corticosteroids, proton pump inhibitors).
• Investigate family history of osteoporosis or fractures, particularly first-degree relatives.
• Explore menopausal status and hormonal history, as menopause contributes to bone loss.
• Identify any red flags for secondary osteoporosis, including chronic illnesses, gastrointestinal malabsorption, renal disease, or thyroid dysfunction.

Task 2: Explain the likely diagnosis and outline key investigations required.

The competent candidate should:

• Explain that a minimal trauma fracture is a red flag for osteoporosis and warrants further assessment.
• Discuss that vitamin D deficiency is likely due to prolonged sun avoidance, use of high-SPF sunscreen, and lack of supplementation.
• Justify the need for a bone mineral density (DEXA) scan to assess bone mass and fracture risk.
• Explain the rationale for blood tests, including:
  • Serum calcium, phosphate, and alkaline phosphatase (to evaluate bone metabolism).
  • Vitamin D levels (to confirm deficiency).
  • Parathyroid hormone (PTH) (to rule out secondary hyperparathyroidism).
  • Thyroid function tests (if hyperthyroidism is suspected).
  • Renal function and liver function tests (for secondary causes).

Task 3: Address the patient’s concerns about osteoporosis and vitamin D levels.

The competent candidate should:

• Acknowledge the patient’s concerns and provide empathetic reassurance.
• Explain that osteoporosis is common in postmenopausal women and can be managed with lifestyle and medical interventions.
• Discuss that vitamin D deficiency is treatable, and supplementation is safe and effective.
• Address concerns about sun exposure by balancing the need for bone health with skin cancer prevention.
• Clarify that weight-bearing exercises, calcium-rich diets, and vitamin D supplements are essential for bone strength.

Task 4: Develop a management plan, including lifestyle advice, pharmacological options, and fracture prevention strategies.

The competent candidate should:

• Recommend lifestyle modifications, including:
  • Weight-bearing and resistance exercises (walking, strength training).
  • Calcium-rich diet or supplements (if dietary intake is insufficient).
  • Vitamin D supplementation:
    • The half-life of vitamin D is around 3 weeks, so it takes time for changes to be apparent.
    • 3000-5000 IU daily for 6-12 weeks then 1000-2000 IU daily.
• Discuss pharmacological management based on DEXA results:
  • Bisphosphonates (first-line therapy) for osteoporosis.
  • Denosumab, selective estrogen receptor modulators (SERMs), or teriparatide as alternatives if indicated.
• Explain fracture prevention strategies, including fall risk assessment, home modifications, and balance training.
• Arrange follow-up for review of investigations and treatment adherence.

SUMMARY OF A COMPETENT ANSWER

• Elicits a comprehensive history, covering risk factors, family history, lifestyle, and past fractures.
• Explains osteoporosis and vitamin D deficiency in simple terms, addressing patient concerns empathetically.
• Outlines necessary investigations, including DEXA scans and blood tests.
• Develops a holistic management plan, covering lifestyle modifications, supplementation, pharmacotherapy, and fracture prevention.
• Engages in shared decision-making, balancing osteoporosis treatment with the patient’s dermatological concerns.

PITFALLS

• Failing to explore key risk factors, such as family history, dietary intake, and exercise habits.
• Overlooking secondary causes of osteoporosis (e.g., hyperparathyroidism, thyroid disease).
• Providing vague or incorrect advice on vitamin D and calcium intake.
• Neglecting to discuss exercise and lifestyle modifications alongside pharmacological management.
• Dismissing patient concerns about sun exposure and long-term medication use instead of engaging in shared decision-making.

REFERENCES

• RACGP – Vitamin D And the musculoskeletal health of older adults
• RACGP – Osteoporosis management and fracture prevention in post-menopausal women and men > 50 years of age
• Healthy Bones Australia
• GP Exams – Osteoporosis

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.
1.5 Uses appropriate non-verbal communication strategies.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets relevant history and risk factors.
2.3 Selects and justifies relevant investigations.

3. Diagnosis, Decision-Making and Reasoning

3.1 Demonstrates a structured approach to clinical reasoning.
3.5 Considers differential diagnoses and justifies decision-making.

4. Clinical Management and Therapeutic Reasoning

4.3 Develops a safe and patient-centred management plan.
4.5 Provides appropriate pharmacological and non-pharmacological treatment options.

5. Preventive and Population Health

5.2 Provides lifestyle and preventive health advice relevant to osteoporosis and vitamin D deficiency.

6. Professionalism

6.1 Practices patient-centred care with empathy and respect.

7. General Practice Systems and Regulatory Requirements

7.3 Appropriately follows Medicare guidelines for osteoporosis management and bone density testing.

9. Managing Uncertainty

9.1 Recognises and manages clinical uncertainty in osteoporosis risk assessment and fracture prevention.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and appropriately manages a patient at high risk of future fractures.

Competency at Fellowship Level

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