THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Task 1: Take a focused history, including onset, growth pattern, symptoms, and signs of infection.

The competent candidate should:

• Clarify key features of the lump:
  • Duration: Present for one year, gradually increasing in size.
  • Symptoms: Painless, except when pressed or rubbed against clothing.
  • History of discharge: Foul-smelling, thick, yellow-white discharge that occurred once.
  • Signs of infection: No redness, warmth, swelling, or fever.
• Assess risk factors:
  • No rapid growth, ulceration, bleeding, or weight loss (reducing likelihood of malignancy).
  • No history of previous skin cancers, diabetes, or immunosuppression.
• Explore past medical and surgical history:
  • Past sebaceous cyst drainage (indicating a possible recurrence risk).
• Identify patient concerns and expectations:
  • Fear of cancer or a serious condition.
  • Desire to know whether it should be removed and if it will return.

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Task 2: Identify key clinical features and assess whether the cyst requires excision, drainage, or referral.

The competent candidate should:

• Recognise clinical features of a sebaceous cyst:
  • Slow-growing, mobile, firm nodule beneath the skin.
  • Punctum may be present (blocked sebaceous gland opening).
  • Non-tender unless inflamed or infected.
• Differentiate from other skin lesions:
  • Lipoma: Soft, mobile, non-tender, deeper in the skin.
  • Abscess: Painful, red, swollen, fluctuant.
  • Epidermoid cyst: Similar but contains keratin, not sebum.
  • Malignant lesions: Rapid growth, ulceration, bleeding, irregular shape.
• Decide on management approach:
  • Watchful waiting if asymptomatic.
  • Excision if bothersome, recurrent, or infected.
  • Incision and drainage if acutely inflamed but not definitive treatment.

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Task 3: Explain the likely diagnosis, management options, and need for follow-up.

The competent candidate should:

• Explain the diagnosis in simple terms:
  • Likely a sebaceous cyst, a benign blocked sebaceous gland.
  • Not a tumour or cancer, but can become infected or recur.
• Discuss management options:
  • Observation if not bothersome.
  • Complete excision is the best option to prevent recurrence.
  • Incision and drainage if infected but does not remove the cyst completely.
• Provide reassurance and follow-up advice:
  • Monitor for signs of infection or recurrence.
  • If removed, low chance of regrowth but possible scarring.
  • Review in 4-6 weeks or sooner if symptoms worsen.

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Task 4: Develop a safe, evidence-based management plan, including procedural options, infection control, and patient education.

The competent candidate should:

• If asymptomatic and small:
  • Reassure patient, no urgent intervention needed.
  • Monitor for changes and return if rapid growth, pain, or infection occurs.
• If symptomatic or cosmetically concerning:
  • Surgical excision under local anaesthesia (definitive treatment).
  • Discuss risks: Scarring, recurrence, minor bleeding.
• If infected or inflamed:
  • Incision and drainage for immediate relief, but excision needed later to prevent recurrence.
  • Oral antibiotics (flucloxacillin) if cellulitis present.
• Post-procedure care:
  • Wound care instructions to prevent infection.
  • Educate on signs of infection and recurrence risks.
  • Follow-up to assess healing and discuss histopathology results if excised.

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SUMMARY OF A COMPETENT ANSWER

• Takes a thorough history, assessing lump characteristics and red flag signs.
• Differentiates a sebaceous cyst from other skin lesions, ruling out malignancy.
• Explains the benign nature of sebaceous cysts, reassuring the patient.
• Develops a structured management plan, including observation, drainage, or excision.
• Provides clear post-procedure care and follow-up recommendations.

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PITFALLS

• Failing to differentiate from malignant or other concerning lesions.
• Not offering excision for a bothersome or recurrent cyst.
• Mismanaging an infected cyst by only prescribing antibiotics without drainage.
• Failing to address patient concerns about recurrence and scarring.
• Not providing adequate post-procedure care instructions.

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REFERENCES

• RACGP – RACGP Guidelines for Skin Lesions
• GP Exams – Sebaceous cyst

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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, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a thorough history, including onset, growth pattern, symptoms, and signs of infection.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises clinical features suggestive of a sebaceous cyst and excludes concerning differentials.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan, including observation, drainage, or excision.

5. Preventive and Population Health

5.1 Educates the patient on sebaceous cyst care, infection prevention, and recurrence risk.

6. Professionalism

6.1 Demonstrates patient-centred care and acknowledges cosmetic concerns.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and referral for surgical management if required.

8. Procedural Skills

8.1 Performs or refers for incision and drainage or excision when indicated.

9. Managing Uncertainty

9.1 Recognises when histopathological assessment is needed for an atypical lesion.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies cases requiring referral for suspected malignancy or complex cysts.

Competency at Fellowship Level

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