THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate neurological history from the patient.

The competent candidate should:

• Establish rapport and acknowledge the patient’s concerns and anxiety, especially regarding the possibility of motor neurone disease (MND).
• Take a structured neurological history, including:
  • Onset, progression, and distribution of weakness (focal vs. generalised, proximal vs. distal).
  • Presence of sensory symptoms (numbness, tingling, pain).
  • Associated features, including muscle twitches (fasciculations), cramping, speech/swallowing difficulties, or cognitive changes.
  • Bowel and bladder function, to rule out spinal cord involvement.
  • Exacerbating or relieving factors (fatigue, heat sensitivity, diurnal variation).
• Ask about red flag symptoms (rapid progression, respiratory involvement, weight loss).
• Explore risk factors for neurological disease, including family history, exposure to toxins, recent infections, autoimmune conditions, and trauma.
• Address the patient’s concerns about work, driving, and independence.

Task 2: Explain the possible causes of his symptoms and need for further investigations.

The competent candidate should:

• Explain that progressive limb weakness with fasciculations requires urgent assessment but that MND is not the only possible cause.
• Outline a differential diagnosis, including:
  • MND (Amyotrophic Lateral Sclerosis – ALS) – progressive, painless weakness with fasciculations, no sensory involvement.
  • Multiple Sclerosis (MS) – may present with weakness, sensory loss, or optic neuritis.
  • Cervical myelopathy – weakness, sensory changes, gait imbalance, and bladder dysfunction.
  • Myasthenia Gravis – fluctuating muscle weakness, worsened with exertion.
  • Peripheral neuropathy (e.g., diabetic, toxic, inflammatory) – distal weakness with sensory loss.
• Recommend urgent investigations, including:
  • MRI brain and spine (to rule out MS, structural lesions, myelopathy).
  • Nerve conduction studies and electromyography (NCS/EMG) (to assess for MND, neuropathy, myopathy).
  • Blood tests (FBC, UEC, LFTs, thyroid function, CK, autoimmune markers, B12).
• Emphasise that early referral to a neurologist is crucial for diagnosis and management planning.

Task 3: Outline your immediate management plan and referral requirements.

The competent candidate should:

• Prioritise patient safety by advising caution with driving, falls prevention, and workplace adjustments.
• Arrange urgent referral to a neurologist, emphasising the importance of specialist evaluation and further investigations.
• Order preliminary tests, including MRI and blood work, while awaiting neurology input.
• Discuss potential supportive measures, such as physiotherapy and occupational therapy for mobility and function.
• Plan follow-up within one week to review results and ensure timely specialist review.
• Provide written information about neurological conditions and encourage the patient to keep a symptom diary.

Task 4: Address the patient’s concerns, including prognosis and impact on daily life.

The competent candidate should:

• Acknowledge the patient’s anxiety and provide reassurance without false certainty.
• Explain that a definitive diagnosis requires further testing, and that many neurological conditions are treatable.
• Discuss the impact on daily life, including:
  • Driving – advise the patient to notify the Austroads Medical Standards for Licensing, with possible temporary restrictions.
  • Work – suggest adjustments (e.g., ergonomic support, reduced hours if fatigued).
  • Family & independence – discuss mobility concerns, home safety, and support networks.
• Encourage the patient to focus on practical next steps rather than worst-case scenarios.
• Provide contact details for support organisations, such as MND Australia and MS Australia.

SUMMARY OF A COMPETENT ANSWER

• Takes a comprehensive neurological history, covering symptom onset, progression, and associated features.
• Considers a broad differential diagnosis, not just MND.
• Explains the need for investigations and neurology referral in a clear, structured manner.
• Addresses the patient’s concerns about driving, work, and prognosis.
• Provides reassurance while balancing uncertainty, ensuring ongoing follow-up and safety planning.

PITFALLS

• Failing to identify red flags – not recognising that progressive weakness with fasciculations requires urgent neurological referral.
• Focusing too much on MND – not exploring other possible causes (e.g., MS, neuropathy, cervical myelopathy).
• Providing false reassurance – downplaying the symptoms without acknowledging the need for further testing.
• Not discussing driving restrictions – failing to inform the patient about potential licensing implications.
• Delaying specialist referral – attempting to trial treatment or “wait and see” instead of prioritising neurology review.
• Not addressing emotional concerns – neglecting to acknowledge patient anxiety or failing to provide support resources.

REFERENCES

• RACGP – RACGP Guidelines on Neurological Disorders
• GP Exams – Neurological disease NOS

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

Competency Areas Assessed

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 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive neurological history.
2.2 Identifies red flags requiring urgent referral.

3. Diagnosis, Decision-Making and Reasoning

3.1 Forms an appropriate differential diagnosis.
3.3 Recognises the need for further investigations.

4. Clinical Management and Therapeutic Reasoning

4.2 Develops a safe and evidence-based management plan.
4.5 Ensures appropriate follow-up and referrals.

5. Preventive and Population Health

5.3 Provides education on symptom monitoring and safety measures.

6. Professionalism

6.2 Manages uncertainty and ensures patient-centred care.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures timely specialist referral and documentation.

9. Managing Uncertainty

9.2 Balances risks while awaiting a confirmed diagnosis.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies progressive neurological disease requiring specialist input.

Competency at Fellowship Level

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