THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a structured history of the patient’s rectal bleeding, pain, and associated symptoms.

The competent candidate should:

• Establish rapport and create a comfortable, non-judgmental environment for the patient to discuss their symptoms.
• Take a structured gastrointestinal history, including:
  • Onset, duration, and frequency of bleeding (bright red vs dark, coating stool vs mixed in).
  • Associated symptoms, including pain, itching, fullness, or a palpable lump.
  • Changes in bowel habits, such as diarrhoea, constipation, stool shape changes, or urgency.
  • Presence of red flags: weight loss, fatigue, night sweats, unexplained anaemia, or abdominal pain.
  • Straining during defecation and dietary factors, including fibre and fluid intake.
  • Family history of colorectal cancer or other gastrointestinal diseases.
  • Social history, including smoking, alcohol intake, and physical activity level.

Task 2: Explain the likely diagnosis and need for further investigations if required.

The competent candidate should:

• Explain that the symptoms are most consistent with haemorrhoids, which are common and treatable.
• Differentiate haemorrhoids from other potential diagnoses, including:
  • Anal fissures (painful bleeding, sharp pain with defecation).
  • Colorectal cancer (change in bowel habits, weight loss, age >50, family history).
  • Inflammatory bowel disease (IBD) (bloody diarrhoea, systemic symptoms, family history).
  • Diverticular disease (painless bleeding, common in older adults).
• Address the patient’s concerns about cancer, explaining that:
  • The features are more suggestive of haemorrhoids, but further evaluation may be needed.
  • A colonoscopy is recommended earlier than 50 due to a family history of bowel cancer.
• Outline investigations based on symptoms, including:
  • Digital rectal examination (DRE) and anoscopy in-clinic if appropriate.
  • Full blood count (FBC) to check for anaemia.
  • Colonoscopy referral if there are red flags or persistent bleeding.

Task 3: Outline your management plan, including conservative treatments and when referral is necessary.

The competent candidate should:

• Provide immediate symptomatic relief:
  • Topical haemorrhoid creams (hydrocortisone + local anaesthetic).
  • Sitz baths (warm water soaks) for relief.
  • Oral analgesia (paracetamol, avoiding NSAIDs if bleeding persists).
• Address constipation and straining:
  • Increase dietary fibre intake (fruits, vegetables, whole grains).
  • Increase water intake (at least 2L/day).
  • Consider bulk-forming laxatives (e.g., psyllium husk) if needed.
• Lifestyle modifications:
  • Reduce prolonged sitting at work.
  • Encourage physical activity to promote gut motility.
  • Smoking cessation and limiting alcohol intake.
• Referral to a specialist if:
  • Symptoms persist despite treatment.
  • There is severe pain or thrombosed haemorrhoids.
  • Red flags suggest the need for a colonoscopy.

Task 4: Address the patient’s concerns, including prognosis, dietary changes, and prevention strategies.

The competent candidate should:

• Acknowledge the patient’s concerns about cancer and explain the rationale for investigations.
• Provide reassurance that haemorrhoids are not dangerous but can be bothersome.
• Discuss prevention strategies:
  • Fibre intake of 25–30g/day to prevent constipation.
  • Adequate hydration (2–3L water per day).
  • Regular exercise to support bowel motility.
  • Proper toilet habits (avoiding straining and prolonged sitting on the toilet).
• Set expectations for recovery: symptoms should improve with conservative management within a few weeks.
• Encourage follow-up to assess symptom resolution and discuss investigation results if required.

SUMMARY OF A COMPETENT ANSWER

• Takes a thorough history, assessing bleeding, stool characteristics, associated symptoms, and red flags.
• Explains the likely diagnosis in an understandable manner, differentiating haemorrhoids from serious gastrointestinal conditions.
• Recommends appropriate investigations, ensuring red flags are addressed.
• Develops a structured management plan, balancing conservative treatment, symptom relief, and long-term prevention.
• Addresses the patient’s concerns with empathy, particularly their worries about bowel cancer.

PITFALLS

• Failing to assess red flags, particularly family history of bowel cancer and weight loss.
• Providing premature reassurance without explaining the need for risk assessment and investigations.
• Neglecting dietary and lifestyle advice, missing an opportunity for long-term symptom control.
• Not discussing bowel cancer screening, despite the family history requiring earlier colonoscopy.
• Overprescribing medication without addressing underlying causes, leading to temporary relief but no long-term prevention.
• Ignoring patient embarrassment, failing to normalise the conversation about anal health.

REFERENCES

• RACGP – RACGP Guidelines on Gastrointestinal Conditions
• GP Exams – Haemorrhoids

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 Uses appropriate questioning techniques to explore symptoms and concerns.
1.5 Provides clear explanations about diagnosis and management.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive gastrointestinal history.
2.2 Identifies red flags requiring further investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates haemorrhoids from other anorectal conditions.
3.3 Recognises indications for further investigations.

4. Clinical Management and Therapeutic Reasoning

4.2 Develops a safe and patient-centred management plan.
4.4 Balances conservative, pharmacological, and referral strategies.

5. Preventive and Population Health

5.3 Provides education on dietary and lifestyle modifications to prevent recurrence.

6. Professionalism

6.2 Manages patient embarrassment sensitively and ensures dignity in care.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and referral pathways when needed.

9. Managing Uncertainty

9.2 Recognises when further investigations (e.g., colonoscopy) are required.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies features of serious gastrointestinal disease requiring urgent management.

Competency at Fellowship Level

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