THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Task 1: Take an appropriate history, exploring symptoms, occupational and recreational risk factors.

The competent candidate should:

• Use open-ended questions to encourage the patient to describe their symptoms in their own words.
• Identify the nature of the pain (onset, duration, progression, character, exacerbating and relieving factors).
• Establish the impact of work-related activities (e.g., prolonged computer use, mouse handling) and recreational activities (e.g., tennis, gym, or other repetitive arm movements).
• Ask about previous treatments and their effectiveness (e.g., use of NSAIDs, bracing, physiotherapy, activity modifications).
• Explore red flag symptoms such as night pain, swelling, systemic symptoms (e.g., fever, weight loss), or neurological symptoms (numbness, tingling, weakness) that may indicate alternative diagnoses.
• Take a relevant past medical history (e.g., previous injuries, arthritis, diabetes, or neuropathic conditions).
• Inquire about the patient’s concerns and expectations, including their desire for imaging or specific treatments.

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Task 2: Explain your working diagnosis and outline your differential diagnoses.

The competent candidate should:

• Clearly communicate Tennis Elbow (Lateral Epicondylitis) as the most likely diagnosis, explaining it in lay terms.
• Describe how repetitive wrist extension and gripping activities lead to overuse and microtears in the extensor tendons of the forearm.
• Address the patient’s concerns: reassure that this is a common, self-limiting condition but may take weeks to months to improve.
• Outline key differential diagnoses:
  • Radial Tunnel Syndrome (similar lateral elbow pain but with nerve involvement, leading to weakness and sensory changes).
  • Osteoarthritis of the elbow (joint stiffness, crepitus, and swelling).
  • Cervical Radiculopathy (C6) (pain radiating from the neck, with neurological symptoms).
  • Olecranon Bursitis or Posterior Impingement (posterior elbow swelling and pain).

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Task 3: Discuss and formulate a management plan including conservative treatments, physiotherapy, and when to consider escalation.

The competent candidate should:

• Recommend conservative management as first-line treatment, including:
  • Relative rest: Avoid aggravating activities but encourage gentle movement.
  • Ice application: Apply for 10–15 minutes after activity to reduce pain.
  • Pain relief: Use paracetamol or NSAIDs as needed, considering contraindications.
  • Bracing (counterforce brace or wrist splint): May reduce tendon strain.
  • Ergonomic adjustments: Modify work setup to reduce strain (e.g., vertical mouse, ergonomic keyboard).
  • Physiotherapy referral: Strengthening and stretching exercises for the forearm extensors.
• Address patient expectations: Explain why imaging is not routinely required unless red flags are present.
• Discuss prognosis: Most cases resolve within 6–12 months, but some may require escalation if symptoms persist.
• When to escalate:
  • Consider corticosteroid injection if symptoms persist despite conservative measures (though evidence suggests only short-term benefit).
  • Refer to a specialist if severe pain, functional limitations, or failure to improve with physiotherapy.
  • Imaging (MRI or ultrasound) is indicated only if atypical symptoms persist or another diagnosis is suspected.

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Task 4: Address the patient’s concerns regarding prognosis, imaging, and work-related implications.

The competent candidate should:

• Provide reassurance that this is a self-limiting condition, with most cases improving over months with proper management.
• Explain why imaging (X-ray, MRI) is not necessary unless atypical symptoms are present.
• Advise on workplace modifications to reduce strain, such as ergonomic changes or using the opposite hand for mouse work.
• Discuss realistic expectations regarding pain relief and functional improvement, avoiding promises of a quick recovery.
• Provide education about activity modification rather than complete avoidance to prevent muscle deconditioning.
• Offer a clear follow-up plan, advising when to return for review (e.g., 4–6 weeks if no improvement).

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive history-taking, including occupational and recreational factors.
• Clear explanation of the diagnosis, using layman’s terms and addressing concerns.
• Differential diagnoses considered, including nerve entrapment and joint pathology.
• Structured, evidence-based management plan, focusing on conservative treatment.
• Effective patient-centred communication, addressing expectations and prognosis.
• Clear escalation criteria and follow-up recommendations.

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PITFALLS

• Failure to explore occupational and sports history, missing the key contributing factors.
• Over-reliance on imaging, ordering X-rays or MRI unnecessarily.
• Lack of patient education, failing to explain the nature of the condition and its prognosis.
• Recommending corticosteroid injection too early, without trialling conservative measures.
• Not addressing ergonomic adjustments, missing an important aspect of management.
• Ignoring red flags, failing to differentiate from conditions like radial nerve entrapment or cervical radiculopathy.
• No structured follow-up plan, leaving the patient uncertain about next steps.

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REFERENCES

• RACGP – RACGP Guidelines on Musculoskeletal Conditions
• GP Exams – Tennis elbow

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MARKING

Each competency area is assessed on the following scale:

☐ 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.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers relevant clinical information through history-taking.
2.2 Interprets clinical findings appropriately.

3. Diagnosis, Decision-Making and Reasoning

3.1 Forms a relevant problem list.
3.2 Generates appropriate differential diagnoses.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan.
4.4 Provides patient education on self-care and treatment options.

5. Preventive and Population Health

5.1 Discusses lifestyle modifications and ergonomic adjustments.
5.3 Provides advice on injury prevention.

9. Managing Uncertainty

9.1 Recognises when additional investigations or referrals are needed.

Competency at Fellowship Level

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

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