THE COMPETENT CANDIDATE

Task 1: Take an appropriate history from the patient, considering red flags and risk factors.

The competent candidate should:

• Establish rapport and ensure a supportive, non-judgemental approach to discussing rectal bleeding.
• Elicit details about the onset, duration, frequency, and characteristics of the rectal bleeding (e.g., bright red vs. dark, mixed with stool vs. separate).
• Identify associated symptoms such as altered bowel habits, weight loss, abdominal pain, tenesmus, or fatigue.
• Assess alarm features suggestive of malignancy:
  • Unintentional weight loss
  • Changes in bowel habits (e.g., constipation, diarrhoea, narrower stools)
  • Iron deficiency anaemia symptoms (fatigue, pallor, dizziness)
  • Persistent bleeding despite conservative measures
• Explore relevant medical history including previous episodes, family history of bowel cancer or polyps, and any history of inflammatory bowel disease.
• Ask about lifestyle factors (dietary fibre intake, smoking, alcohol consumption, exercise) that may contribute to gastrointestinal health.
• Enquire about medications such as anticoagulants, NSAIDs, or iron supplements that could impact bleeding risk.
• Provide empathetic reassurance while ensuring the patient understands the need for further evaluation.

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Task 2: Discuss the differential diagnoses and explain potential causes of rectal bleeding.

The competent candidate should:

• Explain that rectal bleeding can result from benign conditions or serious pathology, and further assessment is required.
• Discuss common benign causes:
  • Haemorrhoids (bright red bleeding, exacerbated by straining, minimal pain)
  • Anal fissures (painful defecation, bright red bleeding)
  • Diverticular disease (painless bleeding, associated with constipation)
  • Proctitis (inflammation from infection or inflammatory bowel disease)
• Highlight serious conditions requiring further investigation:
  • Colorectal cancer (progressive symptoms, weight loss, altered stool calibre, anaemia)
  • Polyps (often asymptomatic but can bleed intermittently)
  • Inflammatory bowel disease (IBD) (bloody diarrhoea, abdominal pain, systemic symptoms)
• Explain that given the age (>50 years) and family history, further testing such as a colonoscopy is recommended.
• Use patient-friendly language and visual aids if necessary to improve understanding.

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Task 3: Outline an appropriate management plan, including necessary investigations and referrals.

The competent candidate should:

• Discuss a structured management approach based on risk stratification.
• Arrange urgent colonoscopy based on age, rectal bleeding, weight loss, and family history (per NHMRC guidelines).
• Consider initial investigations:
  • Full blood count (FBC) to assess for anaemia.
  • Faecal occult blood test (FOBT) if colonoscopy is delayed.
  • Iron studies if symptoms suggest iron deficiency.
• Provide symptomatic management:
  • Fibre supplementation and hydration if constipation is contributing.
  • Topical treatments if haemorrhoids or fissures are suspected but ensuring follow-up.
• Arrange urgent referral to a gastroenterologist for a colonoscopy.
• Offer follow-up in 2-4 weeks to review results and address any concerns.
• Provide preventive advice:
  • Encourage a high-fibre diet, regular exercise, smoking cessation, and alcohol moderation.
  • Discuss the National Bowel Cancer Screening Program and the importance of surveillance.

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Task 4: Provide preventive health advice regarding colorectal cancer screening and lifestyle modifications.

The competent candidate should:

• Explain bowel cancer risk factors:
  • Age >50
  • Family history of colorectal cancer
  • Low-fibre, high-red-meat diet
  • Smoking, alcohol consumption, obesity
• Discuss screening guidelines:
  • Offer a colonoscopy given the age, symptoms, and family history.
  • Explain the role of faecal occult blood testing (FOBT) every 2 years for those at average risk.
• Provide lifestyle advice:
  • Increase dietary fibre (fruits, vegetables, whole grains).
  • Reduce processed meats and alcohol intake.
  • Encourage regular exercise (≥150 minutes per week).
  • Smoking cessation support if relevant.
• Offer educational resources such as Cancer Council Australia guidelines.

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SUMMARY OF A COMPETENT ANSWER

• Thorough history-taking, including red flag symptoms and risk factors.
• Clear and structured differential diagnosis, explaining both benign and serious causes.
• Logical management plan, incorporating appropriate investigations and specialist referral.
• Preventive health advice, including colorectal cancer screening and lifestyle modifications.
• Patient-centred communication, using lay terms, empathy, and reassurance.

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PITFALLS

• Failing to identify red flag symptoms (e.g., weight loss, altered bowel habits).
• Assuming all rectal bleeding is from haemorrhoids without considering malignancy.
• Not offering a colonoscopy in a high-risk patient.
• Providing reassurance without appropriate follow-up and risk stratification.
• Not addressing lifestyle modifications and preventive screening.
• Poor communication, using overly technical language or failing to check patient understanding.

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REFERENCES

• RACGP Red Book – Preventive activities in general practice
• GP Exams – Rectal bleeding

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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 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 on their lives.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a structured and thorough history to identify red flags.
2.2 Interprets findings to differentiate between benign and serious causes of rectal bleeding.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates a differential diagnosis for rectal bleeding.
3.2 Identifies alarm symptoms suggestive of malignancy.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan for rectal bleeding.
4.2 Provides appropriate referrals and follow-up based on risk stratification.

5. Preventive and Population Health

5.1 Discusses colorectal cancer screening and preventive strategies.

6. Professionalism

6.1 Respects patient autonomy and confidentiality when discussing sensitive issues.

7. General Practice Systems and Regulatory Requirements

7.1 Refers appropriately under the National Bowel Cancer Screening Program and Medicare guidelines.

8. Procedural Skills

8.1 Explains the indications for and process of a digital rectal examination and sigmoidoscopy.

9. Managing Uncertainty

9.1 Provides a structured approach to managing rectal bleeding when the cause is unclear.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises red flags for colorectal cancer and refers urgently if indicated.

Competency at Fellowship Level

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