Introduction

The aim of this book is to help you prepare for Australian general practice exams using clinical case role-plays.

General practice activity data¹ indicate that general practitioners’ work has become increasingly complicated: patients have multiple comorbidities and are prescribed more drugs. My impression is that more research information can counter-intuitively create less certainty. GPs spend more time assessing patients’ personal risk–benefit of any particular intervention. Screening for prostate cancer and prescribing hormone replacement therapy are prime examples of where there is a high risk of iatrogenic disease. The GP needs to be an expert in reading patients’ personalities and fears, as well as scientific data. The cases in this book test the skill of taking a holistic approach to managing uncertainty in a complex context.

Most doctors find the time restrictions of the exam difficult. Three minutes is not long to read a patient’s notes but may be longer than many doctors take to do this in clinical practice. Likewise, dealing with a problem in eight minutes, challenges some candidates, while others expertly breeze through with time to spare to include opportunistic health promotion, confirming that the examiners do not ask the impossible. Cases should be quicker than in real life as the ‘patient’ knows in advance the answers to the important questions and candidates are not required to make clear, contemporaneous written notes.

Before you take a general practice exam you need to have a clear understanding of general practice. Let’s look at some definitions of general practice (also called family practice in some countries).

The Royal Australian College of General Practitioners (RACGP) says:²

General practice is part of the Australian health care system and operates predominantly through private medical practices, which provide universal unreferred access to whole person medical care for individuals, families and communities. General practice care means comprehensive, coordinated and continuing medical care drawing on biomedical, psychological, social and environmental understandings of health.

The World Organization of Family Doctors (WONCA Europe) defines the competencies and characteristics of general practitioners as:³

• normally the point of first medical contact within the health care system, providing open and unlimited access to its users, dealing with all health problems regardless of the age, sex or any other characteristic of the person concerned

• making efficient use of health care resources through coordinating care, working with other professionals in the primary care setting and by managing the interface with other specialties, taking an advocacy role for the patient when needed

• developing a person-centred approach, orientated to the individual, his/her family and their community

• having a unique consultation process, which establishes a relationship over time through effective communication between doctor and patient

• being responsible for the provision of longitudinal continuity of care as determined by the needs of the patient

• having a specific decision-making process determined by the prevalence and incidence of illness in the community

• managing simultaneously both acute and chronic health problems of individual patients

• managing illness that presents in an undifferentiated way at an early stage in its development, which may require urgent intervention

• promoting health and wellbeing both by appropriate and effective intervention

• having a specific responsibility for the health of the community

• dealing with health problems in their physical, psychological, social, cultural and existential dimensions.

Doctors working in rural and remote Australia can face clinical situations that require skills in a wider scope of practice. Doctors can now choose to qualify as a general practitioner via the Australian College of Rural and Remote Medicine (ACRRM) Fellowship examination. ACRRM expects Fellows to be performing all the functions of a GP listed by RACGP and WONCA plus:

• responding to emergencies including stabilisation and definitive management as appropriate; providing hospital-based secondary care where required; delivering obstetric care; and undertaking a range of population health interventions at the practice and community level.⁴

Those planning to sit the ACRRM exam may still find the cases useful by thinking through what they would do in each case if the nearest hospital or referral centre was more than an hour’s flight away, or they were the only doctor in town running both a general practice and a small hospital.

The above definitions demonstrate the breadth of the general practice specialty and remind me why it is such an interesting profession. The illnesses we see are common but we are also alert for potentially serious conditions. For this we need a system of diagnosis that differentiates the headache caused by a brain tumour from a tension headache or a hangover and, if it is a tension headache, we need ways of exploring possible causes of the tension and discussing with the patient how to manage them.

The traditional consultation framework comprises history, examination, investigation, diagnosis, treatment and follow-up. While suitable for emergency care, this model is inadequate for the complexity of general practice.

I recommend the following texts that suggest some task-based and some process-based consultation frameworks:

• Pendleton, D, Schofield, T, Tate, P, et al. 2003, The new consultation: developing doctor–patient communication, Oxford.

• Neighbour, R 2004, The inner consultation: how to develop an effective and intuitive consulting style, 2nd ed, Oxford.

• Stewart, M, Brown, J. B., Weston, W. W., et al. 2003, Patient-centred medicine: transforming the clinical method, 2nd ed, Oxford.

In 2001 a meeting of medical educators and communication skills experts reached a consensus on the essential elements of communication in medical encounters (Kalamazoo Consensus Statement).⁵ In this book I have adopted the elements of their suggested approach to cases, summarised as:

• build the doctor–patient relationship

• open the discussion

• gather information

• understand the patient’s perspective

• share information

• reach agreement on problems and plans

• provide closure.

General practice exams need to ensure that, to be effective, GPs have the appropriate attitude and a broad range of knowledge and skills. So prepare to be tested on any of the characteristics outlined in the above definitions. Reading a textbook on clinical medicine is not enough, you have to apply the textbook knowledge to a particular person in their particular context, making the best use of the resources available.

One way to do this is to consider the domains of general practice. The RACGP domains are:⁶

1. Communication skills and the doctor–patient relationship

2. Applied professional knowledge and skills

3. Population health and the context of care

4. Professional and ethical roles

5. Organisational and legal dimensions.

The ACRRM domains are:⁷

1. Core clinical knowledge and skills

2. Extended clinical practice

3. Emergency care

4. Population health

5. Aboriginal and Torres Strait Islander health

6. Professional, legal and ethical practice

7. Rural and remote contexts.

Imagine that you have just completed your reading on diabetes. You are now up-to-date with the latest research and the signs of early diabetic retinopathy. How will you apply this as a GP?

RACGP domain 1. Communication skills and the doctor–patient relationship

Domain 1 reminds you that diabetes affects a person. In consultations you will focus on the patient and their experience of life with diabetes. You will communicate clearly in terms they understand and that are free of medical jargon.

A trap for doctors, particularly those from non-English speaking backgrounds, is to assume that patients whose first language is English understand all English. This is a myth: it is said that first-year medical students learn more new words than first-year language students. We need to constantly distinguish between medical English and colloquial Australian English, and use each when appropriate.

Another aspect of practice that varies between countries is how much patients direct consultations. In Australia, GPs do not automatically have patients’ agreement to give advice or recommendations. This right has to be earned by first listening carefully to patients’ ideas, concerns, and expectations. Only then can doctors outline their ideas and plans, and negotiate with patients a management plan. There are exceptions, such as emergencies, but in general shared decision-making is expected(1). Learning this skill is essential and requires a considerable shift in approach if you trained in a system where doctors were expected to give advice and patients passively acquiesced.

Domain 1 also includes health promotion, so discuss immunisations, smoking, alcohol and maintaining health, as well as the illness of diabetes, with your patient.

RACGP domain 2. Applied professional knowledge and skills

This is the most familiar domain, in which you ensure your patient has good diabetic control and you work to prevent complications.

RACGP domain 3. Population health and the context of general practice

‘Population health’ requires you as a GP to broaden your thinking beyond your patient to encompass the wider community. What is your role in preventing or screening for diabetes? Is there a group of patients with an increased risk of diabetes—Torres Strait Islander people, for instance—who need culturally appropriate screening?

‘The context of general practice’ includes consideration of your patient’s life circumstances. Can they get fresh fruit and vegetables easily? What exercise can they safely do? Does their family or religious background influence their health? For example, how would you advise a Muslim patient with diabetes on hypoglycaemics to cope during Ramadan?

RACGP domain 4. Professional and ethical role

Your role as a GP requires you to look at the standard of care that you provide for patients with diabetes. Use clinical audit to check that you are following the national guidelines. Consider how your care integrates with the rest of the health care system: what are your links with the local optometrist who could screen your patients for diabetic retinopathy? Are you making the best use of resources? Could a practice nurse do routine diabetic care so that you can focus on complex cases?

Your ethical role might include such dilemmas as a case where a diabetic patient whose livelihood depends on holding a commercial driving licence also requires insulin.

RACGP domain 5. Organisational and legal dimensions

Are you using information technology to improve the quality of care for your patients with diabetes? What are the recall systems? How do you ensure patient confidentiality when they attend for repeat prescriptions? When did you last calibrate your glucometer and sphygmomanometer? Do you make comprehensive and comprehensible notes? Is yours an accredited practice eligible for Service Incentive Payments?

ACRRM domains. Emergency care, rural and remote context and Aboriginal and Torres Strait Islander health

For diabetes this may mean managing diabetic ketoacidosis in a small rural hospital, starting newly diagnosed diabetic children on insulin or running a screening program at a football carnival in a remote Aboriginal community.

In this book, long cases usually test a whole consultation. Short cases usually test part of a consultation, perhaps focusing on taking a history, performing a physical examination, giving a diagnosis or negotiating management. This challenges doctors who are used to conducting full consultations.

In cases that require management only, both students and doctors often still begin with a history and examination. This is a normal (and good) clinical response but it wastes precious time because it isn’t required. Several cases in this book give you practice at picking up the consultation halfway through.

GPs would never finish our day’s work if we took a full history and performed a complete examination on every patient. We take appropriate short cuts and focused histories, examining the patient for specific information to rule a diagnosis in or out. Our expertise ‘is the ability to access knowledge and make connections across seemingly disparate fields and life experiences’.⁸ The art of exams is to demonstrate this expertise.

Medical students can eventually reach the answer but only experienced clinicians can connect the disparate elements of a scenario into a diagnostic approach in the time available. This ‘elaborated knowledge’ is essential for an independent general practitioner.⁹

For example, what diagnosis comes to mind when you read ‘headache’, ‘fever’, ‘rash’? The safe, experienced GP asks, ‘Is this meningitis?’ The clinical encounter will focus on excluding meningitis by a short, focused history and an immediate look at the rash. If it is purpuric they would exclude an allergy, give parenteral antibiotics and arrange immediate hospital admission. By contrast, a student might approach this case using a systematic, hypothetico-deductive method,¹⁰ first taking a detailed history of the presenting symptoms, then a review of current medication and allergies, followed by a social history, family history, systems review and finally conducting a top-to-toe clinical examination. Once all the data is gathered the student will begin to piece together a possible hypothesis or diagnosis and deduce the most likely diagnosis from the evidence available, or perhaps decide that further information is needed. By this time the experienced GP will have given the patient antibiotics. In this extreme example, the speed of the GP’s diagnosis may be life-saving. This is rare in clinical practice but it illustrates the efficiency of pattern recognition as a diagnostic process. There is no short cut to this. It requires considerable study and experience and underlines the need for GPs to undergo supervised clinical practice.

Clinical practice is still the best preparation for general practice and general practice exams. My hope is that this book will supplement your clinical work so that during exams you can demonstrate that you have the knowledge, skills and attitudes necessary for general practice in Australia.