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.