Domains of Competence

Read up on any condition you come across with which you are insufficiently familiar. Use WEB resources, SystmOne linked resources (Prodigy, CKS Clinical Topics), Oxford Textbook of GP, BNF etc

Read with an inquiring mind: What happens in this condition if it is not treated? What difference does treatment make? What is the best treatment? How strong is the evidence for this treatment? etc

Lots of General Practice consultations, Joint surgeries, COT's and CBD's

How it will be assessed?:

AKT, CSA, WPBA

Specific Training Tools:

Much of this will covered as above but the following tutorials may help -

Information finding

Information appraisal

Models of consultation

Management of chronic conditions

Knowledge of epidemiology of primary care conditions

An approach that allows easy access for patients with unselected problems

An organisational approach to management of chronic conditions

Knowledge of primary care conditions & treatment

To cover the full range of health conditions

How to achieve this competence?:

Read up on prevention in primary care

On-call duties in general practice

Out-of-hours training

Lots of General Practice consultations, Joint surgeries, COT's and CBD's

Immunisation clinic and read up on routine immunisation schedules.

Read the BNF

How it will be assessed?:

AKT, CSA, WPBA, DOPS

Specific Training Tools:

Much of this will covered as above but the following tutorials may help -

NHS Screening services (Breast, Cervical cytology, PSA etc)

Palliative Care

Knowledge of preventative activities in primary care

Skills in acute, chronic, emergency, preventative and palliative care

Diagnostic skills - history-taking, examination, investigation

Therapeutic skills - drug and non-drug

Ability to prioritise problems

To coordinate care with other professionals in primary care and with other specialists

How to achieve this competence?:

Much of this should be acquired just by doing the job and being around the practice - but be aware of the competence requirements.

How it will be assessed?:

Mostly WPBA and Appraisal

Specific Training Tools:

Attachment with various members of the practice and primary care teams.

Tutorial in practice management / staff

Knowledge of organisation of primary care

Understanding of importance of good communications with patients and staff

Skills in effective teamwork

To master effective and appropriate care provision and health care utilisation

How to achieve this competence?:

Much of this should be acquired just by doing the job and being around the practice - but be aware of the competence requirements.

Read up on the structure of the Healthcare system / NHS (where?) - perhaps look at comparative systems in other countries.

How it will be assessed?:

Mostly WPBA

Specific Training Tools:

Tutorials - Review of referrals

Knowledge of structure of healthcare system

Understanding the process of referral

Skills in managing the interface between primary and secondary care

To make available to the patient the appropriate services within the healthcare system

How to achieve this competence?:

Communication skills will be developed through COT and joint surgery

Learn the practice clinical system thoroughly

Read a book on communication skills (e.g. Silverman, kurtz, Draper "Skills for Communicating with Patients")

Do an Audit

How it will be assessed?:

Mostly WPBA

Specific Training Tools:

Tutorial in practice management

Tutorial in Audit

Communication Skills - counselling, teaching and treating patients families carers

Organisational skills for record-keeping, information management, teamwork, practice management and audit

To act as an advocate for the patient

How to achieve this competence?:

This depends on a good understanding of those parts of the consultation that encourage the patients contribution, exploring the reason for attendance and the ideas concerns and expectations that led to the decision to attend. Give explanations that the patient can understand, check understanding when appropriate. Offer choice when appropriate and allow the patient to make an informed choice from sensible options. etc.

This should all come out of COT and reading (e.g. Silverman)

How it will be assessed?:

Mostly WPBA

Specific Training Tools:

Developing & maintaining a relationship and a style of communication that treats a patient as an equal

Skills in effective leadership, negotiation and compromise

Domain 2: Person-centred care

Tutorial on the GP Curriculum Person-centredness and holism

See related topics and documents

Holism.doc

McWhinneys 3 core principles of patient-centred care

1. Comit to the person rather than to a body of knowledge

2. Seek to understand the context of the illness

3. Attach importance to the subjective aspects of medicine

Adopt a person-centred approach in dealing with patients and their problems

Basic knowledge and understanding of the individual, their aims and expectations in life

Develop a frame of reference to understand and deal with the family community social and cultural dimensions in a persons attitudes values and beliefs

Master patient illness and disease concepts

Skills and attitudes to apply these in practice

Use the consultation to bring about an effective doctor-patient relationship, respecting the patient's autonomy

Adopt a patient-centred consultation model, explore patient's ICE, integrate doctor's agenda, find common ground, negotiate plan

Communicate findings in a comprehensible way

Make decisions that respect patient autonomy

Be aware of subjectivity in the medical relationship: patient's feelings, values and preferences; doctor's feelings, values and attitudes.

Communicate, set priorities and act in partnership

Skills and attitude to establish a partnership

Skills and attitude to achieve a balance between emotional distance and proximity to the patient

Provide continuity of care as determined by the needs of the patient

Understand & master 3 aspects of continuity

Personal continuity

Episodic contnuity - making appropriate information available for each patient contact

Long-term continuity - 24 hours, 365 days a year

Domain 3: Specific Problem-solving skills

Problem-solving in general practice

Problem-based approach (rather than the disease-based approach of hospital practice)

GP approach Hospital specialist approach

Tolerate uncertainty Reduce uncertainty

Explore probability Explore possibility

Marginalise danger Marginalise error

Marrinker "Clinical Futures" 1998

Use of time as a diagnostic tool is also far more available to the primary care physician.

To relate specific decision-making processes to the prevalence and incidence of illness in the community

K Knowledge of the prevalence and incidence of disease

K Knowledge of the practice community (age–sex distribution, prevalence of chronic diseases)

S Skills to apply specific decision-making (using tools such as clinical reasoning and decision rules).

To selectively gather and interpret information from history-taking, physical examination and investigations, and apply it to an appropriate management plan in collaboration with the patient

K Knowledge of relevant questions in the history and items in the physical examination relevant to the problem presented

K Knowledge of the patient’s relevant context, including family and social factors

K Knowledge of available investigations and treatment resources

S History-taking and physical examination skills, and skills in interpreting data

A A willingness to involve the patient in the management plan.

To adopt appropriate working principles (e.g. incremental investigation, using time as a tool), and to tolerate uncertainty

A Adopting skills and attitudes to demonstrate curiosity, diligence and caring

S Adopting stepwise procedures in medical decision-making, using time as a diagnostic and therapeutic tool

A Understanding and acceptance of the inevitability of uncertainty in primary care problem-solving and development of strategies that demonstrate this.

To intervene urgently when necessary

S Specific decision-making skills for emergency situations

S Specific skills in emergency procedures that may occur in primary care situations.

To manage conditions that may present early and in an undifferentiated way

S Knowledge of when to wait and reassure, and when to initiate additional diagnostic and therapeutic action.

To make effective and efficient use of diagnostic and therapeutic interventions.

K Knowledge that symptoms and signs vary in their predictive value, as do findings from ancillary tests

K An understanding of the cost-efficiency and cost–benefit of tests and treatments.

Domain 4: A comprehensive approach

To simultaneously manage multiple complaints and pathologies, both acute and chronic health problems

K An understanding of the concept of co-morbidity in a patient

S The skill to manage the concurrent health problems experienced by a patient through identification, exploration, negotiation, acceptance and prioritisation

S Skill in using the medical record and other information

S The skill to seek, and the attitude to use, the best evidence in practice.

To promote health and wellbeing by applying health promotion and disease prevention strategies appropriately

K The ability to understand the concept of health

S The ability to promote health on an individual basis as part of the consultation

S The ability to promote health through a health promotion or disease prevention programme within the primary care setting

A Understanding and recognising the importance of ethical tensions between the needs of the individual and the community, and acting appropriately.

To manage and coordinate health promotion, prevention, cure, care, rehabilitation and palliation.

K Understanding the complex nature of health problems in general practice

K Understanding the variety of possible approaches

S The ability to use different approaches in an individual patient and to modify these according to an individual’s needs

S The ability to coordinate teamwork in primary care.

Domain 5: Community orientation

To reconcile the health needs of individual patients and the health needs of the community in which they live, balancing these with available resources.

K An understanding of the health needs of communities through the epidemiological characteristics of their population

K An understanding of the interrelationships between health and social care

K An understanding of the impact of poverty, ethnicity and local epidemiology on a local community’s health

K An awareness of inequalities in healthcare provision

K An understanding of the structure of the healthcare system and its economic limitations

K An understanding of the roles of the other professionals involved in community policy relating to health

K An understanding of the importance of practice- and community-based information in the quality assurance of each doctor’s practice

K An understanding of how the healthcare system can be used by the patient and the doctor (referral procedure, co-payments, sick leave, legal issues, etc.) in their own context

S The ability to reconcile the needs of the individual with the needs of the community in which they live

K An understanding of the GP’s role in the commissioning of health care.

Domain 6: A holistic approach

To use bio-psycho-social models, taking into account cultural and existential dimensions.

K Knowledge of the holistic concept and its implications for the patient’s care

A The ability to understand a patient as a bio-psycho-social ‘whole’

S The skills to transform holistic understanding into practical measures

K Knowledge of the cultural background and beliefs of the patient, in so far as they are relevant to health care

A Tolerance and understanding towards patients’ experiences, beliefs, values and expectations, as they affect healthcare delivery.

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Audley Mills Medical Education	Last updated: 16 August 2009 18/08/2009

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