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X4 X=  X X Q X X X   (  @ X    X   X P  `εCore blueprint newi Web version,# _Toc115538276:8L9BSBNKEFSEQ3 A@@   /Person-centred care This requires an understanding of: " the theories of aging " the development of a frame of reference to understand and deal with the family, community, social and cultural dimensions in a person s attitudes, values and beliefs " the special features of prognosis of diseases in old age and how to use the knowledge to produce an appropriate plan for further investigation and management " the way in which the management of disease processes in old age is influenced by the psychological state and the social situation of the old person{Specific problem-solving skills Focusing on problem-solving is a crucial part of GP training, because family doctors need to adopt a problem-based approach rather than a disease-based approach. This is particularly true when working with older people who often have complex physical, psychological and social problems. The general practitioner should have the ability to; Relate specific decision-making processes to the prevalence and incidence of illness in the community This requires: " knowledge of the prevalence and incidence of disease in the elderly population " knowledge of the practice community (number of elderly patients, prevalence of chronic diseases) 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 This requires: " skills of taking a mental health assessment from an old person, including how to assess brain function (e.g. using short mental state questionnaires) and mood, and how to evaluate the testimony of third parties " a willingness to involve the patient and if appropriate their carer and family in the management plan To make effective and efficient use of diagnostic and therapeutic interventions This requires: " understanding of the changes in the normal range of laboratory values that are found in older people Contextual aspects " Understand the key government policy documents that influence healthcare provision for older people " Recognise how geographical distance influences the treatment of older people Scientific aspects " Understand and implement the key national guidelines that influence healthcare provision for older people. " Describe the key research finding that influence management of older people Primary care management The work of the general practitioner increasingly involves the care of older people in partnership with the wider primary health care team, both within their own practice, in the local community, and also with specialists in secondary care, using the diagnostic and treatment resources available in hospitals. " understanding of the theories of aging " understanding of the physical, psychological and social changes that may occur with age and relating them to the adaptations which an older person makes, and to the breakdown of these adaptations " understanding of the special factors associated with drug treatment e.g. the physiology of absorbtion, metabolism and excretion of drugs, the hazards posed by multiple prescribing, non-compliance and iatrogenic disease " understanding of physical factors, particularly diet, exercise temperature and sleep which affect the health of older people " understanding of the management of the conditions and problems commonly associated with old age such as Parkinson s disease, falls, gait disorders, stroke, confusion etc. " mastering an approach which allows easy access to the primary health care team for older people, appropriate timing of appointments and an organizational approach to the management of chronic conditions and co-morbidities " knowledge of the locally agreed protocols for preventing and managing stroke " understanding of the management of the transfer from the system of care to another, the complications that can arise and how they can be prevented and managed " knowledge of the of different forms of residential accommodation available and the ability to advise patients about them " knowledge of how to use the various s< tatutory and voluntary organisations for support of older people in the community " appropriate communication skills for counselling, teaching and treating patients, their families and carers recognising the difficulties of communicating with older patients including the slower tempo, possible unreliability and the evidence of third parties " skills to develop policies for the primary care team so as to ensure effective management of repeat prescriptions, the appropriate use of screening and case finding programmes, auditing the quality of care of elderly people in all forms of residential accommodation " the ability to develop and maintain a relationship, and a style of communication that treats the patient with respect, as an equal and does not patronise the patient " ensuring that the provision of care promotes the patient s sense of identity and personal dignity and that the patient is not discriminated against as a result of their age A comprehensive approach " understanding the special features of psychiatric diseases in old age, including an appreciation of the features of dementia, and the effects of physical function on the mental state " the importance of ethical tensions between the needs of the individual and the community, and acting appropriately e.g. driving and the DVLA regulations " knowledge of preventative strategies required in the care of older people " understanding the complex nature of health problems of older patients " the ability to co-ordinate teamwork in primary care including involvement of family members nearby, or at a distance. " understanding moral, ethical and emotional issues at the end of life as well as after deathPerson-centred care " Take a sexual history (from a male or female patient) in a way that is non-judgemental, avoids assumptions and is responsive to the reactions of the patient. A comprehensive approach " Use the sexual history (including partner history and information on sexual practices including condom use) and other relevant information to assess risk of sexually transmitted infection, unwanted pregnancy and cervical cancer. " Use risk assessment to tailor advice and care accordingly, including advice on safer sexual practices and Hepatitis B immunisation. " Be aware of factors which may indicate that a woman is at high risk of cervical cancer and the value of an opportunistic approach to screening in this group. " Be aware of when to refer a patient with cervical smear abnormalities, and what is involved in secondary care management. " Aware of specific interventions for HIV prevention such as post-exposure prophylaxis and the prevention of mother to baby transmission. " Understand the screening programmes in use in the UK and the benefits, limitations and need for informed consent. Community orientation " Understand the epidemiology of sexual health problems and how it is reflected in their local community. " Recognise that the prevalence of sexual health problems, including HIV, will be affected by the make-up of the local population. " Be aware of local sexual health services, including services which provide specialist contraceptive care; termination of pregnancy; STI diagnosis and management; HIV management and services for relationship problems and sexual dysfunction. " Be aware how to access local sexual health services, for their patients. They should also be aware how to obtain specialist expertise through their local cytology and microbiology laboratories. " Understand the principles of partner notification and contact tracing A holistic approach " Understand that sexual health problems may impact on the physical or mental health of the individual, or the well being of the relationship or family. " Understand and take into account cultural and existential factors which affect the patient s risk of having sexual health problems and also their reactions to them. " Understand the social stigma that may be associated with sexual health problems. Contextual aspects " Recognise the central role of general practitioners and their primary care teams in prev< ention, diagnosis and management of sexual health problems. " Be aware of the availability of sexual health services in the local health community and how their practice contributes to that local network. " Be aware of the legal aspects relating to sexual health including termination of pregnancy and the methods used in the UK. Attitudinal aspects " Take a sensitive, non-judgmental and person-centred approach to dealing with sexual health problems " Describe the ethical principles involved when treating patients who have sexual health concerns e.g. contraception and abortion " Understand the importance of confidentiality and informed consent " Ensure that the doctor s own beliefs, moral or religious reservations about any contraceptive methods or abortion do not adversely affect the management of a patient s sexual health. wScientific aspects " Understand and implement the key national guidelines that influence sexual healthcare provision Psychomotor skills " Perform a sexual health examination including, digital and speculum examination, assessment of the size, position and mobility of the uterus and the recognition of abnormality of the pelvic organs " Take a cervical smear " Take microbiology and virology swabs from ano-genital areas " Ability to teach the patient about male and female condom use " Ability to give an intramuscular injection Digestive problemsPrimary care management " Manage primary contact with patients who have a digestive problem. " Demonstrate a consistent, evidence-based approach to prescribing for dyspepsia. " Explain the indications for urgent referral to specialist services, especially for patient with suspected GI cancer. The knowledge base Symptoms " Dyspeptic symptoms (epigastric pain, heartburn, regurgitation, nausea, bloating) " Abdominal pain " Nausea, vomiting, anorexia, weight loss " Haematemesis and melaena " Rectal bleeding, tenesmus " Jaundice " Diarrhoea & constipation " Dysphagia Common and/or important conditions " Gastro-oesophageal reflux disease (GORD) " Non-ulcer dyspepsia, gastritis, peptic ulceration " Gall stones " Irritable bowel syndrome " Gastroenteritis " Constipation " Coeliac disease " GI cancers (oesophageal, gastric, hepatic, pancreatic, colonic) " Inflammatory bowel disease " Diverticulosis " Acute abdominal conditions e.g. Appendicitis, cholecystitis, pancreatitis " Perianal disease (e.g. haemorrhoids, perianal haematoma, pilonidal sinus) Investigations " Liver function tests " Amylase " H. pylori testing  serology, breath test, stool antigen testing " Coeliac antibody screening " Stool testing " Faecal occult bloods " Abdominal ultrasound " Knowledge of secondary care investigations including endoscopy (oesophago-gastro-duodenoscopy, sigmoidoscopy, colonoscopy), abdominal imaging techniques (Barium swallow, barium enema, CT), liver biopsy, ERCP, jejunal biopsy Treatment " Understand principles of treatment for common conditions managed largely in primary care " Be aware of secondary care management of digestive problems, including surgical options Emergency care " Recognition of the acute abdomen " Acute management of heamatemesis and melaena Prevention " Dietary advice to include five portions of fruit or vegetables daily " Smoking cessation and alcohol reduction to prevent GI cancers The knowledge base Symptoms " Dyspeptic symptoms (epigastric pain, heartburn, regurgitation, nausea, bloating) " Abdominal pain " Nausea, vomiting, anorexia, weight loss " Haematemesis and melaena " Rectal bleeding, tenesmus " Jaundice " Diarrhoea & constipation " Dysphagia Common and/or important conditions " Gastro-oesophageal reflux disease (GORD) " Non-ulcer dyspepsia, gastritis, peptic ulceration " Gall stones " Irritable bowel syndrome " Gastroenteritis " Constipation " Coeliac disease " GI cancers (oesophageal, gastric, hepatic, pancreatic, colonic) " Inflammatory bowel disease " Diverticulosis " Acute abdominal conditions e.g. Appendicitis, cholecystitis, pancreatitis " Perianal disease (e.g. haemorrhoids, perianal haematoma, pilonidal sinus) Investigations " Liver functi< on tests " Amylase " H. pylori testing  serology, breath test, stool antigen testing " Coeliac antibody screening " Stool testing " Faecal occult bloods " Abdominal ultrasound " Knowledge of secondary care investigations including endoscopy (oesophago-gastro-duodenoscopy, sigmoidoscopy, colonoscopy), abdominal imaging techniques (Barium swallow, barium enema, CT), liver biopsy, ERCP, jejunal biopsy Treatment " Understand principles of treatment for common conditions managed largely in primary care " Be aware of secondary care management of digestive problems, including surgical options Emergency care " Recognition of the acute abdomen " Acute management of heamatemesis and melaena Prevention " Dietary advice to include five portions of fruit or vegetables daily " Smoking cessation and alcohol reduction to prevent GI cancers Specific problem-solving skills " Intervene urgently when patients present with an acute abdomen " Recognise and respond urgently to red flag symptoms, which may indicate GI cancer " Demonstrate a structured, logical approach to the diagnosis of abdominal pain, e.g. to enable a positive diagnosis of irritable bowel syndrome to be made, rather than making the diagnosis by exclusion. Person-centred care " Recognise that some patients may find digestive problems, particularly lower GI, difficult to discuss openly. " Demonstrate a non-judgmental, caring and professional consulting style to minimise embarrassment of patients with digestive problems. bA comprehensive approach " Advise patients appropriately regarding lifestyle interventions that have an impact on gastrointestinal health, such as advice on diet and on stress reduction " Describe the gastrointestinal side effects of common medicines. " Modify the form or modalities of treatment to cater for the patient s GI function and preferences. Community orientation " Evaluate the arguments for and against a national screening programme for colorectal cancer. " Discuss the rationale for restricting referrals for upper gastrointestinal endoscopy in the management of dyspepsia. " Recognise the need for increased availability of lower gastrointestinal endoscopy for the diagnosis of colorectal cancer. " Recognise the place of simple therapy and expectant measures in cost-effective management, whilst ensuring that the patient s condition is adequately monitored. {A holistic approach " Recognise the effects psychological stress can have upon the gastrointestinal tract, especially with functional disorders e.g. non-ulcer dyspepsia, irritable bowel syndrome, abdominal pain in children " Recognise the impact of social and cultural diversity and the important role of health beliefs relating to diet, nutrition and gastrointestinal function. 3Contextual aspects " Recognise how common digestive problems are amongst the general population. " Summarise the debate about the role of upper gastrointestinal endoscopy in the management of dyspepsia. " Summarise the debate about the role of rapid access GI investigation, including imaging and endoscopy Attitudinal aspects " Recognise the embarrassment and reluctance of some patients to undergo rectal examination and respect the patient s autonomy. Scientific aspects " Understand and implement the key national guidelines that influence healthcare provision for digestive problems mPsychomotor skills " Demonstrate complete abdominal examination, including rectal examination. " Proctoscopy Care of older adults The knowledge base Symptoms Key issues in the diagnosis of sexual health problems will be eliciting of the appropriate signs and symptoms and subsequent investigation and treatment or referral of people presenting with: " Genital skin conditions including rashes, ulcers and lichen atrophicus " Lumps " Abnormal genital smell " Vaginal or penile discharge " Pain on passing urine " Lower abdominal pain in women " Testicular pain " Pain on intercourse Common and/or important conditions in men and women " Urinary Tract Infection " Bacterial vaginosis " Candidiasis " Group B Haemolytic Streptococcus " Chlamydial infections " < Gonorrhoea " Genital Ulcers and Warts, Syphilis, Chancroid, Herpes Simplex " HIV / AIDS and the presentations / complications including Pneumocystis pneumonia, Candidiasis, Cryptococcus, Kaposi s sarcoma, Toxoplasmosis, Lymphoma, Hepatitis, tuberculosis " Sexual dysfunction Investigation " Pregnancy testing " Urinalysis " Blood tests for the common conditions including HIV/AIDS " Microbiology and virology swabs " Secondary care investigations e.g. colposcopy Treatment / Management " Contraception  effectiveness rates of all methods and how to provide short term methods including oral contraception and emergency contraception " Contraception  knowledge and availability of long term methods, including natural family planning, implants, intrauterine methods and sterilisation " Termination of pregnancy  methods and the legal procedures relating to referral for termination of pregnancy " Principles of treatment for common conditions managed largely in primary care (see above) " Principles of antiretroviral combination therapy for HIV/AIDS, potential side effects and the role of the GP in their management in primary care Emergency care " Emergency hormonal contraception " Emergency intrauterine contraception Prevention " Health education and prevention advice  safe sex and risk reduction " National screening programmes  cervical screening, Chlamydia, antenatal HIV testing " Hepatitis B immunisation programme " Occupational risks  exposure to needle stick injuries Specific problem-solving skills " Understand the functional anatomy of the male and female genital systems and the female reproductive physiology to aid diagnosis. " Ability to take an appropriate sexual history and apply the information gathered during the history taking and examination, generate a differential diagnosis and formulate a management plan " Recognise common presentations of sexual dysfunction, and of sexual violence and abuse, including covert presentations such as Somatisation. " Be able to counsel patients with sexual problems including issues related to contraception, sexually transmitted infection, pre-test HIV counselling, and for patients who have an unwanted pregnancy " Understand the best practice guidance on the provision of advice and treatment to young people under 16 years. " Understand when urgent intervention is needed in sexual health and if necessary, to refer appropriately, e.g. in provision of emergency contraception or in severe pelvic inflammatory disease, or in serious infections in the immune-compromised patient " Understand that many sexually transmitted infections may present early and in an undifferentiated way or may be present without symptoms. " Understand the limitation of  watching and waiting because some serious infection e.g. Chlamydia and HIV may also lapse back into being asymptomatic, whilst still causing harm to the patient. Primary care management " Manage primary contact with patients who have sexual health concerns and problems. " Work in partnership with members of the Practice s team including the receptionists to ensure accessibility of the services for patients and practice nurses and health visitors in providing coordinated services with respect to sexual health. " Co-ordinate care and make timely appropriate referrals on behalf of patients to specialist services, especially to appropriate gynaecologists, sexual and reproductive health specialists, genito-urinary specialists, urologists and specialists in infectious diseases. " Promote sexual health well-being by applying health promotion and disease prevention strategies appropriately. " Describe strategies for early detection of sexual health problems that may already be present but have not yet produced symptoms. The knowledge base Symptoms Key issues in the diagnosis of sexual health problems will be eliciting of the appropriate signs and symptoms and subsequent investigation and treatment or referral of people presenting with: " Genital skin conditions including rashes, ulcers and lichen atrophicus " Lumps " Abnormal genital smell " Vagin< al or penile discharge " Pain on passing urine " Lower abdominal pain in women " Testicular pain " Pain on intercourse Common and/or important conditions in men and women " Urinary Tract Infection " Bacterial vaginosis " Candidiasis " Group B Haemolytic Streptococcus " Chlamydial infections " Gonorrhoea " Genital Ulcers and Warts, Syphilis, Chancroid, Herpes Simplex " HIV / AIDS and the presentations / complications including Pneumocystis pneumonia, Candidiasis, Cryptococcus, Kaposi s sarcoma, Toxoplasmosis, Lymphoma, Hepatitis, tuberculosis " Sexual dysfunction Investigation " Pregnancy testing " Urinalysis " Blood tests for the common conditions including HIV/AIDS " Microbiology and virology swabs " Secondary care investigations e.g. colposcopy Treatment / Management " Contraception  effectiveness rates of all methods and how to provide short term methods including oral contraception and emergency contraception " Contraception  knowledge and availability of long term methods, including natural family planning, implants, intrauterine methods and sterilisation " Termination of pregnancy  methods and the legal procedures relating to referral for termination of pregnancy " Principles of treatment for common conditions managed largely in primary care (see above) " Principles of antiretroviral combination therapy for HIV/AIDS, potential side effects and the role of the GP in their management in primary care Emergency care " Emergency hormonal contraception " Emergency intrauterine contraception Prevention " Health education and prevention advice  safe sex and risk reduction " National screening programmes  cervical screening, Chlamydia, antenatal HIV testing " Hepatitis B immunisation programme " Occupational risks  exposure to needle stick injuries Person-centred care " Communicate sensitively with women about sexuality and intimate issues (particularly in recognising the impact of past sexual abuse) " Recognise the prevalence of domestic violence and question sensitively where this may be an issue. " Recognise that many women consult for lifestyle advice, and that GPs should not over-medicalise these issues " Recognise the issues of gender and power, and the patient-doctor relationship, and know how to prevent these issues adversely affecting women's health care " Understand the importance of confidentiality and informed consent " Understand the issues relating to the use of chaperones A comprehensive approach " Outline screening strategies relevant to women (e.g. cervical, breast, other cancers, postnatal depression) and discuss their advantages/disadvantages; " Outline prevention strategies relevant to women (e.g. safe sex, pre-pregnancy counselling, antenatal care, immunisation, osteoporosis) " Understand the impact of other illness, in both the patient and her family on the presentation and management and of women s health problems. Community orientation " Understand the issues of equity and access to health information and services for women " Evaluate the effectiveness of the primary care service you provide from the female patient s point of view. " Appraise the role of well-woman clinics in primary care. A holistic approach " Discuss the psycho-social component of women's health and the need, in some cases, to provide women patients with additional emotional and organisational support (e.g. in relation to pregnancy options, hormone replacement therapy, breast cancer, and unemployment) " Understand the impact of culture and ethnicity on womens perceived role in society and their attendant health beliefs, and tailor healthcare accordingly Contextual aspects " Be familiar with legislation relevant to women's health (e.g. termination of pregnancy, contraception for minors) Attitudinal aspects " Discuss their own values, attitudes and approach to ethical issues (e.g. termination of pregnancy, contraception for minors, consent, confidentiality, cosmetic surgery) Scientific aspects " Being aware of tensions between science and politics of screening " Understand and implement the key national guidelines tha< t influence healthcare provision for women s problems (and note that the documents will vary across the UK following devolution) Psychomotor skills " Perform a gentle and thorough pelvic examination, including, digital and speculum examination, assessment of the size, position and mobility of the uterus and the recognition of abnormality of the pelvic organs paying attention to professional etiquette, patient consent, comfort and information " Competently perform a cervical smear with sensitivity and care, providing a positive, informative experience for the woman that allows her to control the process and enhances her view of herself and her body " Perform a competent and sensitive examination of the breasts paying attention to professional etiquette, informed consent, comfort and explanation " Catheterisation " Change ring pessaries The knowledge base Symptoms " breast pain, breast lumps, nipple discharge, " pruritis vulvae, vaginal discharge " dysparunia, pelvic pain, endometriosis " amenorrhoea, menorrhagia, dysmenorrhoea, inter-menstrual bleeding, irregular bleeding patterns, post menopausal bleeding, pre-menstrual syndrome, menopause, menopausal problems " infertility - primary and secondary " urinary malfunction: dysuria, urinary incontinence " faecal incontinence " emotional problems, including low mood and symptoms of depression Common and/or important conditions " abnormal cervical cytology, " vaginal and uterine prolapse " fibroids " gynaecological infections including Bartholin s abscess and sexually transmitted diseases (covered in detail in the RCGP Curriculum Statement on Sexual Health) " gynaecological malignancies " miscarriage & termination of pregnancy " ectopic pregnancy " trophoblastic disease " normal pregnancy and pregnancy problems including hyperemesis, back pain, symphysis pubis dysfunction, multiple pregnancy, growth retardation, pre-eclampsia, ante-partum haemorrhage and abruption, premature labour, polyhydramnios, abnormal lies, placenta praevia, deep vein thrombosis and pulmonary embolism, post dates, reduced movements, intrauterine infection, intrauterine death, foetal abnormality " sexual dysfunction including psychosexual conditions " mental health issues including anxiety, depression, suicide and the relationship between these, pregnancy and the menopause Investigations " Pregnancy testing " urinalysis, MSU and urine dipstick " blood tests including renal function tests, hormone tests " bacteriological and virology tests " knowledge of secondary care investigations including colposcopy and sub fertility investigations Treatment " primary care management of the conditions listed above. (note sexually transmitted disease and contraception are dealt with in depth in the Curriculum Statement on Sexual Health) " menopause management including Hormone Replacement Therapy " knowledge of specialist treatments and surgical procedures including: laparoscopy, D&C, hysterectomy, oopherectomy, ovarian cystectomy, pelvic floor repair, medical and surgical termination of pregnancy, sterilisation " understand the risks of prescribing during pregnancy " palliative care, including management of pain, vomiting, anxiety Emergency care " bleeding in pregnancy " suspected ectopic pregnancy " domestic violence Prevention " health education regarding lifestyle and sexual and mental health " pre pregnancy issues discontinuing contraception, folic acid, family & genetic history and lifestyle advice " pregnancy care including health promotion, social and cultural factors, smoking and alcohol, age factors, previous obstetric history, diabetes and obesity, rhesus problems and use of anti d, hypertension and other medical problems, anaemia, acid reflux, leg ache and varicose veins, haemorrhoids, rubella testing and immunisation " risk assessment, screening and management of osteoporosis Specific problem-solving skills " Recognise and intervene immediately when patients present with a gynaecological emergency " Intervene urgently with suspected malignancy and have a low threshold for the referral of breast lu< mps " Demonstrate an understanding of the importance of risk factors in the diagnosis and management of women s problems " Understand the importance of promoting health and a healthy lifestyle in women, and in particular the impact of this on the unborn child, growing children and the familyPrimary care management " Demonstrate knowledge of women's health problems, conditions and diseases " Understand how practice management issues impact on the provision of care to women including choice and availability of female doctors " Maintain patient records that are accurate, facilitate continuity of care, and respect the patient's confidentiality (particularly in relation to family issues, domestic violence, termination of pregnancy, and contact tracing); " Be familiar with local support services, referral services, networks, and groups for women (e.g. Family Planning, Breast Cancer Nurses, domestic violence resources) " Understand the importance of informing patients of results of screening, and ensuring follow up The knowledge base Symptoms " breast pain, breast lumps, nipple discharge, " pruritis vulvae, vaginal discharge " dysparunia, pelvic pain, endometriosis " amenorrhoea, menorrhagia, dysmenorrhoea, inter-menstrual bleeding, irregular bleeding patterns, post menopausal bleeding, pre-menstrual syndrome, menopause, menopausal problems " infertility - primary and secondary " urinary malfunction: dysuria, urinary incontinence " faecal incontinence " emotional problems, including low mood and symptoms of depression Common and/or important conditions " abnormal cervical cytology, " vaginal and uterine prolapse " fibroids " gynaecological infections including Bartholin s abscess and sexually transmitted diseases (covered in detail in the RCGP Curriculum Statement on Sexual Health) " gynaecological malignancies " miscarriage & termination of pregnancy " ectopic pregnancy " trophoblastic disease " normal pregnancy and pregnancy problems including hyperemesis, back pain, symphysis pubis dysfunction, multiple pregnancy, growth retardation, pre-eclampsia, ante-partum haemorrhage and abruption, premature labour, polyhydramnios, abnormal lies, placenta praevia, deep vein thrombosis and pulmonary embolism, post dates, reduced movements, intrauterine infection, intrauterine death, foetal abnormality " sexual dysfunction including psychosexual conditions " mental health issues including anxiety, depression, suicide and the relationship between these, pregnancy and the menopause Investigations " Pregnancy testing " urinalysis, MSU and urine dipstick " blood tests including renal function tests, hormone tests " bacteriological and virology tests " knowledge of secondary care investigations including colposcopy and sub fertility investigations Treatment " primary care management of the conditions listed above. (note sexually transmitted disease and contraception are dealt with in depth in the Curriculum Statement on Sexual Health) " menopause management including Hormone Replacement Therapy " knowledge of specialist treatments and surgical procedures including: laparoscopy, D&C, hysterectomy, oopherectomy, ovarian cystectomy, pelvic floor repair, medical and surgical termination of pregnancy, sterilisation " understand the risks of prescribing during pregnancy " palliative care, including management of pain, vomiting, anxiety Emergency care " bleeding in pregnancy " suspected ectopic pregnancy " domestic violence Prevention " health education regarding lifestyle and sexual and mental health " pre pregnancy issues discontinuing contraception, folic acid, family & genetic history and lifestyle advice " pregnancy care including health promotion, social and cultural factors, smoking and alcohol, age factors, previous obstetric history, diabetes and obesity, rhesus problems and use of anti d, hypertension and other medical problems, anaemia, acid reflux, leg ache and varicose veins, haemorrhoids, rubella testing and immunisation " risk assessment, screening and management of osteoporosis A comprehensive approach " Identify the pati< ent s health beliefs regarding illness and lifestyle and either reinforce, modify or challenge these beliefs as appropriate. " Educate men about symptoms, and the link between lifestyle and health. " Promote well-being by applying health promotion and disease prevention strategies appropriately. " Use consultations with infrequent attenders opportunistically for health education. &Community orientation " Describe the features of a successful men s health service. " Evaluate the effectiveness of the primary care service you provide from the male patient s point of view. " Develop practical means of engaging with men more effectively regarding their health. " Appraise the role of well-man clinics in primary care. " Recognise that violence and aggression is more common amongst men, assess the risk of harm to others and intervene when appropriate. " Evaluate the arguments for and against a national PSA screening programme. Attitudinal aspects " Recognise that relationships with male patients will be different depending on the gender of the doctor, and intervene when this is adversely affecting the doctor-patient relationship e.g. sexual advances from the patient. " Demonstrate a non-judgmental approach towards male health beliefs, to encourage these beliefs to be expressed and modified. " Recognise that male circumcision is important for several religious groups. eScientific aspects " Summarise the key statistical differences between the health of men and women. }Psychomotor skills " Testicular examination " Digital rectal examination " Injection of anti-androgens for testicular cancer *Specific problem-solving skills " Recognise that men consult less frequently and have more illness. This should lower the doctor s threshold for suspicion of significant disease " Utilise knowledge of the relative prevalence of all medical conditions in men compared to women to assist diagnosis. Person-centred care " Recognise that men may be less articulate about their health compared with women, and describe strategies to compensate for this during the consultation. " Understand the impact of gender on individual cognitions and lifestyle, and formulate strategies for responding to this. For example, some men may have limited control over lifestyle choices, such as those from low socio-economic groups, or living with an addiction. " Recognise that men from different cultural backgrounds have widely different attitudes towards health and expectations of the doctor. They may seem more dismissive about their symptoms than women, but be no less concerned. " Describe the particular difficulties that adolescent males have when accessing primary care services. " Detect whether the male patient wishes to see a doctor of the same sex and arrange this where practical and appropriate. " Demonstrate a non-judgmental, caring and professional consulting style to minimise embarrassment of male patients. A holistic approach " Describe the changing gender roles that men are expected to conform with. " Recognise the importance of the parental fathering role in family structures. " Appreciate the psychological, social, cultural and economic problems caused by unemployment amongst men. Contextual aspects " Recognise important variations in men s health according to ethnicity, social class and geography. " Describe the local demography, social deprivation and service provision which may contribute to poor male health. Primary care management " Describe the management of the key medical conditions which affect men. " Manage primary contact with patients who have a male genito-urinary problem. " Understand the role of the practice nurse in delivering effective health promotion for men. " Understand the indications for urgent referral to specialist services, for patients with testicular lumps and suspected prostate cancer. The knowledge base Symptoms " Dysuria " Frequency of micturition " Haematuria " Prostatism " Retention of urine " Abdominal and loin pains " Testicular lumps " Testicular pain (orchalgia) " Sore / painful penis, ulceration " Erectile dysfunc< tion Common and/or important conditions " Male-specific cancers: Testicular and prostate cancer " Benign Prostatic Hypertrophy (BPH) and prostatitis " Other testicular conditions e.g. cryptorchidism, varicocele, haematocele, hydrocele, epiydymo-orchitis and epidydmitis " Sexual dysfunction including psychosexual conditions, premature ejaculation and erectile dysfunction " Male contraception: vasectomy " Male infertility " Circumcision (religious and non-religious) " Mental health issues including depression, suicide and andropause " Sexually transmitted diseases (covered in detail in the RCGP Curriculum Statement on Sexual Health) Investigations " Urinalysis, MSU and dipstick " Blood tests including renal function tests and Prostate specific antigen (PSA) test " Semen analysis " Knowledge of secondary care investigations including prostate biopsy and testicular ultrasound Treatment " Understand principles of treatment for common conditions managed largely in primary care  benign prostatic hypertrophy, prostatitis, sexual dysfunction, infertility etc " Injection of anti-androgens for testicular cancer Emergency care " Acute management of testicular torsion " Acute management of paraphimosis and priapism " Acute urinary retention " Acute management of ureteric colic Prevention " Health education regarding lifestyle and risk taking behaviour, sexual and mental healtPerson-centred care " Communicate prognosis truthfully and sensitively to patients with incurable disabling neurological conditions, such as Parkinson s disease and multiple sclerosis, and share uncertainty when the patient wants this information. " Demonstrate empathy and compassion towards patients with incurable disabling neurological conditions. " Understand the importance of continuity of care for patients with chronic neurological conditions. A comprehensive approach " Counsel patients appropriately regarding epilepsy medication drug interactions and side effects, including contraceptive and pregnancy advice Community orientation " Describe the current medical standards of fitness to drive for neurological conditions, in particular epilepsy. A holistic approach " Recognise that neurological conditions often affect patients during their working lives, and consequently have a large impact on the family s social and economic well-being. " Recognise the stigma associated with neurological disability. Contextual aspects " Recognise the central role of primary care in managing epilepsy. " Recognise that the higher death rate amongst patients with epilepsy may be related to poor seizure control. ZAttitudinal aspects " Describe the ethical principles involved when treating an incompetent patient (e.g. unconsciousness), and when treating a patient who is unable to communicate (e.g. dysphasia). " Ensure that a patient s neurological disability does not prejudice the doctor s attitude towards or the information communicated to the patient. Scientific aspects " Understand and implement the key national guidelines that influence healthcare provision for neurological problems (e.g. the NICE guidelines on epilepsy diagnosis and management) Psychomotor skills " Demonstrate complete neurological examination of cranial and peripheral nervous system including visual acuity, visual fields and fundoscopic examination Primary care management " Knowledge of the epidemiology of major cancers along with, risk factors and unhealthy behaviours " Knowledge of the principles and design of primary and secondary screening programmes " The ability to function as both leader and member of cancer care teams, as required " Knowledge of referral guidelines and protocols, both local and national " Knowledge of the principles of palliative care and how it applies to non-cancer illnesses such as cardiovascular, neurological, respiratory and infectious diseases. }Person-centred care " The ability to attend to the full range of physical, social and spiritual needs of the patient and carer " The ability to communicate effectively with the patient and carer regarding difficult information < about the disease, its treatment or its prognosis " Knowledge about how to provide and manage 24 hour continuity of care through various clinical systems Specific problem-solving skills " Knowledge of the signs and symptoms of the early presentation of cancer " The ability to suspect a cancer diagnosis early in the disease process " Knowledge of the appropriate investigations of patients with cancer and of how they fit in with national guidelines " The ability to manage pain " Knowledge about a syringe driver: Suitable drugs Conversion of drugs from oral dosage to syringe drive, either, IV or subcutaneous " The knowledge of various palliative care emergencies and their appropriate management: " Major haemorrhage " Hypercalcaemia " Superior Vena Caval obstruction " Spinal cord compression " Bone fractures " Anxiety/panic " Use of emergency drugs A comprehensive approach " The ability to manage cancer and non-cancer symptomatology in the same patient " The ability to counsel and explain: " Risk of disease " Behaviour change " Treatment options " symptom control [Community orientation " Knowledge of the social benefits and services available to patients and carers " Understand the current population trends in the prevalence of risk factors and cancer in the community. " Appreciate the importance of the social and psychological impact of cancer on the patient s family, friends, dependents and employers. A holistic approach " The ability to offer spiritual care the patient and carers " Knowledge of normal and abnormal grieving and its impact upon symptomatology Contextual aspects " Understand the key government policy documents that influence healthcare provision for cancer and palliative care. " Recognise how geographical factors influence the prevalence and treatment of cancers. vAttitudinal aspects " Knowledge of the ethical dimensions of treatment and investigation choices, palliative and terminal care, and advanced directives " Knowledge of the ethical principles and how they apply to cancer care and control " Knowledge of their own personal attitudes and experiences which can affect their attitude towards patients with cancer or who are dying Scientific aspects " The ability to define and apply evidence-based care in patients with cancer " The ability to learn from the clinical experience " Knowledge of cancer treatment trials and how to inform patients about their participation  The knowledge base Symptoms " Headache " Vertigo / dizziness (neurological, otological, psychological and cardiovascular causes) " Tremor " Neuropathies " Abnormal movements / chorea " Seizures " Drowsiness " Loss of consciousness and coma Common and/or important conditions " Epilepsy " Common causes of headache - Tension headache, Migraine, cluster headache, cervical neuralgia, sinusitis, dental pain, drug rebound headache. " Important causes of headache  raised intracranial pressure, thunderclap headache (subarachnoid haemmorhage, enlarging aneurism or migraine) temporal arteritis, trigeminal neuralgia, herpes zoster, cancers " Brain Infections: Meningitis, encephalitis, brain abscess, Tuberculosis, HIV " Neurological causes of vertigo  stroke (brain stem & cerebellar haemorrhage/infarction), multiple sclerosis, trauma & concussion, acoustic neuroma, brain tumours " Mononeuropathies - Trigeminal neuralgia, Bell s Palsy, Carpal tunnel syndrome, nerve entrapments e.g. ulnar, sciatic and femoral nerves " Polyneuropathies - Metabolic causes (diabetes, alcohol, Vitamin B12 and Folate, Porphyria, Uraemia), infectious causes (e.g. Gullain-Barre, Post Viral, HIV), drugs induced neuropathy " Multiple sclerosis " Amyotrophic lateral sclerosis " Essential tremor " Parkinson s disease " Congenital conditions e.g. cerebral palsy, spina bifida " Genetic conditions e.g. Huntingdon s disease Investigation " Knowledge of secondary care investigations and treatment including electroencephalography (EEG), Computerised Tomography (CT) and Magnetic Resonance Imaging (MRI), nerve conduction studies. Treatment " Understand principles of treatment for c< ommon conditions managed largely in primary care - epilepsy, headaches, vertigo, neuropathic pain, mononeuropathies, essential tremor and Parkinson s disease Emergency care " Acute management of meningitis and meningococcal septicaemia " Acute management of people presenting with collapse, loss of consciousness or coma " Understand indications for emergency referral of people with stroke, intra-cranial haemorrhage, raised intra-cranial pressure and temporal arteritis Prevention " Health education and accident prevention advice for people with epilepsy " Vaccination for meningococcal disease " Understand avoidance of triggers and prophylaxis for migraine " Investigation of people with family history of genetic neurological disease e.g. Berry aneurysm Specific problem-solving skills " Understand the functional anatomy of the nervous system to aid diagnosis. " Demonstrate a structured, logical approach to the diagnosis of  difficult symptoms with multiple causes e.g. headache, dizziness " Use time as a diagnostic tool for chronic neurological conditions. Primary care management " Manage primary contact with patients who have a neurological problem. " Co-ordinate care with other primary care health professionals, such as occupational therapists, physiotherapists and district nurses to enable chronic disease management and rehabilitation. " Understand the indications for referral to a neurologist for chronic conditions requiring ongoing specialist management (e.g. multiple sclerosis, Parkinson s disease) and conditions that are irreversible without early treatment (e.g. ulnar nerve entrapment). The knowledge base Symptoms " Headache " Vertigo / dizziness (neurological, otological, psychological and cardiovascular causes) " Tremor " Neuropathies " Abnormal movements / chorea " Seizures " Drowsiness " Loss of consciousness and coma Common and/or important conditions " Epilepsy " Common causes of headache - Tension headache, Migraine, cluster headache, cervical neuralgia, sinusitis, dental pain, drug rebound headache. " Important causes of headache  raised intracranial pressure, thunderclap headache (subarachnoid haemmorhage, enlarging aneurism or migraine) temporal arteritis, trigeminal neuralgia, herpes zoster, cancers " Brain Infections: Meningitis, encephalitis, brain abscess, Tuberculosis, HIV " Neurological causes of vertigo  stroke (brain stem & cerebellar haemorrhage/infarction), multiple sclerosis, trauma & concussion, acoustic neuroma, brain tumours " Mononeuropathies - Trigeminal neuralgia, Bell s Palsy, Carpal tunnel syndrome, nerve entrapments e.g. ulnar, sciatic and femoral nerves " Polyneuropathies - Metabolic causes (diabetes, alcohol, Vitamin B12 and Folate, Porphyria, Uraemia), infectious causes (e.g. Gullain-Barre, Post Viral, HIV), drugs induced neuropathy " Multiple sclerosis " Amyotrophic lateral sclerosis " Essential tremor " Parkinson s disease " Congenital conditions e.g. cerebral palsy, spina bifida " Genetic conditions e.g. Huntingdon s disease Investigation " Knowledge of secondary care investigations and treatment including electroencephalography (EEG), Computerised Tomography (CT) and Magnetic Resonance Imaging (MRI), nerve conduction studies. Treatment " Understand principles of treatment for common conditions managed largely in primary care - epilepsy, headaches, vertigo, neuropathic pain, mononeuropathies, essential tremor and Parkinson s disease Emergency care " Acute management of meningitis and meningococcal septicaemia " Acute management of people presenting with collapse, loss of consciousness or coma " Understand indications for emergency referral of people with stroke, intra-cranial haemorrhage, raised intra-cranial pressure and temporal arteritis Prevention " Health education and accident prevention advice for people with epilepsy " Vaccination for meningococcal disease " Understand avoidance of triggers and prophylaxis for migraine " Investigation of people with family history of genetic neurological disease e.g. Berry aneurysm Person-centred care " Identify the patient s healt< h beliefs regarding smoking and either reinforce, modify or challenge these beliefs as appropriate. " Negotiate a patient self-management plan for asthma in partnership with the patient. " Communicate prognosis truthfully and sensitively to patients with incurable disabling respiratory conditions, such as COPD and metastatic lung cancer, and share uncertainty when the patient wants this information. " Demonstrate empathy and compassion towards patients with incurable disabling respiratory conditions. " Utilise disease registers and data recording templates effectively for opportunistic and planned monitoring of respiratory problems to ensure continuity of care between different health care providers. \A comprehensive approach " Assess the likelihood of occupational exposure as a cause of respiratory disease (e.g. COPD). " Recognise that breathlessness may have several co-existing causes (e.g. simultaneous cardiac and respiratory disease) and determine optimum management for these. " Consider safety issues when prescribing home oxygen therapy. _Community orientation " Understand the current population trends in the prevalence allergic and respiratory conditions in the community. " Appreciate the importance of the social and psychological impact of respiratory problems on the patient s family, friends, dependents and employers. " Consider safety issues when prescribing home oxygen therapy A holistic approach " Appreciate the importance of the social and psychological impact of respiratory problems on the patient s family, friends, dependents and employers. " Appreciate the disability suffered by people with chronic respiratory problems. " Empower patients to self-manage their conditions as far as practicable. " Recognise the stigma associated with smoking when giving health promotion advice to ensure the doctor-patient relationship is not damaged. Contextual aspects " Understand the current population trends in the prevalence allergic and respiratory conditions in the community. " Recognise the central role of primary care in managing asthma and COPD. " Recognise that sub-optimal care and poor adherence to medication contribute to unnecessary deaths from asthma. " Recognise that lung cancer is the leading cause of cancer deaths in both men and women, often affecting young patients. Attitudinal aspects " Ensure that personal opinion regarding smoking does not influence management decisions for people with respiratory problems. JScientific aspects " Understand and implement the key national guidelines that influence healthcare provision for respiratory problems (e.g. the BTS / SIGN guidelines on asthma management, the NICE guidelines on COPD management). " Understand the evidence regarding antibiotic prescribing in upper respiratory tract infections. cPsychomotor skills " Demonstrate peak flow measurement technique using child and adult meters, and interpret the results. " Describe how to use peak flow diaries and evaluate the results. " Describe, demonstrate and assess technique for using common inhaler types. " Demonstrate the use of a hand-held spirometer. " Interpret the results from spirometry. N  The knowledge base Symptoms " Breathlessness, cough, wheeze, chest pain, sputum production, haemoptysis. Common and/or important conditions " Upper respiratory tract infections: Sore throats and colds, tonsillitis, peri-tonsillar abscess, epiglottitis, laryngitis and tracheitis " Lower respiratory tract infections: Influenza, bronchiolitis, bronchitis and pneumonia (of any cause) " Acute non-infective respiratory problems: Allergy and anaphylaxis, hypersensitivity pneumonitis, pulmonary embolus, pneumothorax, aspiration of a foreign body " Chronic lower respiratory problems: Chronic cough, asthma, chronic obstructive pulmonary disease (COPD), tuberculosis, cystic fibrosis, chronic interstitial lung diseases " Lung cancer Investigation " Serial peak flow measurement, including patient diaries " Reversibility testing using peak flow meter " Spirometry " Knowledge of secondary care investigations and treatment including lung funct< ion assessment, Computerised Tomography (CT) and Magnetic Resonance Imaging (MRI) Treatment " Understand principles of treatment for common conditions managed largely in primary care  upper and lower respiratory tract infections, asthma, COPD, allergic reactions and anaphylaxis. " Inhaler technique for using commonly used devices. Emergency care " Acute management of people presenting with shortness of breath " Acute management of anaphylaxis " Management of exacerbations of asthma and COPD " Understand indications for emergency referral of people with asthma, COPD and anaphylaxis Prevention " Smoking cessation assessment, advice and management. " Vaccination against influenza, Streptococcus Pneumoniae, Haemophilus Influenza b, Diphtheria and Pertussis. " Health education advice and patient self-management plans for people with asthma and COPD " Understand avoidance of triggers and prophylaxis for allergic conditions " Investigation of people with family history of genetic respiratory disease e.g. cystic fibrosis Specific problem-solving skills " Utilise knowledge of the relative prevalence of respiratory problems to assist diagnosis. " Describe the alarm symptoms for lung cancer. " Recognise particular groups of patients at higher risk of acquiring a respiratory infection e.g. asthmatics and those with other underlying lung pathology, HIV/AIDS, immune-compromised, alcoholics, the frail (old and young) " Explain the role of serial peak flow measurement, reversibility testing and spirometry in the diagnosis of asthma and COPD. " Intervene urgently when patients present with a respiratory emergency e.g. anaphylaxis, inhaled foreign body, epiglottitis etc. Primary care management " Manage primary contact with patients who have a respiratory problem. " Demonstrate a consistent, evidence-based approach to antibiotic prescribing for respiratory infections. " Co-ordinate care with other primary care health professionals, such as practice nurses, district nurses and physiotherapists to enable chronic disease management and pulmonary rehabilitation. " Apply the guidelines for emergency admission of patients with an acute exacerbation of asthma, to help reduce preventable deaths. " Explain the indications for urgent referral to specialist services, especially for patient with suspected lung cancer. " Describe the indications for home oxygen therapy and home nebulisers, and evaluate individual patient s requirements for these. The knowledge base Symptoms " Breathlessness, cough, wheeze, chest pain, sputum production, haemoptysis. Common and/or important conditions " Upper respiratory tract infections: Sore throats and colds, tonsillitis, peri-tonsillar abscess, epiglottitis, laryngitis and tracheitis " Lower respiratory tract infections: Influenza, bronchiolitis, bronchitis and pneumonia (of any cause) " Acute non-infective respiratory problems: Allergy and anaphylaxis, hypersensitivity pneumonitis, pulmonary embolus, pneumothorax, aspiration of a foreign body " Chronic lower respiratory problems: Chronic cough, asthma, chronic obstructive pulmonary disease (COPD), tuberculosis, cystic fibrosis, chronic interstitial lung diseases " Lung cancer Investigation " Serial peak flow measurement, including patient diaries " Reversibility testing using peak flow meter " Spirometry " Knowledge of secondary care investigations and treatment including lung function assessment, Computerised Tomography (CT) and Magnetic Resonance Imaging (MRI) Treatment " Understand principles of treatment for common conditions managed largely in primary care  upper and lower respiratory tract infections, asthma, COPD, allergic reactions and anaphylaxis. " Inhaler technique for using commonly used devices. Emergency care " Acute management of people presenting with shortness of breath " Acute management of anaphylaxis " Management of exacerbations of asthma and COPD " Understand indications for emergency referral of people with asthma, COPD and anaphylaxis Prevention " Smoking cessation assessment, advice and management. " Vaccination against influenza, S< treptococcus Pneumoniae, Haemophilus Influenza b, Diphtheria and Pertussis. " Health education advice and patient self-management plans for people with asthma and COPD " Understand avoidance of triggers and prophylaxis for allergic conditions " Investigation of people with family history of genetic respiratory disease e.g. cystic fibrosis  Primary care management " Manage primary contact with patients who have a cardiovascular problem. " Co-ordinate care with other primary care health professionals, cardiologists and other appropriate specialists, leading to effective and appropriate acute and chronic disease management including prevention and rehabilitation. " Make timely appropriate referrals on behalf of patients to specialist services, especially to rapid access chest pain and heart failure clinics. " Promote cardiovascular well-being by applying health promotion and disease prevention strategies appropriately. " Describe strategies for early detection of cardiovascular problems that may already be present but have not yet produced symptoms The knowledge base Symptoms Key issues in the diagnosis of cardiovascular problems will be eliciting of the appropriate signs and symptoms and subsequent investigation and / or referral of people presenting with: " chest pain (Cardiac causes e.g. ischaemic heart disease, pericarditis and aortic dissection versus non-cardiac causes e.g. chest wall/musculoskeletal, psychological, respiratory) " breathlessness (heart failure, respiratory problems, thromboembolism, anaemia, obesity, malignancy) " ankle swelling (heart failure, thromboembolism, venous stasis, varicose veins, DVT, leg ulcers, lymphoedema, anaemia, obesity, malignancy, hypoproteinamia) " symptoms or signs thought to be due to peripheral vascular disease (arterial and venous) " palpitations and silent arrhythmias " signs and symptoms of cerebrovascular disease " collapse Common and/or important conditions " Coronary heart disease (angina, acute coronary syndromes, cardiac arrest) " Heart failure " Arrhythmias (Ectopic beats, atrial fibrillation & flutter, narrow & broad complex tachycardias, brady-arrythmias) " Other heart dis      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrsuvwxyz{|}~ease (valve disease, cardiomyopathy, congenital) " Peripheral vascular disease (arterial and venous) " Cerebrovascular disease (stroke and TIA) " Thromboembolic disease Investigations " Blood pressure measurement " Electrocardiogram (ECG) " 24 hour ambulatory blood pressure measurement " Venous Dopplers and ABPI measurement " Knowledge of secondary care investigations and treatment including echocardiography, 24 hour arrthymia monitoring, venography, invasive procedures such as angioplasty, coronary artery bypass grafting. Treatment " Treatment of people at risk from cardiovascular problems including specific management of raised blood pressure and lipids. " Chronic disease management including specific disease management, systems of care, multidisciplinary team work for people with established cardiovascular problems and rehabilitation " Communication with patients and their families and inter professional communication both within the PHCT and between primary and secondary care Emergency care " Acute treatment of people presenting with cardiovascular problems or symptoms thought to be due to cardiovascular problems Prevention This will involve the following risk factors " Blood Pressure " Lipids " Smoking " Other modifiable risk factors (including alcohol, exercise, obesity and diet) " Fixed factors: age ethnicity, sex and family history " Co-morbidities especially diabetes (See also the Metabolic Problems Curriculum Statement) " Combining Risk Factors  risk calculation and communicating risk A comprehensive approach " Advise patients appropriately regarding lifestyle interventions including skin protection and occupational health advice. " Describe the side effects of common medicines used to prevent and treat other conditions that may cause skin problems.  Community orientation " Describe the rationale for restricting certain investigations and treatments in the management of skin problems<  e.g. prescribing of retenoids, access to phototherapy. " Understand the importance of occupational risk in the aetiology of skin diseasexA holistic approach " Recognise how disfigurement and cosmetic skin changes fundamentally affect patients confidence, mood and interpersonal relationships " Appreciate the importance of the social and psychological impact of skin problems on the patient s quality of life, including, for example, the effects of disfigurement. " Recognise the impact that skin problems have on fitness to work. " Appreciate the importance of the social and psychological impact of skin problems on the patient s family, friends, dependents and employers. " Empower patients to self-manage their skin conditions as far as practicable e.g. eczema. Attitudinal aspects " Ensure that skin problems are not dismissed as trivial or unimportant by health care professionals. " Empower patients with chronic skin problems to manage the effects of disfigurement. AContextual aspects " Recognise how common skin problems are amongst the general population. " Recognise the risk of inappropriate referrals and under-referral. " Describe the need for close collaboration with primary care and specialist services in the management of many skin problems e.g. pigmented lesions, psoriasis. Scientific aspects " Understand and implement the key national guidelines that influence healthcare provision for skin problems (e.g. the NHS cancer plan 2000). Psychomotor skills " Skin biopsy " Demonstrate the ability to take specimens for mycology from skin, hair and nail. " Curettage, cautery and cryosurgery > The knowledge base Symptoms Key issues in the diagnosis of skin problems will be eliciting of the appropriate signs and symptoms and subsequent investigation and / or referral of people presenting with: " hair loss " a disorder of their nails " itch (also known as pruritis) " pigmented skin lesions " skin rashes " signs of infections of the skin " bruising or purpura " lumps under the skin " photosensitivity Common and/or important skin conditions " Eczema " Psoriasis " Generalised pruritus " Urticaria and Vasculitis " Acne and rosacea " Infections (bacterial, viral and fungal) " Infestations including scabies and head lice " Leg ulcers and lymphoedema " Skin tumours (benign and malignant) " Disorders of hair and nails " Drug eruptions " Other less common conditions such as the bullous disorders, lichen planus, vitiligo, photosensitivity, pemphigus, pemphigoid, discoid lupus, granuloma annulare and lichen sclerosus Investigations " Ability to take specimens for mycology from skin, hair and nail " Basic interpretation of histology reports " Skin biopsy Treatment " Those commonly used in primary care (including an awareness of appropriate quantities to be prescribed) " Principles of protective care (sun care, occupational health and hand care) " An awareness of specialised treatments, such as retinoids, ciclosporin, phototherapy and methotrexate " The skills to perform curettage, cautery and cryosurgery Emergency care " Acute treatment of people presenting with skin problems or symptoms thought to be due to skin problems and appropriate referral if necessary. Including: " Angioedema and Anaphylaxis " Meningococcal sepsis " Disseminated herpes simplex " Erythroderma " Pustular psoriasis " Toxic epidermal necrolysis " Stevens-Johnson syndrome " Necrotising fasciitis Prevention This will involve the following risk factors " Sun exposure " Fixed factors: family history and genetics " Occupation and care of the hands Genetics " Describe how genetic factors influence the inheritance of common diseases such as psoriasis and atopic eczema. Specific problem-solving skills " Intervene urgently when patients present with an emergency skin problem (see  knowledge base for examples). " Demonstrate a reasoned approach to the diagnosis of skin symptoms using history, examination, incremental investigations and referral. IPerson-centred care " Appreciate the importance of the social and psychological impact of skin problems on the patient s < quality of life, including, for example, the effects of disfigurement. " Identify the patient s health beliefs regarding skin problems and either reinforce, modify or challenge these beliefs as appropriate. Primary care management " Manage primary contact with patients who have a skin problem. " Co-ordinate care with other primary care health professionals, dermatologists and other appropriate specialists, leading to effective and appropriate acute and chronic disease management including prevention and rehabilitation. " Make timely appropriate referrals on behalf of patients to specialist services, especially to rapid access pigmented lesion (sometimes called skin cancer, mole or melanoma) clinics. " Promote skin well-being by applying health promotion and disease prevention strategies appropriately including sun protection, occupational health advice and hand care. The knowledge base Symptoms Key issues in the diagnosis of skin problems will be eliciting of the appropriate signs and symptoms and subsequent investigation and / or referral of people presenting with: " hair loss " a disorder of their nails " itch (also known as pruritis) " pigmented skin lesions " skin rashes " signs of infections of the skin " bruising or purpura " lumps under the skin " photosensitivity Common and/or important skin conditions " Eczema " Psoriasis " Generalised pruritus " Urticaria and Vasculitis " Acne and rosacea " Infections (bacterial, viral and fungal) " Infestations including scabies and head lice " Leg ulcers and lymphoedema " Skin tumours (benign and malignant) " Disorders of hair and nails " Drug eruptions " Other less common conditions such as the bullous disorders, lichen planus, vitiligo, photosensitivity, pemphigus, pemphigoid, discoid lupus, granuloma annulare and lichen sclerosus Investigations " Ability to take specimens for mycology from skin, hair and nail " Basic interpretation of histology reports " Skin biopsy Treatment " Those commonly used in primary care (including an awareness of appropriate quantities to be prescribed) " Principles of protective care (sun care, occupational health and hand care) " An awareness of specialised treatments, such as retinoids, ciclosporin, phototherapy and methotrexate " The skills to perform curettage, cautery and cryosurgery Emergency care " Acute treatment of people presenting with skin problems or symptoms thought to be due to skin problems and appropriate referral if necessary. Including: " Angioedema and Anaphylaxis " Meningococcal sepsis " Disseminated herpes simplex " Erythroderma " Pustular psoriasis " Toxic epidermal necrolysis " Stevens-Johnson syndrome " Necrotising fasciitis Prevention This will involve the following risk factors " Sun exposure " Fixed factors: family history and genetics " Occupation and care of the hands Genetics " Describe how genetic factors influence the inheritance of common diseases such as psoriasis and atopic eczema. Sexual HealthPsychomotor skillsENT and facial problemsRespiratory problems Skin problemsCardiovascular problemsCancer care and control Men's HealthWomen's Health!Care of children and young peopleNeurological problemsMusculoskeletal OphthalmologyPrimary care managementPerson-centred careComprehensive approachCommunity orientationHolistic approachUnspecified contextSpecific Problem-solving skillsContextual AspectsAttitudinal AspectsScientific Aspects1a1b1c3a3b8a8bMetabolic problemsq " Manage primary contact with patients who have an eye problems " Co-ordinate care with other primary care health professionals, optometrists, ophthalmologists, orthoptists, school health services, community eye clinics, social worker to provide effective and appropriate care to patients with eye problems " Make timely appropriate referrals on behalf of patients to specialist services " Promote visual well-being by applying health promotion and disease prevention strategies appropriately. " Describe strategies for early detection of eye problems that may already be present but have not yet produced symptoms The knowledge base Symptoms Key issues in the diagnosis of eye problems will be eliciting of the appropriate signs and symptoms and subsequent investigation, treatment and / or referral of persons presenting with: Disorders of the l< ids and lacrimal drainage apparatus " blepharitis " stye and chalazion " entropion and ectropion " basal cell carcinoma " naso-lacrimal obstruction and dacryocystitis External eye disease: sclera, cornea and anterior uvea " conjunctivitis (infective and allergic) " dry eye syndrome " episcleritis and scleritis " corneal ulcers and keratitis " iritis and uveitis Disorders of refraction " cataract " myopia, hypermetropia, astigmatism " principles of refractive surgery " problems associated with contact lenses Disorders of aqueous drainage " acute angle closure glaucoma " primary open angle glaucoma " secondary glaucomas Vitreo-retinal disorders " flashes and floaters " vitreous detachment " vitreous haemorrhage " retinal detachment Disorders of the optic disc and visual pathways " swollen optic disc: recognition and differential diagnosis " atrophic optic disc: recognition and differential diagnosis " pathological cupping of the optic disc " migraine " transient ischaemic attacks - TIAs Eye movement disorders and problems of binocularity amblyopic " diplopia " non-paralytic and paralytic strabismus Investigations Undertake an examination of the eye assessing both structure and function Understanding of appropriate investigations to exclude systemic disease e.g. ESR test for Temporal Arteritis, CXR for Sarcoid etc Knowledge of secondary care investigations and treatment including slit lamp, eye pressure measurement Treatment Understanding of and be able to explain to the patient about the use of medications including mydriatics, topical anaesthetics, corticosteroids, antibiotics, glaucoma agents Removal of superficial foreign bodies from the eye Emergency care Ability to recognise and institute primary management of ophthalmic emergencies and refer appropriately " superficial ocular trauma, including assessment of foreign bodies, abrasions and minor lid lacerations " Arc Eye " severe blunt injury, including hyphaema " severe orbital injury, including blow-out fracture " penetrating ocular injury and tissue prolapse " retained intra-ocular foreign body " sudden painless loss of vision " severe intra-ocular infection " acute angle closure glaucoma Prevention This will involve the following risk factors " Genetics - family history " Co-morbidities especially diabetes and hypertension 0" Adopt a person centred approach in dealing with patients with eye problems in the context of the patient s circumstances. " Appreciate the importance of the social and psychological impact of eye problems on the patient. " Identify the patient s health beliefs regarding eye problems and either reinforce, modify or challenge these beliefs as appropriate. " Communicate the patient s risk of eye problems clearly and effectively in a non-biased manner " Respect the autonomy of the patient as a partner during the decision making process of the consultation The knowledge base Symptoms Key issues in the diagnosis of eye problems will be eliciting of the appropriate signs and symptoms and subsequent investigation, treatment and / or referral of persons presenting with: Disorders of the lids and lacrimal drainage apparatus " blepharitis " stye and chalazion " entropion and ectropion " basal cell carcinoma " naso-lacrimal obstruction and dacryocystitis External eye disease: sclera, cornea and anterior uvea " conjunctivitis (infective and allergic) " dry eye syndrome " episcleritis and scleritis " corneal ulcers and keratitis " iritis and uveitis Disorders of refraction " cataract " myopia, hypermetropia, astigmatism " principles of refractive surgery " problems associated with contact lenses Disorders of aqueous drainage " acute angle closure glaucoma " primary open angle glaucoma " secondary glaucomas Vitreo-retinal disorders " flashes and floaters " vitreous detachment " vitreous haemorrhage " retinal detachment Disorders of the optic disc and visual pathways " swollen optic disc: recognition and differential diagnosis " atrophic optic disc: recognition and differential diagnosis " pathological cupping of the optic disc " migraine " transient i< schaemic attacks - TIAs Eye movement disorders and problems of binocularity amblyopic " diplopia " non-paralytic and paralytic strabismus Investigations Undertake an examination of the eye assessing both structure and function Understanding of appropriate investigations to exclude systemic disease e.g. ESR test for Temporal Arteritis, CXR for Sarcoid etc Knowledge of secondary care investigations and treatment including slit lamp, eye pressure measurement Treatment Understanding of and be able to explain to the patient about the use of medications including mydriatics, topical anaesthetics, corticosteroids, antibiotics, glaucoma agents Removal of superficial foreign bodies from the eye Emergency care Ability to recognise and institute primary management of ophthalmic emergencies and refer appropriately " superficial ocular trauma, including assessment of foreign bodies, abrasions and minor lid lacerations " Arc Eye " severe blunt injury, including hyphaema " severe orbital injury, including blow-out fracture " penetrating ocular injury and tissue prolapse " retained intra-ocular foreign body " sudden painless loss of vision " severe intra-ocular infection " acute angle closure glaucoma Prevention This will involve the following risk factors " Genetics - family history " Co-morbidities especially diabetes and hypertension Specific problem-solving skills " Understand the normal appearance, neurological and motor responses in patients from newborns to the elderly " To apply the information gathered during the history taking and examination, generate a differential diagnosis and formulate a management plan to include assessment of severity and need for referral to secondary care " Ability to recognise and institute primary management of ophthalmic emergencies and refer appropriately (see above) " Demonstrate an understanding of the importance of risk factors in the diagnosis and management of eye problems. " Demonstrate a reasoned approach to the diagnosis of eye symptoms using history, examination, incremental investigations and referral. " Ability to recognise ocular manifestations of neurological disease, manage appropriately, assess urgency of referral e.g. hemianopia, nystagmus, manifestations of pituitary and cerebral tumours " Ability to recognise ocular manifestations of systemic disease, know when to refer to secondary care specialist services e.g. diabetic retinopathies, retinal vascular occlusions, amaurosis fugax/transient ischaemic (TIA), macular diseases, hypertensive retinopathy |A comprehensive approach " Prioritise interventions for multiple risk factors and symptoms of eye problems according to their severity and prognostic risk. " Manage simultaneously both acute and chronic problems in the in the patient with eye problems " Explain the definition of blindness and partial sightedness, when and how to register a patient, the value of registration and the role of specialist social workers " Understand the problems associated with adjustment to chronic visual impairment " Help the patient to maximise visual function through management of disease, preventative care and control of environmental factorsCommunity orientation " Understand the role of, and appropriate referral to, the community optician " Describe the DVLA driving regulations for people with visual problems " Facilitate patients access to sources of social support for the visually impaired child o The  Statementing process for children with special educational needs o Schooling requirements and role of peripatetic teachers o Career guidance for visually impaired children " Facilitate patients access to sources of social support for visually impaired adults o RNIB, talking book services, s o Social services, care of the family financial support o Local services o Low vision aids A holistic approach " Appreciate the importance of the social and psychological impact of eye problems on the patient s family, friends, dependents and employers. " Assess individual and family psycho-dynamics and their effect on patients with ocular disability " Recog< nise the impact eye problems may have on disability and fitness to work " Describe the long term care needs of patients with debilitating eye conditions and the necessary environmental adaptation and use of community resources Contextual aspects " Describe local counselling services for genetic eye disease " Explain the organisation of screening for eye problems in primary and secondary care and how to access it e.g. diabetic retinopathy, glaucoma, visual acuity testing, squint " Describe the services offered by the health promotion agencies, school health service, community eye clinics, orthoptist, optometrist, secondary care, social services and voluntary agencies and know when referral is appropriate.Attitudinal aspects " Be able to balance the autonomy of patients with visual problems and public safety " Recognise that patients with visual impairment may have difficulty receiving written information and accessing health care services, and implement measures to overcome these obstacles to effective healthcare. " Ensure that patients with visual impairment are treated with dignity and respect. Scientific aspects " Understand and implement the key national guidelines that influence healthcare provision for eye problems (e.g. National Service Framework for Diabetes).Psychomotor skills Demonstrate complete examination of the eye, assessing both structure and function, including: " measurement of visual acuity " pinhole testing " external examination of the eye " eversion of eyelid " examination of the pupil and assessment of the red reflex " assessment of ocular movements and cover testing " visual field testing by confrontation " direct ophthalmoscopy " colour vision testing " fluorescein staining of the cornea # Primary care management " Manage primary contact with patients who have an ENT or facial problem. " Identify symptoms that within the range of normal and require no treatment e.g. cyclical blocking of nose, senile rhinorrhoea, small neck lymph nodes in well children. " Explain the indications for appropriate referral to an ENT specialist e.g. recurrent tonsillitis (current guidelines are to refer if more than five attacks in two years or recurrent quinsy), Ear drum perforations (pars tensa are safe, whereas pars flaccida are unsafe). " Identify where services are deficient or frequently have long waiting times for ENT surgery e.g. audiometry, hearing aids, cochlear implants. " Describe arrangements for referral to specialist nurse services e.g. audiometry. The knowledge base Symptoms " Hearing loss; ear wax, otalgia; discharging ear; dizziness; tinnitus; epistaxis; sore throat, hoarseness; dysphagia; croup; goitre, lymph nodes and other neck swellings; speech delay; foreign bodies; facial weakness Common and/or important conditions " Otitis media (suppurative/secretory); otitis externa; perforated tympanic membrane; cholesteatoma " Vertigo; Mnire s disease; " Bell s palsy; Tempero-mandibular pain, Trigeminal neuralgia " Pharyngitis; tonsillitis; laryngitis; glandular fever; oral candida, herpes; salivary stones; GORD " Infective and allergic rhinitis; sinusitis; nasal polyps " Nasal fracture, haematoma auris " Snoring and sleep apnoea " Suspected Head and Neck Cancer: " Unilateral hearing loss in the absence of external ear pathology or obvious cause Investigation " Otoscopy, " Tuning fork tests " Awareness of: pure tone threshold audiogram; speech audiometry, impedance tympanometry, auditory brainstem responses and otoacoustic emissions. " Investigations may delay referral in suspected head and neck cancer (see Appendix 1) Treatment " Watchful waiting and use of delayed prescriptions " Nasal cautery " Fracture nose (need manipulation under anaesthetic within 2 weeks for optimum result) Emergency care " Septal haematoma " Epistaxis " Tonsillitis with Quinsy " Otitis externa if extremely blocked or painful " Foreign body " Auricular haematoma or perichondritis Prevention " Screening for hearing impairment in adults and children " Awareness of iatrogenic causes of ototoxicity U The knowledge base < Symptoms " Hearing loss; ear wax, otalgia; discharging ear; dizziness; tinnitus; epistaxis; sore throat, hoarseness; dysphagia; croup; goitre, lymph nodes and other neck swellings; speech delay; foreign bodies; facial weakness Common and/or important conditions " Otitis media (suppurative/secretory); otitis externa; perforated tympanic membrane; cholesteatoma " Vertigo; Mnire s disease; " Bell s palsy; Tempero-mandibular pain, Trigeminal neuralgia " Pharyngitis; tonsillitis; laryngitis; glandular fever; oral candida, herpes; salivary stones; GORD " Infective and allergic rhinitis; sinusitis; nasal polyps " Nasal fracture, haematoma auris " Snoring and sleep apnoea " Suspected Head and Neck Cancer: " Unilateral hearing loss in the absence of external ear pathology or obvious cause Investigation " Otoscopy, " Tuning fork tests " Awareness of: pure tone threshold audiogram; speech audiometry, impedance tympanometry, auditory brainstem responses and otoacoustic emissions. " Investigations may delay referral in suspected head and neck cancer (see Appendix 1) Treatment " Watchful waiting and use of delayed prescriptions " Nasal cautery " Fracture nose (need manipulation under anaesthetic within 2 weeks for optimum result) Emergency care " Septal haematoma " Epistaxis " Tonsillitis with Quinsy " Otitis externa if extremely blocked or painful " Foreign body " Auricular haematoma or perichondritis Prevention " Screening for hearing impairment in adults and children " Awareness of iatrogenic causes of ototoxicity Specific problem-solving skills " Utilise knowledge of the relative prevalence of ENT problems to assist diagnosis. " Describe the alarm symptoms for head and neck cancer e.g. hoarseness persisting for more than 6 weeks, ulceration of oral mucosa persisting for more than 3 weeks. " Demonstrate appropriate use of time as a diagnostic tool, including clear review procedures and safety netting. " Understand the likely outcomes of tests e.g. ear swabs after multiple antibiotic courses always grow pseudomonas.A comprehensive approach " Describe ENT presentations of systemic diseases e.g. GORD, CVA, AIDS " Assess the likelihood of occupational exposure as a cause of ENT disease (e.g. industrial deafness). 6Community orientation " Prioritise referrals accurately so people with minor conditions don t compromise the care of those with more serious conditions " Describe the national screening programme for hearing loss. " Understand that certain services have limited availability e.g. Cochlear implants, digital hearing aids. " Understand the legal implications of the Disability Discrimination Act 1995 including the need for 'reasonable adjustments' e.g., allowing more time for appointments or having a display board to announce the next appointment. They can also include providing communications support, such as a BSL/English interpreter or purchasing helpful equipment, such as a conversor and putting a prominent reminder on the jacket of a patient's notes or on the computer record to tell staff the patient is deaf. oA holistic approach " Appreciate the impact of deafness on people s lives.  Blindness separates people from things. Deafness separates people from people " Demonstrate awareness that certain ENT symptoms can indicate psychological distress e.g. globus  sensation of not swallowing in a patient who can swallow, the  dizzy patient who can walk without difficulty. Contextual aspects " Recognise that training in ENT problems has been very limited outside specialist programmes in the past, increasing the risk of inappropriate referrals and under-referral. Attitudinal aspects " Ensure that a patient s hearing impairment or deafness does not prejudice the information communicated or doctor s attitude towards < the patient. " Demonstrate empathy and compassion towards patients with incurable disabling ENT conditions e.g. tinnitus. Scientific aspects " Demonstrate a thorough knowledge of the scientific backgrounds of symptoms, diagnosis and treatment, particularly with respect to ENT interventions of dubious efficacy. " Demonstrate an evidence based approach to antibiotic prescribing, to prevent the development of resistance e.g. otitis media. " " Understand and implement the key national guidelines that influence healthcare provision for ENT problems e.g. Prodigy. Psychomotor skills " Demonstrate otoscopy. " Ability to perform simple nasal cautery " Demonstrate tuning fork tests (Weber and Rinne s tests) Person-centred care " Describe strategies for communicating effectively with patients with hearing impairment and deafness e.g. remembering to face the patient and speaking clearly so that they can lipread. " Demonstrate effective strategies for dealing with parental concerns regarding ENT conditions e.g. recurrent tonsillitis and glue ear. " Empower patients to adopt self-treatment and coping strategies where possible e.g. hay fever, nosebleeds, dizziness, tinnitus. {Person-centred care " Identify the patient s health beliefs regarding cardiovascular problems and either reinforce, modify or challenge these beliefs as appropriate. " Recognise that non-concordance is common for many preventative cardiovascular medicines and respect the patient s autonomy when negotiating management. " Communicate the patient s risk of cardiovascular problems clearly and effectively in a non-biased manner. " Utilise disease registers and data recording templates effectively for opportunistic and planned monitoring of cardiovascular problems to ensure continuity of care between different health care providers. The knowledge base Symptoms Key issues in the diagnosis of cardiovascular problems will be eliciting of the appropriate signs and symptoms and subsequent investigation and / or referral of people presenting with: " chest pain (Cardiac causes e.g. ischaemic heart disease, pericarditis and aortic dissection versus non-cardiac causes e.g. chest wall/musculoskeletal, psychological, respiratory) " breathlessness (heart failure, respiratory problems, thromboembolism, anaemia, obesity, malignancy) " ankle swelling (heart failure, thromboembolism, venous stasis, varicose veins, DVT, leg ulcers, lymphoedema, anaemia, obesity, malignancy, hypoproteinamia) " symptoms or signs thought to be due to peripheral vascular disease (arterial and venous) " palpitations and silent arrhythmias " signs and symptoms of cerebrovascular disease " collapse Common and/or important conditions " Coronary heart disease (angina, acute coronary syndromes, cardiac arrest) " Heart failure " Arrhythmias (Ectopic beats, atrial fibrillation & flutter, narrow & broad complex tachycardias, brady-arrythmias) " Other heart disease (valve disease, cardiomyopathy, congenital) " Peripheral vascular disease (arterial and venous) " Cerebrovascular disease (stroke and TIA) " Thromboembolic disease Investigations " Blood pressure measurement " Electrocardiogram (ECG) " 24 hour ambulatory blood pressure measurement " Venous Dopplers and ABPI measurement " Knowledge of secondary care investigations and treatment including echocardiography, 24 hour arrthymia monitoring, venography, invasive procedures such as angioplasty, coronary artery bypass grafting. Treatment " Treatment of people at risk from cardiovascular problems including specific management of raised blood pressure and lipids. " Chronic disease management including specific disease management, systems of care, multidisciplinary team work for people with established cardiovascular problems and rehabilitation " Communication with patients and their families and inter professional communication both within the PHCT and between primary and secondary care Emergency care " Acute treatment of people presenting with cardiovascular problems or symptoms thought to be due to cardiovascular problems Prevention This will involve the fol< lowing risk factors " Blood Pressure " Lipids " Smoking " Other modifiable risk factors (including alcohol, exercise, obesity and diet) " Fixed factors: age ethnicity, sex and family history " Co-morbidities especially diabetes (See also the Metabolic Problems Curriculum Statement) " Combining Risk Factors  risk calculation and communicating risk Specific problem-solving skills " Intervene urgently when patients present with a cardiovascular emergency e.g. myocardial infarction, stroke, and critical ischaemia. " Demonstrate an understanding of the importance of risk factors in the diagnosis and management of cardiovascular problems. " Demonstrate a reasoned approach to the diagnosis of cardiovascular symptoms (e.g. chest pain - see above) using history, examination, incremental investigations and referral. ! )A comprehensive approach " Prioritise interventions for multiple risk factors and symptoms of cardiovascular problems according to their severity and prognostic risk. " Advise patients appropriately regarding lifestyle interventions according to their cardiovascular risk and level of disability. 7Community orientation " Describe the rationale for restricting certain investigations and treatments in the management of cardiovascular problems e.g. open access echocardiography, Statin prescribing. " Advise patients appropriately regarding driving according to their cardiovascular risk and DLA guidelines. A holistic approach " Appreciate the importance of the social and psychological impact of cardiovascular problems on the patient. " Appreciate the importance of the social and psychological impact of cardiovascular problems on the patient s family, friends, dependents and employers. " Recognise the impact cardiovascular problems have on disability and fitness to work. " Recognise the cultural significance that people attach to the heart as a seat of emotions. ]Contextual aspects " Understand the current population trends in the prevalence of risk factors and cardiovascular disease in the community. " Understand the key government policy documents that influence healthcare provision for cardiovascular problems. " Recognise how geographical distance influences the treatment of cardiovascular emergencies. Attitudinal aspects " Ensure that personal opinions regarding risk factors for cardiovascular problems (e.g. smoking, obesity, exercise, alcohol, age, race) do not influence management decisions Scientific aspects " Understand and implement the key national guidelines that influence healthcare provision for cardiovascular problems. " Describe the key research findings that influence management of cardiovascular problems (e.g. heart protection study) Psychomotor skills " Clinical Skills including cardiovascular examination and blood pressure measurement " Calculation of Cardiovascular risk " Performing an ECG and basic interpretation " Resuscitation and children and adults Primary care management " Manage primary contact with children and their families - and, with older children, on their own " Understand the importance of multi-agency working (working across professional and agency boundaries) " Co-ordinate care with other primary care professionals, paediatricians and other appropriate specialists, leading to effective and appropriate care provision, taking an advocacy position for the patient or family when needed: " Deal effectively with child abuse. Safeguarding children, understanding that: o the welfare of the child must be the paramount consideration and can help to justify actions that challenge ethical and professional norms. o as GPs we are usually family focused, but in d< ealing with child protection and other vulnerable children (such as domestic violence) if we focus on the family we risk losing sight of the child. o often children in special circumstances are  invisible to the system because they live in the shadow of their parents' problems o dealing effectively with child abuse involves, recognising the clinical features, knowing about local arrangements for child protection, referring effectively and playing a part in assessment and continuing management including prevention of further abuse in the patient and family. " Understand the principles of clinical governance and risk management o clinical governance systems do not always explicitly recognise children and young people as a separate and vulnerable client group. It is essential that the care of children is given a specific focus within the clinical governance arrangements in primary care. o the components of clinical governance strategies in primary care will include: safety of treatment and care; safeguarding; the use of evidence-based practice; clinical audit; effective prescribing and referrals, and continuing professional development. " Ensure that parents or carers, children and young people receive information, advice and support to enable them to: o manage minor illnesses themselves, using community pharmacists and triage services where appropriate o Access appropriate services when necessary " Prescribe and advise appropriately about the use of medicines in children, being competent at: o calculating drug doses o understanding the risks and benefits of medicines in relation to children; o understanding the needs of ethnic minorities, and cultural differences in beliefs about illness and the use of medicines " Understanding the welfare of the unborn baby by: o being aware of the impact of parental problems including domestic violence, substance misuse and mental health problems. o being able to recognise the symptoms and presentations of such problems and being able to make a sensitive enquiry if concerned o providing information about, or referral to, local services for women who have substance misuse problems as they are at greater risk of problem pregnancies and their care should be provided by an integrated multi-disciplinary and multi-agency team The knowledge base Symptoms " vomiting, fever, drowsiness, developmental delay, infantile colic,  Failure to Thrive and growth disorders, behavioural problems Common and/or important conditions " neonatal problems: birthmarks, feeding problems, heart murmur, sticky eye, jaundice " constipation, abdominal pain (acute and recurrent) " pyrexia ,febrile convulsions " cough/dyspnoea, wheezing including respiratory infections, bronchiolitis " otitis media " sensory deficit especially deafness " gastroenteritis " viral exanthems, " urinary tract infection, " meningitis " epilepsy " chronic disease: asthma, diabetes, arthritis, learning disability " child abuse, deprivation " mental health problems such as attention deficit hyperactivity disorder, depression, eating disorders, substance misuse and self-harm, autistic spectrum disorder and related conditions " psychological problems: enuresis, encopresis, bullying, school refusal, behaviour problems including tantrums " child and young person development (physical and psychological); Prevention Areas where healthy choices make a big difference in children s and young people s lives include: " pre-natal diagnosis " breastfeeding; " healthy diet and exercise for children and young people; " social and emotional well-being; " keeping children and young people safe; child protection, accident prevention " immunisation " avoiding smoking, using volatile substances and other drugs and minimising alcohol intake, " reducing the risk of teenagers getting pregnant or acquiring sexually transmitted infections. The knowledge base Symptoms " vomiting, fever, drowsiness, developmental delay, infantile colic,  Failure to Thrive and growth disorders, behavioural problems Common and/or important conditions " neonatal problems: birth< marks, feeding problems, heart murmur, sticky eye, jaundice " constipation, abdominal pain (acute and recurrent) " pyrexia ,febrile convulsions " cough/dyspnoea, wheezing including respiratory infections, bronchiolitis " otitis media " sensory deficit especially deafness " gastroenteritis " viral exanthems, " urinary tract infection, " meningitis " epilepsy " chronic disease: asthma, diabetes, arthritis, learning disability " child abuse, deprivation " mental health problems such as attention deficit hyperactivity disorder, depression, eating disorders, substance misuse and self-harm, autistic spectrum disorder and related conditions " psychological problems: enuresis, encopresis, bullying, school refusal, behaviour problems including tantrums " child and young person development (physical and psychological); Prevention Areas where healthy choices make a big difference in children s and young people s lives include: " pre-natal diagnosis " breastfeeding; " healthy diet and exercise for children and young people; " social and emotional well-being; " keeping children and young people safe; child protection, accident prevention " immunisation " avoiding smoking, using volatile substances and other drugs and minimising alcohol intake, " reducing the risk of teenagers getting pregnant or acquiring sexually transmitted infections. Specific problem-solving skills By the end of training, the GP Registrar should be able to: " Use a decision-making process determined by the prevalence and incidence of illness in the community and the specific circumstances of the patient and family: o being aware of normal growth and development o being aware of neonatal problems including jaundice and feeding problems, breast feeding and nutrition " Manage conditions which may present early and in an undifferentiated way, and to recognize a seriously ill child and intervene urgently when necessary by: o having a thorough understanding of normal development, and being able to recognise delayed development o recognising normal growth, and dealing with faltering growth and failure to thrive o recognising children at risk o being aware that consultations about children may be a presentation of a mother s post-natal depression; and being aware of the effect that post-natal depression may have on her children o recognising the significance of non-attending o understanding that children failing to attend appointments (in primary or secondary care) may trigger concern, given that they are reliant on their parent or carer to take them to the appointment. o failure to attend can be an indicator of a family s vulnerability, potentially placing the child s welfare in jeopardy. o Acknowledging that failure to attend can be an indicator that services are difficult for families to access or considered inappropriate, and need reviewing. 6Person-centred care By the end of training, the GP Registrar should be able to: " Adopt a family-centred approach in dealing with patients, their families and their problems. This requires: o effective communication and engagement (listening to and involving children and working with parents, carers and families) o an understanding the importance of supporting parents and having the skills noting that the role of fathers in parenting their children is frequently overlooked. Their contribution to their child s development and well-being is important. All GPs should be able to support fathers and have the skills for engaging with fathers as well as mothers. " To develop and apply the primary care consultation to bring about an effective doctor, patient, family relationship to enable parents or carers, children and young people to: o participate in their own care planning and delivery; o be routinely involved and supported in making informed decisions and choices about their care, taking into account their age and development, increasing autonomy with age, and the need for confidentiality balanced with the parents need for information o achieve concordance, including active listening and shared decision-making with children and pa< rents o giving information on medicines to children and parents in a clear way; " To provide longitudinal continuity of care as determined by the needs of the patient and family: o understanding the problems with transitions from child to adolescent, and from adolescent to adult. This applies to all children but especially the vulnerable < A comprehensive approach By the end of training, the GP Registrar should be able to: " To manage simultaneously both acute and chronic problems in the child and family by: o assessing children and young people s developmental needs in the context of their family and environmental factors including school and community, and parenting capacity; o understanding the key vulnerability factors for children in special circumstances and responding to their needs, including through referral and joint-working; o recognising inequalities and ethnic diversity and addressing them proactively; " Promote health and well-being by applying health promotion and disease-prevention strategies appropriately, and to detect problems that may already be present but have not yet been detected by : o Being aware of a GP s role in promoting and organising immunisation o being aware of a GP s role in the prevention of accidents " Recognise inappropriate eating habits such as the development of anorexia nervosa or bulimia and are able to make appropriate referrals if specialist help is required " Provide access for young people to confidential contraceptive and sexual health advice services which are tailored to meet their needs, as set out in Best Practice Guidance on the Provision of Effective Contraceptive and Advice Services for Young People o Note that for the provision of contraception to under-sixteen year olds, follow revised guidance. This should include providing young people with rapid access to testing and treatment for sexually transmitted infections including blood borne viruses, rapid access to emergency contraception, early and easy access to free pregnancy testing, unbiased advice, and speedy referral for NHS funded terminations of pregnancy or ante-natal care. " Recognise the importance of supporting parents who have special needs: " Consider the needs of children of parents with substance misuse, mental health or domestic violence problems, teenage mothers and those with severe chronic or short term conditions which affect their capacity to parent their children; some may need referral for multi-agency assessment and support services. o This may include referral to the health visitor for a comprehensive family needs assessment to understand and address the impact of the parent s needs on the children s health and development. Community orientation By the end of training, the GP Registrar should be able to: " Reconcile the health needs of patients and their families and of the community in which they live, in balance with available resources. This requires: o understanding the legal and political context of child care o understanding the organisation of care  care pathways and local systems of care o assessing needs, including the assessment framework A holistic approach By the end of training, the GP Registrar should be able to: " Support transitions (maximising children s achievements and opportunities and understanding their rights and responsibilities); " Understand of the impact of disability on the child and family; " Promote physical health, mental health and emotional well-being by encouraging children and their families to develop healthy lifestyles " Be aware of a GP s role in dealing with enuresis, sleep disturbance, bullying and school refusal }Contextual aspects By the end of training, the GP Registrar should understand the importance of: " The healthcare needs of the paediatric population and the socioeconomic and cultural features of the community that might affect health. " The workload issues raised by the paediatric problems, especially the demand for urgent consultation and the mechanisms for dealing with this. Attitudinal aspects By the end of training, the GP Registrar should < understand the importance of: " Treating children equitably and with respect for their beliefs, preferences, dignity and rights. " Issues of confidentiality and consent " Sharing information " Record-keeping 1Scientific aspects By the end of training, the GP Registrar should be able to: " Access information on the best evidence about interventions and the effectiveness of medicines " Understand the importance of recording significant events and their using them in multi-disciplinary and multi-agency audits. Psychomotor skills By the end of training, the GP Registrar should be competent at: " The examination of the newborn child " The six-week check  Primary care management " Manage primary contact with patients who have a musculoskeletal problem. " Explain the aetiology and natural history of common and important musculoskeletal conditions. " Describe the roles of the primary health care team, allied health professionals, complementary therapists and secondary care (e.g. in shared care protocols), and referring to them appropriately. " Understand the indications for referral within a suitable timeframe to the most appropriate healthcare practitioner (e.g. GPwSI, physiotherapist, podiatrist, osteopath, chiropractor, orthopaedic surgeon, rheumatologist). The knowledge base Symptoms " Inflammation - pain, swelling, redness, warmth " Lack of function  weakness, restricted movement, deformity and disability " Injuries - cuts, bruises, wounds " Systemic manifestations - rashes, tiredness, nerve compression etc. Common and/or important conditions " Acute back/neck pain " Chronic back/neck pain " Shoulder pain " Knee pain " Soft tissue disorders " Osteoarthritis " Osteoporosis " Somatisation/fibromyalgia and allied syndromes " Pain management " Acute Arthropathies " Chronic inflammatory arthropathies " Polymyalgia rheumatica and allied conditions " Awareness of rare diseases " Chronic disability " Common injuries NB - these topics should be considered throughout the age range including children Investigation " Indications for plain radiography, ultrasound, CT and MR scan including the use of tools such as the  Ottawa Rules " General rules of X-ray Interpretation " Implications of "Misses" on X-rays, common errors. " Indications for additional investigations for example blood tests. Treatment " Understand principles of treatment for common conditions managed largely in primary care including the use of NSAIDs and disease modifying drugs " Knowledge of when joint injections and aspirations are appropriate in general practice and the ability to perform when appropriate e.g. Shoulder and knee joints and injections for Tennis and Golfer s Elbow " Understand the roles of allied health professionals (nursing, physiotherapy, chiropody, podiatry, occupational therapy, counselling and psychological services) " Chronic disease management including systems of care, multidisciplinary team work and shared care arrangements Emergency care " The initial management of the patient who has been burnt " To be aware of the safety of the patient, the scene of the incident and medical staff " To be aware of how to summon help in an emergency " Be competent in basic life support (adult and paediatric), the use of simple airway adjuncts (for example oropharyngeal airway and pocket mask) and the safe use of a defibrillator " Be competent in stopping haemorrhage " Be competent in reducing pain by the use of analgesia or other methods. " Be aware of the principles of major incident management " Referrals requiring emergency action to save life or prevent serious long term sequelae Prevention " Advise regarding appropriate levels of exercise " Heath promotion regarding accident prevention 7 The knowledge base Symptoms " Inflammation - pain, swelling, redness, warmth " Lack of function  weakness, restricted movement, deformity and disability " Injuries - cuts, bruises, wounds " Systemic manifestations - rashes, tiredness, nerve compression etc. Common and/or important conditions " Acute back/neck pain " Chronic back/neck pain " Shoulder pain " Knee pa< in " Soft tissue disorders " Osteoarthritis " Osteoporosis " Somatisation/fibromyalgia and allied syndromes " Pain management " Acute Arthropathies " Chronic inflammatory arthropathies " Polymyalgia rheumatica and allied conditions " Awareness of rare diseases " Chronic disability " Common injuries NB - these topics should be considered throughout the age range including children Investigation " Indications for plain radiography, ultrasound, CT and MR scan including the use of tools such as the  Ottawa Rules " General rules of X-ray Interpretation " Implications of "Misses" on X-rays, common errors. " Indications for additional investigations for example blood tests. Treatment " Understand principles of treatment for common conditions managed largely in primary care including the use of NSAIDs and disease modifying drugs " Knowledge of when joint injections and aspirations are appropriate in general practice and the ability to perform when appropriate e.g. Shoulder and knee joints and injections for Tennis and Golfer s Elbow " Understand the roles of allied health professionals (nursing, physiotherapy, chiropody, podiatry, occupational therapy, counselling and psychological services) " Chronic disease management including systems of care, multidisciplinary team work and shared care arrangements Emergency care " The initial management of the patient who has been burnt " To be aware of the safety of the patient, the scene of the incident and medical staff " To be aware of how to summon help in an emergency " Be competent in basic life support (adult and paediatric), the use of simple airway adjuncts (for example oropharyngeal airway and pocket mask) and the safe use of a defibrillator " Be competent in stopping haemorrhage " Be competent in reducing pain by the use of analgesia or other methods. " Be aware of the principles of major incident management " Referrals requiring emergency action to save life or prevent serious long term sequelae Prevention " Advise regarding appropriate levels of exercise " Heath promotion regarding accident prevention Specific problem-solving skills " Intervene urgently when patients present with trauma in a primary care setting e.g. basic life support, control of haemorrhage, summoning help. " Describe the epidemiology of musculoskeletal disorders at all ages, and apply this when developing a differential diagnosis. " Assess the mechanism of injury when considering diagnosis. " Distinguish inflammatory from non-inflammatory conditions. " Assess the possibility that musculoskeletal symptoms can be due to psychological causes (somatisation). " Describe when blood tests and imaging methods are required for diagnosis, how to interpret them and how they influence management. )Person-centred care " Communicate health information effectively to promote better outcomes e.g. use positive terms such as  wear and repair . " Communicate truthfully and sensitively to patients for whom therapeutic options have been exhausted, and share uncertainty when the patient wants this. WA comprehensive approach " Describe problems that can be caused by the treatment of musculoskeletal disorders (e.g. GI bleeds, osteoporosis, coronary heart disease, radiation damage) and explain primary and secondary prevention of these. " Advise patients regarding what they are physically able to do, according to their level of disability. Community orientation " Explain how to access available resources e.g. educational material such as the ARC information leaflets, support groups. " Facilitate self-help strategies to empower the patient e.g. self-treatment measures, the expert patient programme (DH), Challenging Arthritis Programme (Arthritis Care) and local exercise programmes. " Avoid investigations or treatment that are unlikely to alter outcomes, so that availability of these resources is increased (e.g. imaging methods) " Appreciate the resource implications of incapacity for work due to musculoskeletal conditions. " Prioritise referrals accurately so people with minor conditions do not potentially compromise the care of those w< ith more serious conditions (e.g. referrals for joint replacements, non-life threatening orthopaedic conditions). " Identify when referral to complimentary medical services is justified, considering that many services have limited NHS availability or are only available privately. A holistic approach " Recognise that psychosomatic symptoms are commonly described as musculoskeletal problems, and that musculoskeletal problems often have an important psychological component. " Consider the physical, psychological and social impact of musculoskeletal conditions on individuals and their carers (e.g. problems with fatigue, altered body image, work, impact on family relationships and sexual issues). " Recognise the psychological effects of trauma (e.g. post-traumatic stress disorder). " Assess the likelihood of occupational exposure as a cause of musculoskeletal disease (e.g. repetitive strain injury) and advise regarding the likely prognosis in relation to the occupation. Contextual aspects " Understand where services are deficient and have frequent long waiting times (e.g. imaging services, physiotherapy and allied professions, hospital based services including consultant opinion and interventions) " Recognise how geographical distance influences the treatment of trauma in a primary care setting. " Understand the systems of care for rheumatological conditions, including the roles of primary and secondary care, shared care arrangements, multidisciplinary teams and patient involvement. MAttitudinal aspects " Demonstrate empathy and compassion towards patients with incurable, disabling or painful musculoskeletal conditions. " Provide adequate information for informed consent before any procedure is undertaken. " Recognise the emotional impact dealing with trauma and disability can have on the general practitioner. Scientific aspects " Understand and implement the key national guidelines that influence healthcare provision for musculoskeletal problems (e.g. the NICE guidelines, RCGP low back pain guidelines, SIGN guidelines etc.) Psychomotor skills " Demonstrate complete examination of the following areas: o The neck and back o The shoulder, elbow, wrist and hand o The hip, knee and ankle " Demonstrate competence in suturing techniques and applying simple dressings. Primary care management " Manage primary contact with patients who have a metabolic problem. " Co-ordinate care with other primary care health professionals, such as diabetes nurse specialists, dieticians, district nurses, community matrons, chiropodists and opticians to enable chronic disease management. " Explain the indications for referral to an endocrinologist for management of complex metabolic problems or investigation of endocrine disorders. The knowledge base Symptoms Patients with metabolic problems are frequently asymptomatic or have non-specific symptoms, such as tiredness, malaise, weight loss or gain etc. Certain symptoms raise clinical suspicion of metabolic problems: " Diabetes mellitus  tiredness, polydipsia, polyuria, weight loss, infections " Hypothyroidism  tiredness, weight gain, constipation, hoarse voice, dry skin, and hair menorrhagia " Hyperthyroidism  weight loss, tremor, palpitations, hyperactivity, exopthalmos, double vision " Hyperlipidaemia  xanthelasma " Hyperuricaemia  gout " Individual endocrine disorders have typical symptom complexes Common and/or important conditions " Obesity " Diabetes mellitus  type 1 and 2 " Impaired Glucose Tolerance " Thyroid disorders  hypothyroidism, hyperthyroidism, goitre, nodules " Hyperlipidaemia " Hyperuricaemia " Endocrine problems  pituitary disease (e.g. prolactinoma, acromegaly, diabetes inspidus), adrenal disease (e.g. Cushing s syndrome, hyperaldosteronism, Addison s disease, phaeochromocytoma) and parathyroid disease. Investigations " Body mass index calculation " WHO diagnostic criteria for diabetes mellitus " Near patient capillary glucose measurement (including patient self-monitoring) " HbA1c and fructosamine to assess glycaemic control " Albumin: creatinine ratio or dipstick f< or microalbuminuria " Interpret serum electrolyte and urate results " Interpret thyroid function tests and understanding their limitations  TSH, T4, free T4, T3, Auto antibodies " Interpret lipid profile tests  total cholesterol, HDL, LDL, triglycerides " Visual acuity and retinal photography " Knowledge of secondary care investigations including the glucose tolerance test, thyroid ultrasound and fine needle aspiration, specialised endocrine tests Treatment " Understand principles of treatment for common conditions managed largely in primary care  obesity, diabetes mellitus, hypothyroidism, hyperlipidaemia, hyperuricaemia " Chronic disease management including specific disease management, systems of care, and multidisciplinary team work for people with established metabolic problems " Communication with patients and their families and inter professional communication both within the PHCT and between primary and secondary care Emergency care " Acute management of diabetic emergencies  hypoglycaemia, hyperglycaemic ketoacidosis and hyperglycaemic hyperosmolar non-ketotic coma. " Acute management of thyroid emergencies  myxoedema coma and hyperthyroid crisis Prevention " Health promotion activities include dietary modification and exercise advice " Understand when prevention of hyperuricaemia is appropriate e.g. patients treated for myelo/proliferative disorders " Obesity and diabetes mellitus are risk factors for other conditions, so optimal management is preventative  The knowledge base Symptoms Patients with metabolic problems are frequently asymptomatic or have non-specific symptoms, such as tiredness, malaise, weight loss or gain etc. Certain symptoms raise clinical suspicion of metabolic problems: " Diabetes mellitus  tiredness, polydipsia, polyuria, weight loss, infections " Hypothyroidism  tiredness, weight gain, constipation, hoarse voice, dry skin, and hair menorrhagia " Hyperthyroidism  weight loss, tremor, palpitations, hyperactivity, exopthalmos, double vision " Hyperlipidaemia  xanthelasma " Hyperuricaemia  gout " Individual endocrine disorders have typical symptom complexes Common and/or important conditions " Obesity " Diabetes mellitus  type 1 and 2 " Impaired Glucose Tolerance " Thyroid disorders  hypothyroidism, hyperthyroidism, goitre, nodules " Hyperlipidaemia " Hyperuricaemia " Endocrine problems  pituitary disease (e.g. prolactinoma, acromegaly, diabetes inspidus), adrenal disease (e.g. Cushing s syndrome, hyperaldosteronism, Addison s disease, phaeochromocytoma) and parathyroid disease. Investigations " Body mass index calculation " WHO diagnostic criteria for diabetes mellitus " Near patient capillary glucose measurement (including patient self-monitoring) " HbA1c and fructosamine to assess glycaemic control " Albumin: creatinine ratio or dipstick for microalbuminuria " Interpret serum electrolyte and urate results " Interpret thyroid function tests and understanding their limitations  TSH, T4, free T4, T3, Auto antibodies " Interpret lipid profile tests  total cholesterol, HDL, LDL, triglycerides " Visual acuity and retinal photography " Knowledge of secondary care investigations including the glucose tolerance test, thyroid ultrasound and fine needle aspiration, specialised endocrine tests Treatment " Understand principles of treatment for common conditions managed largely in primary care  obesity, diabetes mellitus, hypothyroidism, hyperlipidaemia, hyperuricaemia " Chronic disease management including specific disease management, systems of care, and multidisciplinary team work for people with established metabolic problems " Communication with patients and their families and inter professional communication both within the PHCT and between primary and secondary care Emergency care " Acute management of diabetic emergencies  hypoglycaemia, hyperglycaemic ketoacidosis and hyperglycaemic hyperosmolar non-ketotic coma. " Acute management of thyroid emergencies  myxoedema coma and hyperthyroid crisis Prevention " Health promotion activities include dietary modification and exerc< ise advice " Understand when prevention of hyperuricaemia is appropriate e.g. patients treated for myelo/proliferative disorders " Obesity and diabetes mellitus are risk factors for other conditions, so optimal management is preventative Specific problem-solving skills " Intervene urgently when patients present with a metabolic emergency e.g. hypoglycaemia and hyperglycaemic conditions. " Recognise that patients with metabolic problems are frequently asymptomatic or have non-specific symptoms, and that diagnosis is often made by screening or recognising symptom complexes and arranging appropriate investigations. " Demonstrate a logical, incremental approach to investigation and diagnosis of metabolic problems. Person-centred care " Recognise that non-concordance is common for chronic metabolic conditions (e.g. diabetes) and respect the patient s autonomy when negotiating management. " Communicate the patient s risk of complications from obesity and diabetes mellitus clearly and effectively in a non-biased manner. " Develop a flexible approach to health promotion which reflects that certain groups with obesity or diabetes mellitus require different approaches e.g. children, adolescents and young adults, pregnant women, ethnic minorities, elderly and housebound patients. " Negotiate a programme of weight reduction sensitively with patients, giving appropriate health promotion advice regarding diet, exercise and pharmacological therapies. " Utilise disease registers and data recording templates effectively for opportunistic and planned monitoring of metabolic problems to ensure continuity of care between different health care providers. " Recognise the potential for abuse of thyroxine and propose strategies to reduce dosage. hCommunity orientation " Recognise that environmental and genetic factors affect the prevalence of metabolic problems e.g. Diab      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuwxyz{|}~etes is more prevalent in the UK in patients of Asian and Afro-Caribbean origin21 Hyperuricaemia is more common in prosperous areas and is associated with obesity, diabetes, hypertension and dyslipidaemia22. " Recognise that public health interventions are likely to have the largest impact on obesity and diabetes mellitus and support such programmes where possible e.g. exercise on prescription " Describe the exemptions from prescription charges for patients with metabolic conditions qA comprehensive approach " Recognise that patients with diabetes often have multiple co-morbidities and consequently polypharmacy is common. " Develop strategies to simplify medication regimes and encourage concordance with treatment. " Advise patients appropriately regarding lifestyle interventions for obesity, diabetes mellitus, hyperlipidaemia and hyperuricaemia. KA holistic approach " Recognise the psychosocial impact of diabetes and other long-term metabolic problems e.g. risk of depression, restrictions on employment and driving for diabetes, sexual dysfunction. " Recognise that stigma is associated with obesity. " Empower patients to self-manage their conditions as far as practicable. Contextual aspects " Recognise the central role of primary care in managing diabetes and hypothyroidism. " Understand the key government policy documents that influence healthcare provision for metabolic problems. " Understand the systems of care for metabolic conditions, including the roles of primary and secondary care, shared care arrangements, multidisciplinary teams and patient involvement. Attitudinal aspects " Ensure that a patient s weight does not prejudice the information communicated or the doctor s attitude towards the patient. " Ensure that the risks of diabetic complications are not over-stated in order to coerce a patient into complying with treatment. QScientific aspects " Understand and implement the key national guidelines that influence healthcare provision for cardiovascular problems (e.g. NICE guidelines, British Hypertension Society Joint Committee Recommendations, National frameworks and quality markers). " Describe the key research findings that influence management of metabolic problems < (e.g. UKPDS, DCCT). " Describe the role of particular groups of medication in the management of diabetes (e.g. antiplatelet drugs, angiotension converting enzyme inhibitors, angiotensin-II receptor antagonists, and lipid lowering therapies). Psychomotor skills " Calculate body mass index " Demonstrate lower leg examination for complication of diabetes mellitus " Demonstrate capillary glucose measurement using a near patient test " Demonstrate clinical examination of the neck Mental HealthLearning disabilitiesU Primary care management By the end of their GP Training Programme, the GP Registrar will: " be able to provide treatment for people experiencing mental health problems, bearing in mind that several interventions may be effective for each mental health condition, including different forms of talking therapy, medication, and self help " know specific interventions and guidelines for individual conditions, using where appropriate best practice as described in the SIGN or NICE guidelines " avoid the habit of checking extensively for physical illness while not checking for psychological illness o this can be bad for the patient and the NHS. o Ideas about physical, psychological and social should be integrated in both consultation AND investigation of illness " be able to screen, and diagnose people experiencing mental health problems, using effective and reliable instruments where they are available. " know how to access health and social care organisations, both voluntary and statutory, that are an essential component of managing people with mental health problems " be able to refer to and collaborate with the specialist mental health services (see appendix 6) " identify early indicators of difficulty in the psychological well-being of children and young people o respond quickly to concerns raised by parents, early years workers, teachers and others who are in close contact with the child or young person o understand their responsibilities for supporting children in difficulty and know how to access support and advice from specialist CAMHS and CAMH workers in Primary Care The knowledge base Symptoms " Tired all the time, insomnia, anxiety, depression, multiple somatic complaints, dizziness, palpitations, paraesthesiae, abdominal pain (children), early signs of possible psychotic illness Common and/or important conditions " The most common primary care mental health problems are depression, eating disorders, and anxiety disorders. ADHD, post-traumatic stress disorder. Alcohol and drug misuse (For a fuller list see Appendix 3) Investigation " Use of depression rating scales, and other aids to evaluation of possible diagnosis and severity Treatment " Pharmacology, CBT and simple behavioural techniques, problem solving therapy and basis of systemic and strength focussed therapies, Self-administered therapy. Emergency care " Threatened or attempted suicide, Delirium. Psychosis, Panic, Aggressive or violent patients, Drug overdose and alcohol withdrawal Resources " The family of the patient, " Members of the primary health care team, receptionist, counsellor, CAB worker " Specialist mental health services and non-medical agencies (non professional, lay or voluntary resources) Prevention " Mental health promotion, especially children, families and adolescents " Screening of all language-delayed children for autism " Early intervention in psychosis V The knowledge base Symptoms " Tired all the time, insomnia, anxiety, depression, multiple somatic complaints, dizziness, palpitations, paraesthesiae, abdominal pain (children), early signs of possible psychotic illness Common and/or important conditions " The most common primary care mental health problems are depression, eating disorders, and anxiety disorders. ADHD, post-traumatic stress disorder. Alcohol and drug misuse (For a fuller list see Appendix 3) Investigation " Use of depression rating scales, and other aids to evaluation of possible diagnosis and severity Treatment " Pharmacology, CBT and simple behavioural techniques, problem solving therapy and basis of systemic and strength focus< sed therapies, Self-administered therapy. Emergency care " Threatened or attempted suicide, Delirium. Psychosis, Panic, Aggressive or violent patients, Drug overdose and alcohol withdrawal Resources " The family of the patient, " Members of the primary health care team, receptionist, counsellor, CAB worker " Specialist mental health services and non-medical agencies (non professional, lay or voluntary resources) Prevention " Mental health promotion, especially children, families and adolescents " Screening of all language-delayed children for autism " Early intervention in psychosis Specific problem-solving skills By the end of their GP Training Programme, the GP Registrar will be able to: " assess the prevalence of mental health problems and needs amongst the practice population o This may include the use of valid instruments, and the use of practice registers for specific conditions in association with recording data as part of nGMS " screen and diagnose people experiencing mental health problems, using effective and reliable instruments where they are available. o having an awareness of people at risk for mental health problems (see appendix 7) o be able to understand and appreciate the difference between depression and emotional distress o be able to identify mental health problems which are covert or somatised o be able to assess risk / suicidal ideation o being aware of issues about the effectiveness of screening, early identification, watchful waiting and stepped models of intervention " deal with uncertainty that certain patients produce o frequent attenders, patients who demand drugs, chronic suicidicity in borderline personality disorder Person-centred care By the end of their GP Training Programme, the GP Registrar will: " be able to engage with people experiencing mental health problems, to be able to elicit a persons un-edited story " be able to enable people experiencing mental; health problems to fully engage in delineating their difficulties and deciding on appropriate interventions o be able to work with people experiencing mental health problems to arrive at shared understandings, labels or diagnoses. " appreciate the special challenges of rapport building with patients with mental health problems o have developed the necessary rapport building skills for challenging patients " understand that the concept of concordance is particularly important in mental health care o be able to present individuals with choices as to which intervention may work best for themselves o understand that this ability to choose improves the effectiveness of the intervention " understand the importance of continuity of care for people with mental health problems o co-ordinate care management to enhance doctor-patient continuity " be able to demonstrate gender-specific communication skills A comprehensive approach By the end of their GP Training Programme, the GP Registrar will have: " the ability to deal with the associated physical health problems of people with mental health problems " the ability to screen and diagnose people with physical illness at risk of mental health problems " an understanding of the principles of mental health promotion (see appendix 5) A holistic approach By the end of their GP Training Programme, the GP Registrar will: " understand the impact that social circumstances can have on mental illness and that recovery is contingent on the effective management of those social circumstances o an understanding of the concept of recovery and the principles of promoting recovery - (see appendix 8) " understand that a model of mental illness that creates an artificial separation between mind and body is often unhelpful - particularly in understanding psychosomatic complaints, psychological consequences of physical illness and somatisation " be aware that our understanding of mental illness is culturally determined and depends on assumptions that may not be universal " demonstrate cultural sensitivity Community orientation By the end of their GP Training Programme, the GP Registrar will: " have an a< wareness of the extent and implications of stigma and social exclusion " challenge inequality " be able to work in partnership with other agencies to secure appropriate social interventions for individuals " be able to work in partnership with other agencies to secure wider public health of the local population " be able to contribute to the health improvement programme that reflects the perspective of the local population " understand the importance of avoiding medicalising some mental distresses " be able to debate the ethics the of use of psychotropic drugs to sedate people for social reasons and to practise ethically Contextual aspects The GPR should " have sufficient knowledge of the current Mental Health Act to undertake the responsibilities that this requires of general practitioners }Attitudinal aspects By the end of their GP Training Programme, the GP Registrar will: " Understand that their own attitudes, and feelings are important determinants of how they practice, o people who self harm o people who misuse drugs or alcohol o people who know more about their illnesses than their doctors do o people who engender strong emotions in us for many reasons. " Understand the importance of self-awareness issues for the doctor such as family of origin issues and personal prejudices. " GPs should have personal management plans for how they manage their own mental health " Understand the need for reflective practice Scientific aspects By the end of their GP Training Programme, the GP Registrar will: " Adopt a critical and research based approach to practice is particularly important in mental health, where evidence on effective treatment is often of poor quality. " Understand the major part that drug companies play in promoting use of psychotropic drugs " Recognise the use of value judgements in psychiatric diagnosis and understand the concept of a values-based approach to mental health. Psychomotor skills By the end of their GP Training Programme, the GP Registrar will be able to perform a: " Mental state assessment " Suicide risk assessment Primary care management By the end of their GP Training Programme, the GP Registrar will be able to demonstrate: " An awareness that a significant minority of any practice population will include patients who have mild learning disabilities, who may need no particular special services, but who may have reading writing and comprehension difficulties " An awareness that there will be a few with special needs accessing services with moderate, severe and profound learning disabilities who need to be identified, monitored and reviewed appropriately " An awareness of likely associated conditions; and the knowledge of where to obtain specialist help and advice The knowledge base Symptoms " withdrawal, challenging behaviour, tearfulness, agitation, weight loss Common and/or important conditions " Epilepsy - increased incidence and complexity with severity of learning disability " Sensory impairments - hearing and vision, earwax " Psychiatric problems  emotional and behavioural disorders, sexual and physical abuse, schizophrenia, bipolar affective disorder, Alzheimer's disease in Down's syndrome " Obesity - predisposes to other health problems, stigma " GI - Swallowing problems, reflux oesophagitis, helicobacter pylorii, constipation, gastric carcinoma " Respiratory problems - chest infections, aspiration pneumonia " Cerebral palsy - especially with severe learning disability " Orthopaedic problems - joint contractures, osteoporosis " Dermatological problems Emergency care " In urgent life-threatening cases, treatment needs to proceed without consent in the best interests of person with limited capacity Treatment " Hurdles in the delivery of treatment due to difficulties reading instructions and treatment labels " The risks of  over the counter prescriptions in some patients with a degree of independence, who may not fully understand how to take treatments or what the treatment is for " Implementation depends on carers, the additional difficulties with drug delivery in < inspected residential care homes " hard to identify side-effects Resources " Specialist learning disability teams and non medical agencies Prevention Health reviews proposed for people with learning disabilities The knowledge base Symptoms " withdrawal, challenging behaviour, tearfulness, agitation, weight loss Common and/or important conditions " Epilepsy - increased incidence and complexity with severity of learning disability " Sensory impairments - hearing and vision, earwax " Psychiatric problems  emotional and behavioural disorders, sexual and physical abuse, schizophrenia, bipolar affective disorder, Alzheimer's disease in Down's syndrome " Obesity - predisposes to other health problems, stigma " GI - Swallowing problems, reflux oesophagitis, helicobacter pylorii, constipation, gastric carcinoma " Respiratory problems - chest infections, aspiration pneumonia " Cerebral palsy - especially with severe learning disability " Orthopaedic problems - joint contractures, osteoporosis " Dermatological problems Emergency care " In urgent life-threatening cases, treatment needs to proceed without consent in the best interests of person with limited capacity Treatment " Hurdles in the delivery of treatment due to difficulties reading instructions and treatment labels " The risks of  over the counter prescriptions in some patients with a degree of independence, who may not fully understand how to take treatments or what the treatment is for " Implementation depends on carers, the additional difficulties with drug delivery in inspected residential care homes " hard to identify side-effects Resources " Specialist learning disability teams and non medical agencies Prevention Health reviews proposed for people with learning disabilities Specific problem-solving skills By the end of their GP Training Programme, the GP Registrar will: " Understand how psychiatric and physical illness may present atypically in patients with learning disabilities who have sensory, communication and cognitive difficulties " Understand the need to use additional enquiry, appropriate tests and careful examination in patients unable to describe or verbalise symptoms. " Be aware of the concept of diagnostic overshadowing (see appendix 1) Person-centred care By the end of their GP Training Programme, the GP Registrar will be able to demonstrate: " An awareness of the particular importance of a person centred approach when consulting, often with communications involving carers " A respect for the patient s autonomy, which may be limited, and an awareness of how communicating via carers may skew the doctor patient relationship " An awareness of residential situations, and attendance at day centres " the ability to optimise communication through the use of consulting skills and communication aids " An understanding of the importance of continuity of care in this group " An awareness of the issues of Capacity and Consent and the mechanisms by which these can be determined A comprehensive approach By the end of their GP Training Programme, the GP Registrar will have: " A working knowledge of associated medical problems in commonly encountered conditions which make up learning disabilities, including Down s and Fragile X syndromes, Cerebral Palsy, and Autistic Spectrum disorder. " An understanding of how health can be overlooked in PWLD and the remedial steps, such as health promotion, that can be taken Community orientation By the end of their GP Training Programme, the GP Registrar will: " Ensure that the health needs of patients with learning disabilities are met appropriately by primary care and community services " Be aware of the roles of paid carers, , respite care opportunities, voluntary and statutory agencies, and an ability to work in partnership with them so there is cooperation without duplication. A holistic approach By the end of their GP Training Programme, the GP Registrar will have developed: " A holistic approach to patients with learning disabilities, considering likely bio-psychosocial and cultural factors " An u< nderstanding of the impact of learning difficulties on family dynamics and the implications for physical, psychological and social morbidity in the patient s carers xContextual aspects By the end of their GP Training Programme, the GP Registrar should: " Be aware of the need to provide more time in the consultation in order to deal more effectively with people with learning disabilities. " Understand the impact of the doctor s working environment on the care provided to PWLD, e.g. the measures taken to compensate for sensory impairment Attitudinal aspects By the end of their GP Training Programme, the GP Registrar should understand that: " All citizens should have equal rights to health, and equitable access to health and health information according to their needs " Integration is not simply a matter of health care professionals acquiring skills but rather of health care professionals showing commitment. Inclusion begins with commitment to the development of fully accessible services " PWLD are more prone to the effects of prejudice and unfair discrimination and that doctor s have a duty to recognise this within the self, other individuals and within systems and to take remedial action Scientific aspects By the end of their GP Training Programme, the GP Registrar should be aware of: " The scientific evidence regarding the health needs of people with learning disabilities (see Appendix 2) " The evidence regarding the effectiveness of routine health interventions " The importance of developing and maintaining continuing learning on physician-based issues that are barriers to healthcare including: o a lack of specialist knowledge about health issues of people with intellectual disabilities o a lack of awareness of appropriate specialist support services (behavioural support teams or psychiatric or neurological assessment) and their availability. Psychomotor skills By the end of their GP Training Programme, the GP Registrar will be able to perform a: " Physical and mental state assessment Healthy peopleAcutely ill people Primary care management Primary Care is about providing continuous, comprehensive personal health care at the first point of contact. In the UK, however, the defined  practice list offers a framework to provide appropriate diagnostic, therapeutic and preventative services to individuals and to the registered population . The GP must, therefore, understand the concepts of health, function and quality of life as well as models of disease. These include health promotion and preventative activities , risk management and issues of cost-efficiency and rationing. The GP works as part of the primary health care team and in partnership with public health specialists and with specialists in secondary care to provide care, promote health and apply prevention strategies in their communities. It is important, therefore, that every opportunity is taken to learn with other health professionals during the GP training programme. The GP should also have a wider knowledge of the public s health and prevalence of disease. Health surveillance is an important component of the comprehensive approach to public health with much of the activity based in primary care. For many years, the RCGP has been a key player in the UK through the RCGP Weekly Returns Service which collects data from its network of over 70 practices covering over 660,000 patients. Other key providers of information include the Public Health Laboratory Service in England, NHS Direct. Surveillance is important because it helps with planning of health services, providing alerts for contingency planning and for monitoring the equitable distribution of health care. By the end of GP training, the GP Registrar will require an understanding of: " the epidemiology of problems presenting in primary care " the risk factors for disease including alcohol and substance abuse, accidents, child abuse, diet, exercise, genetics, occupation, social deprivation and sexual behaviour " the principles of prevention and preventive strategies " the principles of immunisation and vaccination<  and a knowledge of the UK s immunisation programmes " the benefits and risks of screening programmes " the importance of changing behaviour in health promotion and disease prevention " the importance of excellent communication and effective teamwork the role of the public health specialist and how to access specialist public health advice " the structure of the healthcare system and the function primary care within the wider NHS " the principles of health surveillance Person-centred care A person-centred and family centred approach focuses on the patient and the family taking into account the patient preferences and expectations at every step in a patient-centred consultation. Involving the patient and where appropriate their family in developing acceptable management plans is a key component of this approach. The GP should encourage questioning by the patient and encourage the patient, their carer and family when appropriate to access further information and use patient support groups. To adopt a person-centred approach, the GP should be able to: " develop an understanding of the patient s (and where appropriate the family s) expectations and the community, social and cultural dimensions of their lives " help the patient understand and achieve an appropriate work-life balance " understand the concept of risk and be able to communicate risk effectively to the patient and their family " understand the effects of smoking, alcohol and drugs on the patient and their family " promote health on an individual basis as part of the consultation " promote health through a health-promotion or disease-prevention programme Specific problem-solving skills The GP requires appropriate skills to be able to promote health and apply prevention strategies for their patients in their communities. By the end of GP Training, the GP Registrar should be able to: " assess an individual patient s risk factors " use basic statistical techniques " interpret evidence about a screening programme and decide whether it is worthwhile " use routinely available data to describe the health of their local population, compare it with that of other populations, and identify localities or groups with poor health within it " undertake a needs assessment of a target group or service Comprehensive approach The GP should aim at an holistic approach to the patient and their family where the main focus would be in promoting their health and general well-being. Reducing risk factors by promoting self-care and empowering patients is an important task of the general GP. The GP should aim to minimise the impact of patient s symptoms on his or her well-being by taking into account the patient s personality, family, daily life, and physical and social surroundings. The GP has a vital role working with other members of the primary health care team to promote health and well-being by applying health promotion and disease prevention strategies appropriately. The GP also has a central responsibility to co-ordinate a patient s care provided by other healthcare professionals and care provided by other agencies. The GP should also be prepared to act as an advocate for the patient and their family. By the end of GP Training, the GP Registrar should have an understanding of: " the concept of health " behavioural approaches to behavioural change and their relevance to health promotion " the role of the general practitioner and the wider primary health care team in health-promotion activities in the community " the importance of ethical tensions between the needs of the individual and the community, and acting appropriately " the importance of teamwork in primary care and work as an effective team member over a prolonged period of time Community orientation General practitioners have a responsibility for the individual patient, their family and the wider community. Because the work of the GP is determined by the makeup of the community in which they work they must, therefore, must understand the characteristics of the community including socio-economic, ethnicity and health features. The GP working with other members of the primary health care team, including public health physicians can make an important contribution to the health of the wider community by engaging in the public health agenda and by influencing health policy in the community. By the end of GP Training the GP Registrar should have gaine< d an understanding of: " the need to reconcile the needs of the individual with the needs of the community in which they live " the scale of health problems in a locality in terms of incidence and prevalence and be able to make comparison with other populations " the interrelationships between health and social care including the wider determinants of health within communities e.g. housing, employment and education " the impact of poverty, genetic, ethnicity and local epidemiology on an individual and a local community s health " the impact of inequalities and discrimination on health " inequalities in health care provision;  the inverse care law " the structure of their local and national healthcare system and its economic limitations " the roles of the other professionals involved in public health e.g. school nurses, health visitors and public health specialists " the importance of involving the public and communities in improving health and reducing inequalities Holistic approach Kemper suggested that holism involves  caring for the whole person in the context of the person s values, their family beliefs, their family system, and their culture in the larger community, and considering a range of therapies based on the evidence of their benefits and cost . Or, as Pietroni puts it, holism involves a  willingness to use a wide range of interventions & an emphasis on a more participatory relationship between doctor and patient; and an awareness of the impact of the  health of the practitioner on the patient. Both of these views indicate that the role of the GP in primary health care involves much more that there is much more to the relationship between the individual patient and the doctor than just that defined by bio-psycho-social model of modern medicine. The GP Registrar should be aware of the concept of holism in their wider role as a family doctor with a key responsibility for the wider public s health and should have: " knowledge of the holistic concept and its implications for the patient s and their family s care " an ability to understand a patient as a bio-psycho-social  whole " skills to transform holistic understanding into practical measures " knowledge of the cultural background and beliefs of the patient, in so far as they are relevant to healthcare " tolerance and understanding towards patients experiences, beliefs, values and expectations, as they affect healthcare delivery &Contextual aspects By the end of GP Training the GP Registrar should have gained an understanding of: " the impact of the local community, including socio-economic factors, geography and culture, on the workplace and patient care. " the impact of overall workload on the care given to the individual patient, and the facilities (e.g. staff, equipment) available to deliver that care. " the financial and legal frameworks in which health care is given at practice level " the impact of the doctor s working environment on the care that they provide Attitudinal aspects By the end of GP Training the GP Registrar should have gained an awareness of: " self: an understanding that their own attitudes, and feelings are important determinants of how they practice " their own capabilities and values " the interaction of work and doctor s own private life and striving for a good balance between them " ethical aspects of clinical practice (prevention, diagnostics, therapy, factors that influence lifestyles) Scientific aspects The essential scientific aspects relating to this statement on Healthy People: promoting health and preventing disease necessarily cross links to other RCGP Curriculum Statements, notably Ethics and Values Based Medicine, Promoting equality and valuing diversity, Evidence Based Health Care and Research and Academic Activity. By the end of GP Training the GP Registrar should have gained an understanding of: " how to access, read and assess medical literature critically " the general principles, methods and concepts of scientific research, and the fundamentals of statistics (incidence, prevalence, predicted value, etc)<  " the scientific backgrounds of public health, epidemiology, preventative healthcare $Primary care management By the end of training, the GP Registrar will be able to: " recognise and evaluate acutely ill patients " understand how the presentation may be changed by age, and other factors such as gender, ethnicity, pregnancy and previous health. " recognise death " be able to make complex ethical decisions demonstrating sensitivity to a patient s wishes in the planning of care " provide clear leadership, demonstrating an understanding of the team approach to care of the acutely ill and the roles of the practice staff in managing patients and relatives " co-ordinate care with other professionals in primary care and with other specialists " take responsibility for a decision to admit an acutely ill person and not be unduly influenced by others, such as secondary care doctors who have not assessed the patient The knowledge base Symptoms " Cardiovascular  chest pain, haemorrhage, shock " Respiratory  wheeze, breathlessness, stridor, choking " Central nervous system  convulsions, reduced conscious level, confusion " Mental Health   threatened self-harm, delusional states, violent patients " Severe pain Common and/or important conditions " Shock (including no cardiac output), acute coronary syndromes, haemorrhage (revealed or concealed), ischaemia, pulmonary embolus, asthma " Dangerous diagnoses (See Appendix 3) " Common problems that may be expected with certain practice activities: Anaphylaxis after immunisation, Local anaesthetic toxicity and vaso-vagal attacks with, for example, minor surgery or IUCD insertion " Parasuicide and suicide attempts, Investigation " Blood glucose " Other investigations are rare in primary care because acutely ill patients needing investigation are usually referred to secondary care. Treatment " Pre-hospital management of convulsions and acute dyspnoea Emergency care " The  ABC principles in initial management " Appreciate the response time required in order to optimise the outcome " Understand the organisational aspects of NHS out of hours care. " Understand the importance of maintaining personal security and awareness and management of the security risks to others Resources " Appropriate use of emergency services; including logistics of how to obtain an ambulance/paramedic crew " Familiarity with available equipment in own car/bag and that carried by emergency services " Selection and maintenance of appropriate equipment and un-expired drugs that should be carried by general practitioners " Being able to organise and lead a response when required, which may include participation by staff, members of the public or qualified responders " Knowledge of training required for practice staff and others as a team in the appropriate responses to an acutely ill person Prevention " Advice to patients on prevention; e.g. with a patient with known heart disease, advice on how to manage ischaemic pain including use of GTN, aspirin and appropriate first-line use of paramedic ambulance By the end of training, the GP Registrar must be competent to provide out of hours care. The GP Registrar will demonstrate: " ability to manage common medical, surgical and psychiatric emergencies in the out-of-hours setting. " understanding of the organisational aspects of NHS out of hours care. " ability to make appropriate referrals to hospitals and other professionals in the out-of-hours setting. " demonstration of communication skills required for out-of-hours care. " individual personal time and stress management. " maintenance of personal security and awareness and management of the security risks to others The knowledge base Symptoms " Cardiovascular  chest pain, haemorrhage, shock " Respiratory  wheeze, breathlessness, stridor, choking " Central nervous system  convulsions, reduced conscious level, confusion " Mental Health   threatened self-harm, delusional states, violent patients " Severe pain Common and/or important conditions " Shock (including no cardiac output), acute coronary syndromes< , haemorrhage (revealed or concealed), ischaemia, pulmonary embolus, asthma " Dangerous diagnoses (See Appendix 3) " Common problems that may be expected with certain practice activities: Anaphylaxis after immunisation, Local anaesthetic toxicity and vaso-vagal attacks with, for example, minor surgery or IUCD insertion " Parasuicide and suicide attempts, Investigation " Blood glucose " Other investigations are rare in primary care because acutely ill patients needing investigation are usually referred to secondary care. Treatment " Pre-hospital management of convulsions and acute dyspnoea Emergency care " The  ABC principles in initial management " Appreciate the response time required in order to optimise the outcome " Understand the organisational aspects of NHS out of hours care. " Understand the importance of maintaining personal security and awareness and management of the security risks to others Resources " Appropriate use of emergency services; including logistics of how to obtain an ambulance/paramedic crew " Familiarity with available equipment in own car/bag and that carried by emergency services " Selection and maintenance of appropriate equipment and un-expired drugs that should be carried by general practitioners " Being able to organise and lead a response when required, which may include participation by staff, members of the public or qualified responders " Knowledge of training required for practice staff and others as a team in the appropriate responses to an acutely ill person Prevention " Advice to patients on prevention; e.g. with a patient with known heart disease, advice on how to manage ischaemic pain including use of GTN, aspirin and appropriate first-line use of paramedic ambulance Specific problem-solving skills By the end of training, the GP Registrar will be able to: " produce differential diagnoses for each presenting symptom " decide whether urgent action is necessary thus protecting patients with non-urgent and self-limiting problems from the potentially detrimental consequences of being over-investigated over-treated or deprived of their liberty " deal sensitively and in line with professional codes of practice with people who may have a serious diagnosis and refuse admission " use telephone triage " to decide to use ambulance where speed of referral to secondary care or paramedic intervention is paramount " to make appropriate arrangements to see the patient " to give advice where appropriate " to use time as a tool and to use iterative review and safety-netting as appropriate /Person-centred care By the end of training, the GP Registrar will be able to: " recognise ways in which the acute illness itself and the anxiety caused by it can impair communication between doctor and patient make the patient s safety a priority " adopt a person-centred approach; respecting patients autonomy whilst recognising that acutely ill patients often have a diminished capacity for autonomy " appreciate the challenges of maintaining continuity of care in acute illness and taking steps to minimise this by making suitable handover and follow up arrangements " appreciate the needs of carers involved at the time of the acutely ill person s presentation " be aware of any conflict regarding management that may exist between patients and their relatives and act in the best interests of the patient :A comprehensive approach By the end of training, the GP Registrar will be able to: " recognise that an acute illness may be an acute exacerbation of a chronic disease " recognise the increased risk of acute events in patients with chronic and co-morbid disease " identify co-morbid diseases " recognise the modifying effect of chronic or co-morbid disease and its treatment on the presentation of acute illness " to recognise patients who are likely to need acute care and offer them advice on prevention ,effective self management and when and who to call for help. Community orientation By the end of training, the GP Registrar will be able to: " use knowledge of patient and family and the availability of special< ist community resources to decide whether a patient should be referred for acute care or less acute assessment or rehabilitation, thus using resources appropriately " deal with situational crises and manipulative patients; avoiding the inappropriate use of healthcare resources QA holistic approach By the end of training, the GP Registrar should: " be aware of the important technical and pastoral support that a GP needs to provide to patients and carers at times of crisis or bereavement including certification of illness or death. " be aware of cultural and other factors that might affect patient management Contextual aspects By the end of training, the GP Registrar should: " be aware legal frameworks affecting acute health care provision especially regarding compulsory admission and treatment " be aware of the tensions between acute and routine care and impact of workload on the care given to the individual patients " be aware of the impact of the doctor s working environment and resources on the care provided " understand the local arrangements for the provision of out of hours care. Attitudinal aspects By the end of training, the GP Registrar should: " ensure that their personal values and attitudes do not influence their professional decisions or the equality of patients access to acute care " be able to identify patients for whom resuscitation or intensive care might be inappropriate and take advice from carers and colleagues " have a balanced view of benefits and harms of medical treatment " be aware of the emotional and stressful aspects of providing acute care; they should ensure that they have strategies for dealing with personal stress to ensure that it does not impair the provision of care to patients Scientific aspects By the end of training, the GP Registrar should: " be able to use decision support to make their interventions evidence based e.g. Cochrane, PRODIGY, etc. " understand written protocols that are available from national bodies and how these may be adapted to unusual circumstances " evaluate their performance in regard to the care of the acutely ill person; including an ability to conduct significant event analyses and take appropriate action IMTPrimary care management All GPs must have appropriate Information Management and Technology Skills. The RCGP recommends that GP Registrars should have reached the standard of the European Computer Driving Licence (ECDL) by the end of their GP training programme (and recognises that many doctors entering Training will have already reached that standard). The seven modules that make up the ECDL are: " Basic concepts of IT " Using the computer and managing files " Word processing " Spreadsheets " Database " Presentation " Information and Communication At the end of their general practice training, the GP should be able to: " Demonstrate an ability to use the practice clinical system effectively and routinely for tasks such as prescribing, entering clinical data , processing pathology results, making referrals and accessing data. " Demonstrate awareness of coding systems in current use for effective record keeping " Demonstrate the effective use of templates for protocol delivered activities such as the management of chronic disease, health promotion and risk assessment. " Demonstrate the use of call/recall systems within the practice to the benefit of patient care " Understand the criteria for good data entry including timeliness, appropriateness and accuracy and the connection between this and improved patient health outcomes " Understand the application of the electronic record to analyse data and: o monitor outcomes, identify trends and warn of deteriorating performance o provide continuous auditing, o provide appropriate prompts to action and reduce risk by warning of potentially adverse outcomes, for example when prescribing. provide population based call and recall systems, for example in screening o share information appropriately and securely with the healthcare team " Demonstrate the use the practice s computer system to improve the<  quality of care both at the level of the individual and that of the practice. " Demonstrate effective use of inter-agency systems such as Pathology links with secondary care, protocol links to the primary care organisations, for example to access local formularies and guidelines, and GP-GP record transfer Person-centred care By the end of their GP training programme the GP Registrar should be able to: " Use the computer in the consultation whilst maintaining rapport with the patient. " Use the availability of computerised resources to tailor information to the needs of patient Specific problem-solving skills By the end of their GP training programme the GP Registrar should be able to: " Demonstrate effective use of expert and web-based information systems e.g. MENTOR & PRODIGY. " Demonstrate the use of the computer for practice-based searches and audit A comprehensive approach GPs need to be able to address multiple complaints and co-morbidity in the patients for whom they care. They should also use an evidence-based approach to the care of patients. Co-ordination of care also means that the general practitioner is skilled not only in managing disease and prevention, but also in caring for the patient, providing rehabilitation and providing palliative care in the end phase of a patient s life. The physician must be able to co-ordinate patient care provided by other healthcare professionals and care provided by other agencies. Effective use of IM&T will assist the GP in achieving these aims. By the end of their GP training programme the GP Registrar should be able to: " Use IM&T in the management of multiple complaints and pathologies, both acute and chronic health problems e.g. by effective use of the medical record and by seeking the best evidence in practice " Use IM&T to share information and coordinate patient care with other health professionals Community orientation By the end of their GP training programme the GP Registrar should be able to: " Use IM&T to gain an understanding of the health needs of communities through the epidemiological characteristics of their population " Understand the IM&T strategies put forward by the NHS in the country that they work and understand the implications of that strategy for their local health economy " Understand of the importance of practice- and community-based information in the quality assurance of each doctor s practice " Demonstrate the use of IM&T to access community based resources e.g. voluntary organisations and self-help groups. A holistic approach Holism and patient-centredness are core values of general practice. Holism, described by Howie as the integration of physical, psychological and social components of health problems in making diagnoses and planning management, is well established as a central issue of good consulting practice , . By the end of their GP training programme the GP Registrar should be able to: " Understand how IM&T contributes to their holistic and patient-centred approach to patient care. " Understand how computer codes and search facilities allow the physical, psychological and social components of the patients of problem to be collated, integrated and made evident. Contextual aspects By the end of their GP training programme the GP Registrar should be: " Aware of the different computer systems used in practices " Aware of local and national IM&T initiatives and strategies Attitudinal aspects By the end of their GP training programme the GP Registrar should be: " Aware of his/her own IM&T capabilities " Able to identify ethical aspects of clinical practice relating to IM&T e.g. security, confidentiality, use of information for insurance company use etc. " Aware of the patient's perspective (positive or negative) regarding the use of the computer and be able to modify the consultation appropriately, keeping the patient as the focus of interaction. 1Scientific aspects By the end of their GP training programme the GP Registrar should be able to: " Search the internet for medical and scientific information including MEDLINE and the < National Electronic Library for Health " Develop and maintain continuing learning and quality improvement by using IM&T Psychomotor skills By the end of their GP training programme the GP Registrar should be able to: " Use a computer to the standard of the European Computer Driving License Management{Primary care management By the end of their GP Training, the GP Registrar would be expected: To coordinate care with other professionals in primary care, and with other specialists " Describe the roles of all members of the primary care team " Demonstrate the ability to co-ordinate a team-based approach to the care of patients " Demonstrate the ability to be an effective member and leader of a team " Understand the role of team dynamics in the functioning of an organisation " Describe strategies for effective communication within the practice organisation " Evaluate own preference for role within teams and in interaction with others To master effective and appropriate care provision and health service utilisation " Describe the management structure of the practice, how decisions are made and how responsibilities are distributed " Understand how the practice functions as a business and the implications various activities and expenses have for profitability " Understand primary care in the context of the wider NHS To make available to the patient the appropriate services within the health care system " Critically appraise the organisational systems of the practice " Delegate tasks effectively " Understand and participate in the motivation of staff " Contribute to staff development and training " Conduct an appraisal interview with staff and/or colleagues " Participate in the recruitment and selection of staff or colleagues in accordance to the law relating to equal opportunities " Organise an effective meeting " Manage own time effectively " Successfully manage a project To act as an advocate for the patient " Negotiate effectively with colleagues " Understand the process of, and factors that influence, change " Demonstrate the ability to improve the quality of healthcare delivered to patients by the practice " Understand how concepts of leadership may be applied in the context of the NHS " Describe how services are commissioned for patients " Where possible provide choice to patients in relation to their future care " Demonstrate where conflicts of interest might arise in the commissioning and provision of services for patients 6Primary care management Research All GPs will be initiators, collaborators or users of research. In this context the minimum competence at the end of the general practice training programme will be that required of a user. The effective user of research will be able to demonstrate competency in the following areas: " Prioritising relevant information " Critical appraisal " Problem framing " Accessing evidence " Implementing change in clinical practice " Basic statistics " Evaluating ethical issues and the need to have projects approved through research governance committees Academic Activity All GPs will be involved in teaching of other practitioners be they medical or allied health professionals. They will be able to: " Identify learning objectives " Use appropriate teaching methods " Evaluate outcomes of teaching In addition, all GPs are expected to undertake continuing professional development. This will includes, as a minimum, an ability to undertake the following: " Significant event analysis " Evaluation of performance across a range of clinical and non-clinical areas " Use of reflective skills for the benefit of oneself and other practitioners Note: The learning objectives are based on the competency grid for academic general practice skills developed by the Society of Academic Primary Care, UK. Person-centred care All GPs engaging in research should comply with all research governance procedures1 and ethical frameworks, including the Good Clinical Practice Guidelines of the British Pharmaceutical Industry. Similarly, all GPs engaged in teaching should be familiar with and comply with the Gen< eral Medical Council s guidance document  The Doctor as a Teacher  . Reflective activities should not be solely individual but to be fully effective need to involve other colleagues and members of the primary care team (e.g. by using the technique of Significant Event Analysis). When patients are involved as research participants, GPs should be aware of the power differential between themselves and the participants, and ensure that participants vulnerability is recognised and appropriately managed. This includes the provision of full information and informed consent. When introducing changes to clinical practice based on research evidence, too, full account should still be taken of patients right to choose to accept new interventions. GPs will also ensure that the relevant team members jointly own the research agenda within a practice. All participation will be voluntary and GPs will ensure confidentiality and in particular, comply with the requirements of the data protection act. Specific problem-solving skills Research All general practitioners should be familiar with essential components of the research process. They should be able to: " Develop a research question " Identify appropriate methods from a range of designs " Be able to draw up a questionnaire " Demonstrate basic quantitative and qualitative data-analysis skills " Draw appropriate conclusions " Summarise results Specific Educational and Reflective Skills All general practitioners should be able to: " Identify their learning objectives " Choose appropriate methods of learning and teaching " Use reflective skills to measure process " Apply their learning to their clinical practice " Identify further objectives A comprehensive approach Most clinical interventions in practice are complex, and require the use of multiple research methods to evaluate them. These include quantitative methods (such as randomised controlled trials) and qualitative methods (such as  grounded theory ). GPs should be familiar with and use the range of resources available from Postgraduate and University Departments. The competent GP should understand the complex processes involved in implementing change in practice. Whether the GP is an initiator, collaborator or user of research, they must be able to choose the appropriate change management skills to achieve the required end point. Community orientation A great deal of research is conducted in secondary care setting; the results are not necessarily applicable in general practice. All GPs must, therefore, be able to judge relevance, applicability and validity of research findings to their own practice. GPs must be able to interpret good teaching practice in the light of conditions prevalent in primary care. Other academic activity  including reflective practice will support themselves, their team and their local communities. A holistic approach The complexity of undertaking research or implementing research findings should not be underestimated. GPs should use the same holistic approach to such scholarly activity as they would in clinical practice. 8Person-centred care The GP should remember that when involved in management, they are acting as an advocate for patients and their families. Just as in the clinical sphere of practice where a person-centred approach focuses on the patient on, in management, the GP should take into account patient preferences and expectations. In managing health services, the GP should encourage questioning by patients and encourage patients, their carers and families when appropriate to access further information and use patient support groups. To adopt a person-centred approach to management the GP Registrar should understand: " The expectations that patients, carers and families have of their practice and local primary care services " How to involve patients in the management of the practice and local primary care services ESpecific problem-solving skills The GP requires appropriate knowledge and skills to be able to participate in the management of the practice and local health services. " By the end of GP Training, the GP Registrar should have an understanding of: " The duties rights and resp< onsibilities of the doctor as employer and the fundamentals of employment law as it applies to general practice " The various means by which general practitioners are contracted and the key features of contractual agreements. " The organisation of general practice in its various forms (e.g. GMS, PMS etc) and organisation and varies with its setting (e.g. rural, inner-city, urban, academic) " The financial aspects of practice, such as sources of income and expenditure, management of funding, use of premises, marketing, and the interpretation of accounts A comprehensive approach The GP has an important role working with managers and other members of the primary health care team to develop appropriate systems for delivering primary care locally. By the end of their GP Training, the GP Registrar would be expected to: " Understand the culture of administrative organisations and contribute to debates on the management of local health services " Recognise the variety of ways in which healthcare may be appropriately delivered in the community Community orientation GPs have a responsibility for the individual patient, their family and the wider community. They will be involved in the management of health care delivery in the practice and locally. Because the work of the GP is determined by the makeup of the community in which they work they must, therefore, must understand the characteristics of the community including socio-economic, ethnic and health features. Many of the competences needed to undertake these roles effectively are covered in the RCGP Curriculum Statement Healthy People: Promoting Health and Preventing Disease By the end of GP Training the GP Registrar should have gained an understanding of: " The need to reconcile the needs of the individual GP and practice with the needs of the wider health economy " The structure of their local healthcare system and its economic limitations " The importance of involving the public and communities in managing health services e.g. encouraging patient participation in decisions about the local provision of healthcare " Reconciling the health needs of individual patients and the health needs of the community in which they live, balancing these with available resources " The local and national and UK health priorities and how they impact on the delivery of health care A holistic approach By the end of their GP Training, the GP Registrar would be expected to: " Understand the positive benefits of involving patients in their care and in the systems of health care provision and quality improvement Contextual aspects (Understanding the context of doctors themselves and the environment in which they work, including their working conditions, community, culture, financial and regulatory frameworks) By the end of their GP Training, the GP Registrar would be expected to: " Have an understanding of the impact of the local community, including socio-economic factors, geography and culture, on the workplace and patient care. " Be aware of the impact of how the health service is organised locally and nationally and how any variation in resources and facilities may affect the delivery of healthcare. " Have an understanding of the important national and local strategies for the development of health care e.g. National Service Frameworks, NHS Plans etc 4Attitudinal aspects (Based on the doctor's professional capabilities, values, feelings and ethics) By the end of their GP Training, the GP Registrar would be expected to: " Be aware of one s own capabilities and values " Identify ethical aspects relating to management and leadership in primary health care e.g. approaches to use of resources / rationing, approaches to involving the public and patients in decision making " Have an awareness of self: an understanding that their own attitudes, and feelings are important determinants of how they manage and lead ZScientific aspects (Adopting a critical and research based approach to practice and maintaining this through continuing learning and quality improvement) By the end of their GP Training<^, the GP Registrar would be expected to: " Understand the key national guidelines that influence healthcare provision in the locality & country that they work Research & Academic Activity CEg8.kR69 rH!_-1<&8*''(CA=y nPE*_c*KcӁd.59DU]cc&  5Ծ  dMbP?_*+%hMBhp deskjet 5800 series!@d߀ 4dBe4 d hpztbu09ArialHBeںںhp deskjet 5800 seriesseries,LocalOnly,DrvConvert$K*`gXX" dX??U} $ !} m$} $ } I } $ }  }  } } I} } } m }  } m } I } $}  } $ } I } $ 50XX@9h@ @    @ h v /. 0j 0d 0Z 0\ 0] 0[ 0 0b 0^ 0_ 0` 0X 0a 0 0c 0v 0 0 0 0 0 0 0 !o #e:"" !p #"     !q 6-4" ~ !@ %f4"  !r 2k899<7777:77777:7 !s&888=8888;88888;7~ !@ 'g 41 ~ !@ (h4 ~ !@ )i: ~ !@ *l !t +m !u +   ~ !"@ ,n: ! $Y  4"PZbT^XTb^ZTZ1h2@3h4h1234 x< zy@by(  @~ @ <|0w XPP? @]4@|0wx Xm BmeX C<DClinical management Understands the natural history of common problems. Understands the characteristics of healthy people. Considers simple therapy/expectant measures where appropriate. Varies management options responsively according to the circumstances, priorities and preferences of those involved. Routinely checks on drug interactions and side-effects and shows awareness of prescribing regulations. Refers appropriately and co-ordinates care with other professionals in primary care and with other specialists Maintains appropriate skills in emergency care. < \ Caxa @ B0w XPP? ]4@0w 'kbE^2 # x<GPrimary care management " Manage primary contact with patients who have an ENT or facial problem. " Identify symptoms that within the range of normal and require no treatment e.g. cyclical blocking of nose, senile rhinorrhoea, small neck lymph nodes in well children. " Explain the indications for appropriate referral to an ENT specialist e.g. recurrent tonsillitis (current guidelines are to refer if more than five attacks in two years or recurrent quinsy), Ear drum perforations (pars tensa are safe, whereas pars flaccida are unsafe). " Identify where services are deficient or frequently have long waiting times for ENT surgery e.g. audiometry, hearing aids, cochlear implants. " Describe arrangements for referral to specialist nurse services e.g. audiometry. The knowledge base Symptoms " Hearing loss; ear wax, otalgia; discharging ear; dizziness; tinnitus; epistaxis; sore throat, hoarseness; dysphagia; croup; goitre, lymph nodes and other neck swellings; speech delay; foreign bodies; facial weakness Common and/or important conditions " Otitis media (suppurative/secretory); otitis externa; perforated tympanic membrane; cholesteatoma " Vertigo; Mnire s disease; " Bell s palsy; Tempero-mandibular pain, Trigeminal neuralgia " Pharyngitis; tonsillitis; laryngitis; glandular fever; oral candida, herpes; salivary stones; GORD " Infective and allergic rhinitis; sinusitis; nasal polyps " Nasal fracture, haematoma auris " Snoring and sleep apnoea " Suspected Head and Neck Cancer: " Unilateral hearing loss in the absence of external ear pathology or obvious cause Investigation " Otoscopy, " Tuning fork tests " Awareness of: pure tone threshold audiogram; speech audiometry, impedance tympanometry, auditory brainstem responses and otoacoustic emissions. " Investigations may delay referral in suspected head and neck cancer (see Appendix 1) Treatment " Watchful waiting and use of delayed prescriptions " Nasal cautery " Fracture nose (need manipulation under anaesthetic within 2 weeks for optimum result) Emergency care " Septal haematoma " Epistaxis " Tonsillitis with Quinsy " Otitis externa if extremely blocked or painful " Foreign body " Auricular haematoma or perichondritis Prevention " Screening for hearing impairment in adults and children " Awareness of iatrogenic causes of ototoxicity <x u       H 5 < B  O . X /  G  9  4   # ~~ @ <D1w XPP?  ,`]4@D1w kO{Z`ݶ @ <The knowledge      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwyz{|}~ base Symptoms Key issues in the diagnosis of skin problems will be eliciting of the appropriate signs and symptoms and subsequent investigation and / or referral of people presenting with: " hair loss " a disorder of their nails " itch (also known as pruritis) " pigmented skin lesions " skin rashes " signs of infections of the skin " bruising or purpura " lumps under the skin " photosensitivity Common and/or important skin conditions " Eczema " Psoriasis " Generalised pruritus " Urticaria and Vasculitis " Acne and rosacea " Infections (bacterial, viral and fungal) " Infestations including scabies and head lice " Leg ulcers and lymphoedema " Skin tumours (benign and malignant) " Disorders of hair and nails " Drug eruptions " Other less common conditions such as the bullous disorders, lichen planus, vitiligo, photosensitivity, pemphigus, pemphigoid, discoid lupus, granuloma annulare and lichen sclerosus Investigations " Ability to take specimens for mycology from skin, hair and nail " Basic interpretation of histology reports " Skin biopsy Treatment " Those commonly used in primary care (including an awareness of appropriate quantities to be prescribed) " Principles of protective care (sun care, occupational health and hand care) " An awareness of specialised treatments, such as retinoids, ciclosporin, phototherapy and methotrexate " The skills to perform curettage, cautery and cryosurgery Emergency care " Acute treatment of people presenting with skin problems or symptoms thought to be due to skin problems and appropriate referral if necessary. Including: " Angioedema and Anaphylaxis " Meningococcal sepsis " Disseminated herpes simplex " Erythroderma " Pustular psoriasis " Toxic epidermal necrolysis " Stevens-Johnson syndrome " Necrotising fasciitis Prevention This will involve the following risk factors " Sun exposure " Fixed factors: family history and genetics " Occupation and care of the hands Genetics " Describe how genetic factors influence the inheritance of common diseases such as psoriasis and atopic eczema. Specific problem-solving skills " Intervene urgently when patients present with an emergency skin problem (see  knowledge base for examples). " Demonstrate a reasoned approach to the diagnosis of skin symptoms using history, examination, incremental investigations and referral. <  (     J   7 7 C   P    =    1   # F w =  @  @  @ B1w XPP?% ]4@1w D8BAy;J% g < The knowledge base Symptoms Key issues in the diagnosis of cardiovascular problems will be eliciting of the appropriate signs and symptoms and subsequent investigation and / or referral of people presenting with: " chest pain (Cardiac causes e.g. ischaemic heart disease, pericarditis and aortic dissection versus non-cardiac causes e.g. chest wall/musculoskeletal, psychological, respiratory) " breathlessness (heart failure, respiratory problems, thromboembolism, anaemia, obesity, malignancy) " ankle swelling (heart failure, thromboembolism, venous stasis, varicose veins, DVT, leg ulcers, lymphoedema, anaemia, obesity, malignancy, hypoproteinamia) " symptoms or signs thought to be due to peripheral vascular disease (arterial and venous) " palpitations and silent arrhythmias " signs and symptoms of cerebrovascular disease " collapse Common and/or important conditions " Coronary heart disease (angina, acute coronary syndromes, cardiac arrest) " Heart failure " Arrhythmias (Ectopic beats, atrial fibrillation & flutter, narrow & broad complex tachycardias, brady-arrythmias) " Other heart disease (valve disease, cardiomyopathy, congenital) " Peripheral vascular disease (arterial and venous) " Cerebrovascular disease (stroke and TIA) " Thromboembolic disease Investigations " Blood pressure measurement " Electrocardiogram (ECG) " 24 hour ambulatory blood pressure measurement " Venous Dopplers and ABPI measurement " Knowledge of secondary care investigations and treatment including echocardiography, 24 hour arrthymia monitoring, venography, invasive procedures such as angioplasty, coronary artery bypass grafting. Treatment " Treatment of people at risk from cardiovascular problems including specific management of raised blood pressure and lipids. " Chronic disease management including specific disease management, systems of care, multidisciplinary team work for people with established cardiovascular problems and rehabilitation " Communication with patients and their families and inter professional communication both within the PHCT and between primary and secondary care Emergency care " Acute treatment of people presenting with cardiovascular problems or symptoms thought to be due to cardiovascular problems Prevention This will involve the following risk factors " Blood Pressure " Lipids " Smoking " Other modifiable risk factors (including alcohol, exercise, obesity and diet) " Fixed factors: age ethnicity, sex and family history " Co-morbidities especially diabetes (See also the Metabolic Problems Curriculum Statement) " Combining Risk Factors  risk calculation and communicating risk Specific problem-solving skills " Intervene urgently when patients present with a cardiovascular emergency e.g. myocardial infarction, stroke, and critical ischaemia. " Demonstrate an understanding of the importance of risk factors in the diagnosis and management of cardiovascular problems. " Demonstrate a reasoned approach to the diagnosis of cardiovascular symptoms (e.g. chest pain - see above) using history, examination, incremental investigations and referral. " Calculation of Cardiovascular risk (moved from psychomotor skills)<    L Q s s  A   h . q u ; G I   4  $ K  L  M m  g   @ B 2w XPP?4@]4@ 2w y~!>DwqV  x<+ The knowledge base Symptoms " Breathlessness, cough, wheeze, chest pain, sputum production, haemoptysis. Common and/or important conditions " Upper respiratory tract infections: Sore throats and colds, tonsillitis, peri-tonsillar abscess, epiglottitis, laryngitis and tracheitis " Lower respiratory tract infections: Influenza, bronchiolitis, bronchitis and pneumonia (of any cause) " Acute non-infective respiratory problems: Allergy and anaphylaxis, hypersensitivity pneumonitis, pulmonary embolus, pneumothorax, aspiration of a foreign body " Chronic lower respiratory problems: Chronic cough, asthma, chronic obstructive pulmonary disease (COPD), tuberculosis, cystic fibrosis, chronic interstitial lung diseases " Lung cancer Investigation " Serial peak flow measurement, including patient diaries " Reversibility testing using peak flow meter " Spirometry " Knowledge of secondary care investigations and treatment including lung function assessment, Computerised Tomography (CT) and Magnetic Resonance Imaging (MRI) Treatment " Understand principles of treatment for common conditions managed largely in primary care  upper and lower respiratory tract infections, asthma, COPD, allergic reactions and anaphylaxis. " Inhaler technique for using commonly used devices. Emergency care " Acute management of people presenting with shortness of breath " Acute management of anaphylaxis " Management of exacerbations of asthma and COPD " Understand indications for emergency referral of people with asthma, COPD and anaphylaxis Prevention " Smoking cessation assessment, advice and management. " Vaccination against influenza, Streptococcus Pneumoniae, Haemophilus Influenza b, Diphtheria and Pertussis. " Health education advice and patient self-management plans for people with asthma and COPD " Understand avoidance of triggers and prophylaxis for allergic conditions " Investigation of people with family history of genetic respiratory disease e.g. cystic fibrosis Specific problem-solving skills " Utilise knowledge of the relative prevalence of respiratory problems to assist diagnosis. " Describe the alarm symptoms for lung cancer. " Recognise particular groups of patients at higher risk of acquiring a respiratory infection e.g. asthmatics and those with other underlying lung pathology, HIV/AIDS, immune-compromised, alcoholics, the frail (old and young) " Explain the role of serial peak flow measurement, reversibility testing and spirometry in the diagnosis of asthma and COPD. " Intervene urgently when patients present with a respiratory emergency e.g. anaphylaxis, inhaled foreign body, epiglottitis etc. Moved from psychomor skills: " Describe how to use peak flow diaries and evaluate the results. " Describe and assess technique for using common inhaler types. " Interpret the results from spirometry.<x  ]  W  =  [  A e  M i X ned @ Bp2w XPP? `%]4@p2w wpDJ*4=~  <s The knowledge base Symptoms " Headache " Vertigo / dizziness (neurological, otological, psychological and cardiovascular causes) " Tremor " Neuropathies " Abnormal movements / chorea " Seizures " Drowsiness " Loss of consciousness and coma Common and/or important conditions " Epilepsy " Common causes of headache - Tension headache, Migraine, cluster headache, cervical neuralgia, sinusitis, dental pain, drug rebound headache. " Important causes of headache  raised intracranial pressure, thunderclap headache (subarachnoid haemmorhage, enlarging aneurism or migraine) temporal arteritis, trigeminal neuralgia, herpes zoster, cancers " Brain Infections: Meningitis, encephalitis, brain abscess, Tuberculosis, HIV " Neurological causes of vertigo  stroke (brain stem & cerebellar haemorrhage/infarction), multiple sclerosis, trauma & concussion, acoustic neuroma, brain tumours " Mononeuropathies - Trigeminal neuralgia, Bell s Palsy, Carpal tunnel syndrome, nerve entrapments e.g. ulnar, sciatic and femoral nerves " Polyneuropathies - Metabolic causes (diabetes, alcohol, Vitamin B12 and Folate, Porphyria, Uraemia), infectious causes (e.g. Gullain-Barre, Post Viral, HIV), drugs induced neuropathy " Multiple sclerosis " Amyotrophic lateral sclerosis " Essential tremor " Parkinson s disease " Congenital conditions e.g. cerebral palsy, spina bifida " Genetic conditions e.g. Huntingdon s disease Investigation " Knowledge of secondary care investigations and treatment including electroencephalography (EEG), Computerised Tomography (CT) and Magnetic Resonance Imaging (MRI), nerve conduction studies. Treatment " Understand principles of treatment for common conditions managed largely in primary care - epilepsy, headaches, vertigo, neuropathic pain, mononeuropathies, essential tremor and Parkinson s disease Emergency care " Acute management of meningitis and meningococcal septicaemia " Acute management of people presenting with collapse, loss of consciousness or coma " Understand indications for emergency referral of people with stroke, intra-cranial haemorrhage, raised intra-cranial pressure and temporal arteritis Prevention " Health education and accident prevention advice for people with epilepsy " Vaccination for meningococcal disease " Understand avoidance of triggers and prophylaxis for migraine " Investigation of people with family history of genetic neurological disease e.g. Berry aneurysm Specific problem-solving skills " Understand the functional anatomy of the nervous system to aid diagnosis. " Demonstrate a structured, logical approach to the diagnosis of  difficult symptoms with multiple causes e.g. headache, dizziness " Use time as a diagnostic tool for chronic neurological conditions. <        <   R . [  % G 3 8 ` 4 k   i @ B2w XPP? ]4@2w f"1MEhL i(<Specific problem-solving skills " Knowledge of the signs and symptoms of the early presentation of cancer " The ability to suspect a cancer diagnosis early in the disease process " Knowledge of the appropriate investigations of patients with cancer and of how they fit in with national guidelines " The ability to manage pain " Knowledge about a syringe driver: Suitable drugs Conversion of drugs from oral dosage to syringe drive, either, IV or subcutaneous " The knowledge of various palliative care emergencies and their appropriate management: " Major haemorrhage " Hypercalcaemia " Superior Vena Caval obstruction " Spinal cord compression " Bone fractures " Anxiety/panic " Use of emergency drugs Moved from psychomotor skills In reference to a syringe driver: " Give Suitable drugs " Convert drugs from oral dosage to syringe drive, either, IV or subcutaneous <(  Q   i  @ B83w XPP?  ]4 @83w cK78 < Primary care management " Describe the management of the key medical conditions which affect men. " Manage primary contact with patients who have a male genito-urinary problem. " Understand the role of the practice nurse in delivering effective health promotion for men. " Understand the indications for urgent referral to specialist services, for patients with testicular lumps and suspected prostate cancer. The knowledge base Symptoms " Dysuria " Frequency of micturition " Haematuria " Prostatism " Retention of urine " Abdominal and loin pains " Testicular lumps " Testicular pain (orchalgia) " Sore / painful penis, ulceration " Erectile dysfunction Common and/or important conditions " Male-specific cancers: Testicular and prostate cancer " Benign Prostatic Hypertrophy (BPH) and prostatitis " Other testicular conditions e.g. cryptorchidism, varicocele, haematocele, hydrocele, epididymo-orchitis and epididymitis " Sexual dysfunction including psychosexual conditions, premature ejaculation and erectile dysfunction " Male contraception: vasectomy " Male infertility " Circumcision (religious and non-religious) " Mental health issues including depression, suicide and andropause " Sexually transmitted diseases (covered in detail in the RCGP Curriculum Statement on Sexual Health) Investigations " Urinalysis, MSU and dipstick " Blood tests including renal function tests and Prostate specific antigen (PSA) test " Semen analysis " Knowledge of secondary care investigations including prostate biopsy and testicular ultrasound Treatment " Understand principles of treatment for common conditions managed largely in primary care  benign prostatic hypertrophy, prostatitis, sexual dysfunction, infertility etc " Injection of anti-androgens for testicular cancer Emergency care " Acute management of testicular torsion " Acute management of paraphimosis and priapism " Acute urinary retention " Acute management of ureteric colic Prevention " Health education regarding lifestyle and risk taking behaviour, sexual and mental health <  x T    T A# 8  .  G ) 4 =   @ B3w XPP? %]4 @3w a6&D'Ԑ x<uPrimary care management " Demonstrate knowledge of women's health problems, conditions and diseases " Understand how practice management issues impact on the provision of care to women including choice and availability of female doctors " Maintain patient records that are accurate, facilitate continuity of care, and respect the patient's confidentiality (particularly in relation to family issues, domestic violence, termination of pregnancy, and contact tracing); " Be familiar with local support services, referral services, networks, and groups for women (e.g. Family Planning, Breast Cancer Nurses, domestic violence resources) " Understand the importance of informing patients of results of screening, and ensuring follow up The knowledge base Symptoms " breast pain, breast lumps, nipple discharge, " pruritis vulvae, vaginal discharge " dysparunia, pelvic pain, endometriosis " amenorrhoea, menorrhagia, dysmenorrhoea, inter-menstrual bleeding, irregular bleeding patterns, post menopausal bleeding, pre-menstrual syndrome, menopause, menopausal problems " infertility - primary and secondary " urinary malfunction: dysuria, urinary incontinence " faecal incontinence " emotional problems, including low mood and symptoms of depression Common and/or important conditions " abnormal cervical cytology, " vaginal and uterine prolapse " fibroids " gynaecological infections including Bartholin s abscess and sexually transmitted diseases (covered in detail in the RCGP Curriculum Statement on Sexual Health) " gynaecological malignancies " miscarriage & termination of pregnancy " ectopic pregnancy " trophoblastic disease " normal pregnancy and pregnancy problems including hyperemesis, back pain, symphysis pubis dysfunction, multiple pregnancy, growth retardation, pre-eclampsia, ante-partum haemorrhage and abruption, premature labour, polyhydramnios, abnormal lies, placenta praevia, deep vein thrombosis and pulmonary embolism, post dates, reduced movements, intrauterine infection, intrauterine death, foetal abnormality " sexual dysfunction including psychosexual conditions " mental health issues including anxiety, depression, suicide and the relationship between these, pregnancy and the menopause Investigations " Pregnancy testing " urinalysis, MSU and urine dipstick " blood tests including renal function tests, hormone tests " bacteriological and virology tests " knowledge of secondary care investigations including colposcopy and sub fertility investigations Treatment " primary care management of the conditions listed above. (note sexually transmitted disease and contraception are dealt with in depth in the Curriculum Statement on Sexual Health) " menopause management including Hormone Replacement Therapy " knowledge of specialist treatments and surgical procedures including: laparoscopy, D&C, hysterectomy, oopherectomy, ovarian cystectomy, pelvic floor repair, medical and surgical termination of pregnancy, sterilisation " understand the risks of prescribing during pregnancy " palliative care, including management of pain, vomiting, anxiety Emergency care " bleeding in pregnancy " suspected ectopic pregnancy " domestic violence Prevention " health education regarding lifestyle and sexual and mental health " pre pregnancy issues discontinuing contraception, folic acid, family & genetic history and lifestyle advice " pregnancy care including health promotion, social and cultural factors, smoking and alcohol, age factors, previous obstetric history, diabetes and obesity, rhesus problems and use of anti d, hypertension and other medical problems, anaemia, acid reflux, leg ache and varicose veins, haemorrhoids, rubella testing and immunisation " risk assessment, screening and management of osteoporosis <x u         A  | . 2  G %  q 4 |  0  @ B4w XPP?@$]4 @4w eElY  x<qPrimary care management " Manage primary contact with patients who have sexual health concerns and problems. " Work in partnership with members of the Practice s team including the receptionists to ensure accessibility of the services for patients and practice nurses and health visitors in providing coordinated services with respect to sexual health. " Co-ordinate care and make timely appropriate referrals on behalf of patients to specialist services, especially to appropriate gynaecologists, sexual and reproductive health specialists, genito-urinary specialists, urologists and specialists in infectious diseases. " Promote sexual health well-being by applying health promotion and disease prevention strategies appropriately. " Describe strategies for early detection of sexual health problems that may already be present but have not yet produced symptoms. The knowledge base Symptoms Key issues in the diagnosis of sexual health problems will be eliciting of the appropriate signs and symptoms and subsequent investigation and treatment or referral of people presenting with: " Genital skin conditions including rashes, ulcers and lichen atrophicus " Lumps " Abnormal genital smell " Vaginal or penile discharge " Pain on passing urine " Lower abdominal pain in women " Testicular pain " Pain on intercourse Common and/or important conditions in men and women " Urinary Tract Infection " Bacterial vaginosis " Candidiasis " Group B Haemolytic Streptococcus " Chlamydial infections " Gonorrhoea " Genital Ulcers and Warts, Syphilis, Chancroid, Herpes Simplex " HIV / AIDS and the presentations / complications including Pneumocystis pneumonia, Candidiasis, Cryptococcus, Kaposi s sarcoma, Toxoplasmosis, Lymphoma, Hepatitis, tuberculosis " Sexual dysfunction Investigation " Pregnancy testing " Urinalysis " Blood tests for the common conditions including HIV/AIDS " Microbiology and virology swabs " Secondary care investigations e.g. colposcopy Treatment / Management " Contraception  effectiveness rates of all methods and how to provide short term methods including oral contraception and emergency contraception " Contraception  knowledge and availability of long term methods, including natural family planning, implants, intrauterine methods and sterilisation " Termination of pregnancy  methods and the legal procedures relating to referral for termination of pregnancy " Principles of treatment for common conditions managed largely in primary care (see above) " Principles of antiretroviral combination therapy for HIV/AIDS, potential side effects and the role of the GP in their management in primary care Emergency care " Emergency hormonal contraception " Emergency intrauterine contraception Prevention " Health education and prevention advice  safe sex and risk reduction " National screening programmes  cervical screening, Chlamydia, antenatal HIV testing " Hepatitis B immunisation programme " Occupational risks  exposure to needle stick injuries <x x c d e  0 c  < V Gd  4 ~   @ Bd4w XPP?s&]4 @d4w hե]Bn ! <  Primary care management " Manage primary contact with children and their families - and, with older children, on their own " Understand the importance of multi-agency working (working across professional and agency boundaries) " Co-ordinate care with other primary care professionals, paediatricians and other appropriate specialists, leading to effective and appropriate care provision, taking an advocacy position for the patient or family when needed: " Deal effectively with child abuse. Safeguarding children, understanding that: o the welfare of the child must be the paramount consideration and can help to justify actions that challenge ethical and professional norms. o as GPs we are usually family focused, but in dealing with child protection and other vulnerable children (such as domestic violence) if we focus on the family we risk losing sight of the child. o often children in special circumstances are  invisible to the system because they live in the shadow of their parents' problems o dealing effectively with child abuse involves, recognising the clinical features, knowing about local arrangements for child protection, referring effectively and playing a part in assessment and continuing management including prevention of further abuse in the patient and family. " Understand the principles of clinical governance and risk management o clinical governance systems do not always explicitly recognise children and young people as a separate and vulnerable client group. It is essential that the care of children is given a specific focus within the clinical governance arrangements in primary care. o the components of clinical governance strategies in primary care will include: safety of treatment and care; safeguarding; the use of evidence-based practice; clinical audit; effective prescribing and referrals, and continuing professional development. " Ensure that parents or carers, children and young people receive information, advice and support to enable them to: o manage minor illnesses themselves, using community pharmacists and triage services where appropriate o Access appropriate services when necessary " Prescribe and advise appropriately about the use of medicines in children, being competent at: o calculating drug doses o understanding the risks and benefits of medicines in relation to children; o understanding the needs of ethnic minorities, and cultural differences in beliefs about illness and the use of medicines " Understanding the welfare of the unborn baby by: o being aware of the impact of parental problems including domestic violence, substance misuse and mental health problems. o being able to recognise the symptoms and presentations of such problems and being able to make a sensitive enquiry if concerned o providing information about, or referral to, local services for women who have substance misuse problems as they are at greater risk of problem pregnancies and their care should be provided by an integrated multi-disciplinary and multi-agency team The knowledge base Symptoms " vomiting, fever, drowsiness, developmental delay, infantile colic,  Failure to Thrive and growth disorders, behavioural problems Common and/or important conditions " neonatal problems: birthmarks, feeding problems, heart murmur, sticky eye, jaundice " constipation, abdominal pain (acute and recurrent) " pyrexia ,febrile convulsions " cough/dyspnoea, wheezing including respiratory infections, bronchiolitis " otitis media " sensory deficit especially deafness " gastroenteritis " viral exanthems, " urinary tract infection, " meningitis " epilepsy " chronic disease: asthma, diabetes, arthritis, learning disability " child abuse, deprivation " mental health problems such as attention deficit hyperactivity disorder, depression, eating disorders, substance misuse and self-harm, autistic spectrum disorder and related conditions " psychological problems: enuresis, encopresis, bullying, school refusal, behaviour problems including tantrums " child and young person development (physical and psychological); Prevention Areas where healthy <choices make a big difference in children s and young people s lives include: " pre-natal diagnosis " breastfeeding; " healthy diet and exercise for children and young people; " social and emotional well-being; " keeping children and young people safe; child protection, accident prevention " immunisation " avoiding smoking, using volatile substances and other drugs and minimising alcohol intake, " reducing the risk of teenagers getting pregnant or acquiring sexually transmitted infections. < x  n2    BT ]  dg '   &  x   7   @ B4w XPP?# ]4 @4w |xIѹ[A 1 <c The knowledge base Symptoms " Inflammation - pain, swelling, redness, warmth " Lack of function  weakness, restricted movement, deformity and disability " Injuries - cuts, bruises, wounds " Systemic manifestations - rashes, tiredness, nerve compression etc. Common and/or important conditions " Acute back/neck pain " Chronic back/neck pain " Shoulder pain " Knee pain " Soft tissue disorders " Osteoarthritis " Osteoporosis " Somatisation/fibromyalgia and allied syndromes " Pain management " Acute Arthropathies " Chronic inflammatory arthropathies " Polymyalgia rheumatica and allied conditions " Awareness of rare diseases " Chronic disability " Common injuries NB - these topics should be considered throughout the age range including children Investigation " Indications for plain radiography, ultrasound, CT and MR scan including the use of tools such as the  Ottawa Rules " General rules of X-ray Interpretation " Implications of "Misses" on X-rays, common errors. " Indications for additional investigations for example blood tests. Treatment " Understand principles of treatment for common conditions managed largely in primary care " Understand the roles of allied health professionals (nursing, physiotherapy, chiropody, podiatry, occupational therapy, counselling and psychological services) " Chronic disease management including systems of care, multidisciplinary team work and shared care arrangements Emergency care " The initial management of the patient who has been burnt " To be aware of the safety of the patient, the scene of the incident and medical staff " To be aware of how to summon help in an emergency " Be competent in basic life support (adult and paediatric), the use of simple airway adjuncts (for example oropharyngeal airway and pocket mask) and the safe use of a defibrillator " Be competent in stopping haemorrhage " Be competent in reducing pain by the use of analgesia or other methods. " Be aware of the principles of major incident management " Referrals requiring emergency action to save life or prevent serious long term sequelae Prevention " Advise regarding appropriate levels of exercise " Heath promotion regarding accident prevention Specific problem-solving skills " Intervene urgently when patients present with trauma in a primary care setting e.g. basic life support, control of haemorrhage, summoning help. " Describe the epidemiology of musculoskeletal disorders at all ages, and apply this when developing a differential diagnosis. " Assess the mechanism of injury when considering diagnosis. " Distinguish inflammatory from non-inflammatory conditions. " Assess the possibility that musculoskeletal symptoms can be due to psychological causes (somatisation). " Describe when blood tests and imaging methods are required for diagnosis, how to interpret them and how they influence management. <    ) )  L c =$  [ } ' A2   7 1  @ B,5w XPP?]4@,5w ' E)UN:F+  H<IWorking with colleagues and in teams Provides adequate personal availability to colleagues Works co-operatively with the other members of the team, seeking their views, acknowledging their contribution and using their skills appropriately. Proactively communicates with team members so that patient care is not compromised. < % H @ B5w XPP?]4@5w ,VͧO+O~ z<{Primary care administration and IMT Understands and uses the primary care organisational and IMT systems appropriately in routine patient care Uses the computer during the consultation whilst maintaining rapport with the patient Produces records that are coherent and comprehensible, appropriately and securely sharing these with others who have legitimate access to them < # z  @ B5w XPP? x]4@5w w|8,GG'K B`<  Effective use of GP clinical software for making clinical notes General Computer skills " All GP trainees shall acquire the European Computer Driving Licence (ECDL), an internationally recognised qualification for computer users " The seven modules that make up the ECDL are: o Basic concepts of IT o Using the computer and managing files o Word processing o Spreadsheets o Database o Presentation o Information and Communication General Practice Computer skills " Practice Clinical data systems o Use READ coded entries to add history, examination findings, diagnoses, o Issue prescriptions, set up and issue repeat therapy o Understand the Quality and Outcomes Framework and make computer records that ensure effective collection of data o be able to search for individual patients and groups of patients for audit and recall " Deal with test results electronically " Make regular use of clinical decision support systems (e.g. PRODIGY, Clinical Evidence, BNF, etc.) Communication skills " be aware of adverse effects of the doctor-computer interface on the doctor-patient relationship and take care to minimise or eliminate harmful effects Keeping up to date: e-learning " Be skilled at searching the internet for medical and patient information " An awareness of formal CD-ROM or web-based learning programs and an understanding of how to use them as part of a Personal Development Plan " The learner should acquire an ability to assess the quality of sources of information and teaching materials to the same standard as they would be expected to assess an article in a medical journal. <`    X   k -      `      Bȷ~~ @ <X6w XPP? ]4@X6w ]LC-Y <Communication and consulting skills Explores the patient s agenda, health beliefs and preferences. Elicits psychological and social information to place the patient s problem in context. Works in partnership with the patient, negotiating a mutually acceptable plan that respects the patient s agenda. Explores the patient s understanding of what has taken place. Provides continuity of care for the patient rather than just the problem, reviewing care at suitable intervals. < $ us @ B6w XPP?T]4@6w 'q vO?"  <Person-centred care " Describe strategies for communicating effectively with patients with hearing impairment and deafness e.g. remembering to face the patient and speaking clearly so that they can lipread. " Demonstrate effective strategies for dealing with parental concerns regarding ENT conditions e.g. recurrent tonsillitis and glue ear. " Empower patients to adopt self-treatment and coping strategies where possible e.g. hay fever, nosebleeds, dizziness, tinnitus. < t iic @ B 7w XPP?  /]4@ 7w Az/ G+~4 ~<Person-centred care " The ability to attend to the full range of physical, social and spiritual needs of the patient and carer " The ability to communicate effectively with the patient and carer regarding difficult information about the disease, its treatment or its prognosis " Knowledge about how to provide and manage 24 hour continuity of care through various clinical systems < \ ~ran @ B7w XPP? ` ]4@7w h׵9tKz4 <Person-centred care " Communicate sensitively with women about sexuality and intimate issues (particularly in recognising the impact of past sexual abuse) " Recognise the prevalence of domestic violence and question sensitively where this may be an issue. " Recognise that many women consult for lifestyle advice, and that GPs should not over-medicalise these issues " Recognise the issues of gender and power, and the patient-doctor relationship, and know how to prevent these issues adversely affecting women's health care " Understand the importance of confidentiality and informed consent " Understand the issues relating to the use of chaperones < \ aic @ B7w XPP?@']4@7w iEޚK (<q Person-centred care " Take a sexual history (from a male or female patient) in a way that is non-judgemental, avoids assumptions and is responsive to the reactions of the patient. <(  _ , a c @ BL8w XPP?sG`]4@L8w  =.GL }fՒ 8<q Person-centred care By the end of training, the GP Registrar should be able to: " Adopt a family-centred approach in dealing with patients, their families and their problems. This requires: o effective communication and engagement (listening to and involving children and working with parents, carers and families) o an understanding the importance of supporting parents and having the skills noting that the role of fathers in parenting their children is frequently overlooked. Their contribution to their child s development and well-being is important. All GPs should be able to support fathers and have the skills for engaging with fathers as well as mothers. " To develop and apply the primary care consultation to bring about an effective doctor, patient, family relationship to enable parents or carers, children and young people to: o participate in their own care planning and delivery; o be routinely involved and supported in making informed decisions and choices about their care, taking into account their age and development, increasing autonomy with age, and the need for confidentiality balanced with the parents need for information o achieve concordance, including active listening and shared decision-making with children and parents o giving information on medicines to children and parents in a clear way; " To provide longitudinal continuity of care as determined by the needs of the patient and family: o understanding the problems with transitions from child to adolescent, and from adolescent to adult. This applies to all children but especially the vulnerable < \ |8i~~ @ <8w XPP?  ]4@8w! YCђA;V` S<Data gathering and interpretation Takes a systematic history that uses questions appropriately targeted to the problem. Makes appropriate use of existing information about the problem and the patient s context. Chooses examinations and targets investigations appropriately. Understands the implications of findings and results. < ! 8S @ B9w XPP? !K]4@9w" G(O9[5(* $<I The knowledge base Symptoms " Hearing loss; ear wax, otalgia; discharging ear; dizziness; tinnitus; epistaxis; sore throat, hoarseness; dysphagia; croup; goitre, lymph nodes and other neck swellings; speech delay; foreign bodies; facial weakness Common and/or important conditions " Otitis media (suppurative/secretory); otitis externa; perforated tympanic membrane; cholesteatoma " Vertigo; Mnire s disease; " Bell s palsy; Tempero-mandibular pain, Trigeminal neuralgia " Pharyngitis; tonsillitis; laryngitis; glandular fever; oral candida, herpes; salivary stones; GORD " Infective and allergic rhinitis; sinusitis; nasal polyps " Nasal fracture, haematoma auris " Snoring and sleep apnoea " Suspected Head and Neck Cancer: " Unilateral hearing loss in the absence of external ear pathology or obvious cause Investigation " Otoscopy, " Tuning fork tests " Awareness of: pure tone threshold audiogram; speech audiometry, impedance tympanometry, auditory brainstem responses and otoacoustic emissions. " Investigations may delay referral in suspected head and neck cancer (see Appendix 1) Treatment " Watchful waiting and use of delayed prescriptions " Nasal cautery " Fracture nose (need manipulation under anaesthetic within 2 weeks for optimum result) Emergency care " Septal haematoma " Epistaxis " Tonsillitis with Quinsy " Otitis externa if extremely blocked or painful " Foreign body " Auricular haematoma or perichondritis Prevention " Screening for hearing impairment in adults and children " Awareness of iatrogenic causes of ototoxicity Specific problem-solving skills " Utilise knowledge of the relative prevalence of ENT problems to assist diagnosis. " Describe the alarm symptoms for head and neck cancer e.g. hoarseness persisting for more than 6 weeks, ulceration of oral mucosa persisting for more than 3 weeks. " Demonstrate appropriate use of time as a diagnostic tool, including clear review procedures and safety netting. " Understand the likely outcomes of tests e.g. ear swabs after multiple antibiotic courses always grow pseudomonas. <      B 4 E D  N 7 Z )  P  3  =  u  B  $ !@ Bx9w XPP? !]4!@x9w# jF!Ŧ{t h<)The knowledge base Symptoms " Dysuria " Frequency of micturition " Haematuria " Prostatism " Retention of urine " Abdominal and loin pains " Testicular lumps " Testicular pain (orchalgia) " Sore / painful penis, ulceration " Erectile dysfunction Common and/or important conditions " Male-specific cancers: Testicular and prostate cancer " Benign Prostatic Hypertrophy (BPH) and prostatitis " Other testicular conditions e.g. cryptorchidism, varicocele, haematocele, hydrocele, epididymo-orchitis and epididymitis " Sexual dysfunction including psychosexual conditions, premature ejaculation and erectile dysfunction " Male contraception: vasectomy " Male infertility " Circumcision (religious and non-religious) " Mental health issues including depression, suicide and andropause " Sexually transmitted diseases (covered in detail in the RCGP Curriculum Statement on Sexual Health) Investigations " Urinalysis, MSU and dipstick " Blood tests including renal function tests and Prostate specific antigen (PSA) test " Semen analysis " Knowledge of secondary care investigations including prostate biopsy and testicular ultrasound Treatment " Understand principles of treatment for common conditions managed largely in primary care  benign prostatic hypertrophy, prostatitis, sexual dysfunction, infertility etc " Injection of anti-androgens for testicular cancer Emergency care " Acute management of testicular torsion " Acute management of paraphimosis and priapism " Acute urinary retention " Acute management of ureteric colic Prevention " Health education regarding lifestyle and risk taking behaviour, sexual and mental health Specific problem-solving skills " Recognise that men consult less frequently and have more illness. This should lower the doctor s threshold for suspicion of significant disease " Utilise knowledge of the relative prevalence of all medical conditions in men compared to women to assist diagnosis. <h    Tw A 8n .w Y Gg i   "@ B9w XPP? +]4"@9w$ QcJN[v_  x<The knowledge base Symptoms " breast pain, breast lumps, nipple discharge, " pruritis vulvae, vaginal discharge " dysparunia, pelvic pain, endometriosis " amenorrhoea, menorrhagia, dysmenorrhoea, inter-menstrual bleeding, irregular bleeding patterns, post menopausal bleeding, pre-menstrual syndrome, menopause, menopausal problems " infertility - primary and secondary " urinary malfunction: dysuria, urinary incontinence " faecal incontinence " emotional problems, including low mood and symptoms of depression Common and/or important conditions " abnormal cervical cytology, " vaginal and uterine prolapse " fibroids " gynaecological infections including Bartholin s abscess and sexually transmitted diseases (covered in detail in the RCGP Curriculum Statement on Sexual Health) " gynaecological malignancies " miscarriage & termination of pregnancy " ectopic pregnancy " trophoblastic disease " normal pregnancy and pregnancy problems including hyperemesis, back pain, symphysis pubis dysfunction, multiple pregnancy, growth retardation, pre-eclampsia, ante-partum haemorrhage and abruption, premature labour, polyhydramnios, abnormal lies, placenta praevia, deep vein thrombosis and pulmonary embolism, post dates, reduced movements, intrauterine infection, intrauterine death, foetal abnormality " sexual dysfunction including psychosexual conditions " mental health issues including anxiety, depression, suicide and the relationship between these, pregnancy and the menopause Investigations " Pregnancy testing " urinalysis, MSU and urine dipstick " blood tests including renal function tests, hormone tests " bacteriological and virology tests " knowledge of secondary care investigations including colposcopy and sub fertility investigations Treatment " primary care management of the conditions listed above. (note sexually transmitted disease and contraception are dealt with in depth in the Curriculum Statement on Sexual Health) " menopause management including Hormone Replacement Therapy " knowledge of specialist treatments and surgical procedures including: laparoscopy, D&C, hysterectomy, oopherectomy, ovarian cystectomy, pelvic floor repair, medical and surgical termination of pregnancy, sterilisation " understand the risks of prescribing during pregnancy " palliative care, including management of pain, vomiting, anxiety Emergency care " bleeding in pregnancy " suspected ectopic pregnancy " domestic violence Prevention " health education regarding lifestyle and sexual and mental health " pre pregnancy issues discontinuing contraception, folic acid, family & genetic history and lifestyle advice " pregnancy care including health promotion, social and cultural factors, smoking and alcohol, age factors, previous obstetric history, diabetes and obesity, rhesus problems and use of anti d, hypertension and other medical problems, anaemia, acid reflux, leg ache and varicose veins, haemorrhoids, rubella testing and immunisation " risk assessment, screening and management of osteoporosis Specific problem-solving skills " Recognise and intervene immediately when patients present with a gynaecological emergency " Intervene urgently with suspected malignancy and have a low threshold for the referral of breast lumps " Demonstrate an understanding of the importance of risk factors in the diagnosis and management of women s problems " Understand the importance of promoting health and a healthy lifestyle in women, and in particular the impact of this on the unborn child, growing children and the family <x    +   A | . 27 GE  4    0 #@ B@:w XPP?@0]4#@@:w% oT~Kv5  x<The knowledge base Symptoms Key issues in the diagnosis of sexual health problems will be eliciting of the appropriate signs and symptoms and subsequent investigation and treatment or referral of people presenting with: " Genital skin conditions including rashes, ulcers and lichen atrophicus " Lumps " Abnormal genital smell " Vaginal or penile discharge " Pain on passing urine " Lower abdominal pain in women " Testicular pain " Pain on intercourse Common and/or important conditions in men and women " Urinary Tract Infection " Bacterial vaginosis " Candidiasis " Group B Haemolytic Streptococcus " Chlamydial infections " Gonorrhoea " Genital Ulcers and Warts, Syphilis, Chancroid, Herpes Simplex " HIV / AIDS and the presentations / complications including Pneumocystis pneumonia, Candidiasis, Cryptococcus, Kaposi s sarcoma, Toxoplasmosis, Lymphoma, Hepatitis, tuberculosis " Sexual dysfunction Investigation " Pregnancy testing " Urinalysis " Blood tests for the common conditions including HIV/AIDS " Microbiology and virology swabs " Secondary care investigations e.g. colposcopy Treatment / Management " Contraception  effectiveness rates of all methods and how to provide short term methods including oral contraception and emergency contraception " Contraception  knowledge and availability of long term methods, including natural family planning, implants, intrauterine methods and sterilisation " Termination of pregnancy  methods and the legal procedures relating to referral for termination of pregnancy " Principles of treatment for common conditions managed largely in primary care (see above) " Principles of antiretroviral combination therapy for HIV/AIDS, potential side effects and the role of the GP in their management in primary care Emergency care " Emergency hormonal contraception " Emergency intrauterine contraception Prevention " Health education and prevention advice  safe sex and risk reduction " National screening programmes  cervical screening, Chlamydia, antenatal HIV testing " Hepatitis B immunisation programme " Occupational risks  exposure to needle stick injuries Specific problem-solving skills " Understand the functional anatomy of the male and female genital systems and the female reproductive physiology to aid diagnosis. " Ability to take an appropriate sexual history and apply the information gathered during the history taking and examination, generate a differential diagnosis and formulate a management plan " Recognise common presentations of sexual dysfunction, and of sexual violence and abuse, including covert presentations such as Somatisation. " Be able to counsel patients with sexual problems including issues related to contraception, sexually transmitted infection, pre-test HIV counselling, and for patients who have an unwanted pregnancy " Understand the best practice guidance on the provision of advice and treatment to young people under 16 years. " Understand when urgent intervention is needed in sexual health and if necessary, to refer appropriately, e.g. in provision of emergency contraception or in severe pelvic inflammatory disease, or in serious infections in the immune-compromised patient " Understand that many sexually transmitted infections may present early and in an undifferentiated way or may be present without symptoms. " Understand the limitation of  watching and waiting because some serious infection e.g. Chlamydia and HIV may also lapse back into being asymptomatic, whilst still causing harm to the patient. <x     < N pd  G K 4V T t   $@ B:w XPP?s?$]4$@:w& Y>Mw,,  H<The knowledge base Symptoms " vomiting, fever, drowsiness, developmental delay, infantile colic,  Failure to Thrive and growth disorders, behavioural problems Common and/or important conditions " neonatal problems: birthmarks, feeding problems, heart murmur, sticky eye, jaundice " constipation, abdominal pain (acute and recurrent) " pyrexia ,febrile convulsions " cough/dyspnoea, wheezing including respiratory infections, bronchiolitis " otitis media " sensory deficit especially deafness " gastroenteritis " viral exanthems, " urinary tract infection, " meningitis " epilepsy " chronic disease: asthma, diabetes, arthritis, learning disability " child abuse, deprivation " mental health problems such as attention deficit hyperactivity disorder, depression, eating disorders, substance misuse and self-harm, autistic spectrum disorder and related conditions " psychological problems: enuresis, encopresis, bullying, school refusal, behaviour problems including tantrums " child and young person development (physical and psychological); Prevention Areas where healthy choices make a big difference in children s and young people s lives include: " pre-natal diagnosis " breastfeeding; " healthy diet and exercise for children and young people; " social and emotional well-being; " keeping children and young people safe; child protection, accident prevention " immunisation " avoiding smoking, using volatile substances and other drugs and minimising alcohol intake, " reducing the risk of teenagers getting pregnant or acquiring sexually transmitted infections. Specific problem-solving skills By the end of training, the GP Registrar should be able to: " Use a decision-making process determined by the prevalence and incidence of illness in the community and the specific circumstances of the patient and family: o being aware of normal growth and development o being aware of neonatal problems including jaundice and feeding problems, breast feeding and nutrition " Manage conditions which may present early and in an undifferentiated way, and to recognize a seriously ill child and intervene urgently when necessary by: o having a thorough understanding of normal development, and being able to recognise delayed development o recognising normal growth, and dealing with faltering growth and failure to thrive o recognising children at risk o being aware that consultations about children may be a presentation of a mother s post-natal depression; and being aware of the effect that post-natal depression may have on her children o recognising the significance of non-attending o understanding that children failing to attend appointments (in primary or secondary care) may trigger concern, given that they are reliant on their parent or carer to take them to the appointment. o failure to attend can be an indicator of a family s vulnerability, potentially placing the child s welfare in jeopardy. o Acknowledging that failure to attend can be an indicator that services are difficult for families to access or considered inappropriate, and need reviewing. <H     4$ - N @ ~~ &@ <;w XPP?  U]4&@;w& J$ I9i  < Making a diagnosis / making decisions Integrates information to aid pattern recognition of conditions, including those that present early and in an undifferentiated way Uses time as a diagnostic tool. Uses an understanding of probability based on prevalence, incidence and natural history of illness to aid decision-making. Revises hypotheses in the light of additional information. Thinks flexibly around problems, generating functional solutions <  & nrm '@ Bl;w XPP?J]4'@l;w' Wj^A$Ȱ  <9Managing medical complexity Simultaneously manages the patient s health problems, both acute and chronic. Is able to tolerate uncertainty, including that experienced by the patient, where this is unavoidable Prioritises appropriately, communicates risk effectively to patients and involves them in its management to the appropriate degree. Consistently encourages improvement, rehabilitation, and, where appropriate, recovery. Encourages the patient to participate in appropriate health promotion and disease prevention strategies <    (@ B;w XPP? ]4(@;w@( |J tj6 $(<%Community orientation Identifies how the services of health care providers and self-help groups can be appropriately used by patient and doctor. Reconciles the health needs of individual patients and the health needs of the community in which they live in balance with available resources.<( m   $ ~~ )@ <4w XPP?  ]4.@(>w, |\0C+mfN <GA holistic approach " The ability to offer spiritual care the patient and carers " Knowledge of normal and abnormal grieving and its impact upon symptomatology < Z   c w /@ B>w XPP? Z []4/@>w- r8Hi7.  <?A holistic approach " Describe the changing gender roles that men are expected to conform with. " Recognise the importance of the parental fathering role in family structures. " Appreciate the psychological, social, cultural and economic problems caused by unemployment amongst men. < Z   nss 0@ B>w XPP? ]40@>w. vzrFZ  <uA holistic approach " Discuss the psycho-social component of women's health and the need, in some cases, to provide women patients with additional emotional and organisational support (e.g. in relation to pregnancy options, hormone replacement therapy, breast cancer, and unemployment) " Understand the impact of culture and ethnicity on womens perceived role in society and their attendant health beliefs, and tailor healthcare accordingly < Z oex 1@ BT?w XPP?s ]41@T?w/ Z?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxy{|}~story, examination, incremental investigations and referral. " Ability to recognise ocular manifestations of neurological disease, manage appropriately, assess urgency of referral e.g. hemianopia, nystagmus, manifestations of pituitary and cerebral tumours " Ability to recognise ocular manifestations of systemic disease, know when to refer to secondary care specialist services e.g. diabetic retinopathies, retinal vascular occlusions, amaurosis fugax/transient ischaemic (TIA), macular diseases, hypertensive retinopathy < + j      Y n q    6 b n z <     )  M A [ Y  1  % ~ G   | 7   ) )  <@ BCw XPP? *]4<@CwP: Qg& JI[*K  <Primary care management Manage primary contact with patients who have an eye problems " Co-ordinate care with other primary care health professionals, optometrists, ophthalmologists, orthoptists, school health services, community eye clinics, social worker to provide effective and appropriate care to patients with eye problems " Make timely appropriate referrals on behalf of patients to specialist services " Promote