Area of capability: Applying clinical knowledge and skill

This capability includes the gathering, interpretation and use of data for clinical judgement, including information gathered from the patient history, clinical records, examination and investigations.

Applying an organised approach to data gathering and investigation

Learning outcomes:

• Selectively gather and interpret information from the patient’s history, physical examination and investigations and use this to develop an appropriate management plan, in collaboration with the patient, by:
  • making appropriate use of existing information about the problem and the patient’s context
  • knowing the relevant questions to ask based on the patient’s history, as well as which elements of the physical examination are relevant to the problem presented
  • recognising and interpreting relevant information from a wide range of sources, including the patient narrative and context, information from carers and professionals, physical examination findings, records, clinical procedures, laboratory data and ancillary tests
  • recognising when a particular examination or investigation will be beyond your scope or ability and ensuring that the patient has access to these interventions in a timely manner to enable the development of an appropriate management plan.
• Tailor your approaches to the contexts in which you work, considering factors such as the accessibility of additional sources of information and the cost-effectiveness and predictive value of investigations.
• Apply techniques that enable you to examine and investigate incrementally, monitoring and reviewing the patient as needed to preserve safety and allowing diagnostic information to be integrated over time. This may, on occasion, include making a conscious decision with the patient not to undertake further investigations.
• Enhance your clinical decision-making through effective and timely record-keeping, information sharing, data management and monitoring of care.

Interpreting findings accurately and appropriately

Learning outcomes:

• Recognise ‘red flags’ and other indicators of high risk, responding promptly and effectively when these occur.
• Demonstrate proficiency in interpreting the patterns of symptoms, signs and other findings that, in a non-selected population, may signify potentially significant health conditions requiring further investigation or action.
• Discuss how the predictive value of symptoms, signs and investigations varies according to the features of your local population and apply this knowledge to your decision-making.
• Demonstrate proficiency in identifying self-limiting health conditions that commonly present in an unselected population that might require self-care rather than medical intervention.
• Identify the mechanisms through which apparently simple health problems may become chronic, complex and severe (known as ‘yellow flags’).

Progression point descriptors – Data gathering and interpretation

By the end of training, the GP registrar must have demonstrated competence in general and systemic examinations of all the clinical curriculum areas. This includes the five GMC-mandated examinations and a range of additional Clinical Examination and Procedural Skills relevant to General Practice which demonstrate clinical competence.

Demonstrating a proficient approach to clinical examination and performance of procedures

Learning outcomes:

• Demonstrate proficiency at performing the scope of examinations necessary to assess, diagnose and monitor the patient’s condition within a general practice or home setting (or ensure timely access if you are not able to do it).
• Adopt a targeted and systematic approach to clinical examination, recognising normal and abnormal findings and tailoring further examinations accordingly.
• Demonstrate communication techniques that ensure that the patient understands the nature and purpose of the examination, what will happen and the role of the chaperone, and respond non-judgementally if consent is declined
• Identify cultural and ethical issues relating to examinations (such as the removal of clothing) and discuss these sensitively with the patient, recognising that different examinations may be perceived as intimate, depending on individual and cultural factors.
• Organise the place of examination to provide the patient with privacy and to respect their dignity, arranging for a suitable chaperone when one is requested by the patient or doctor.
• Perform and accurately interpret focused examinations in challenging circumstances (such as during home visits, in emergencies or when negotiating cultural issues).
• Perform clinical examinations and investigations that are in line with the patient’s problem, identifying abnormal findings and incorporating relevant results.
• Explain the findings meaningfully and sensitively to the patient.

Demonstrating a proficient approach to the performance of procedures

Learning outcomes:

• Communicate the purpose, benefits and risks of a procedure in a meaningful way, giving evidence-based information, checking understanding and obtaining informed consent before proceeding.
• Demonstrate the ability to perform a variety of procedures according to your training, working circumstances, physical capability and the patient’s preferences.
• Communicate throughout a procedure to put the patient at ease, monitor their condition, minimise discomfort and ensure that they are willing for you to continue.
• Use equipment safely and effectively and in accordance with best practice guidelines.
• Comply with medico-legal requirements, such as the recording of consent, mental capacity and the involvement of carers and next of kin when appropriate
• Follow infection-control measures. 
• Demonstrate appropriate onward referral for a procedure when this falls outside your area of competence or capability.
• Arrange aftercare and follow-up. 
• Evaluate the outcomes of your procedures by maintaining a log and auditing the outcomes, discussing adverse incidents with your team and responding promptly to any safety issues.

Progression point descriptors – Clinical examination and procedural skills

The capability covers adopting a conscious, organised approach to making decisions that are tailored to the particular circumstances in which they are required.

Focusing on problem-solving is a crucial part of your GP training because family doctors need to adopt a problem-based approach rather than a disease-based approach. As most learning occurs in non-primary care environments you may find it hard to adjust to the differences in problem-solving between general practice and hospital work. These differences have been described in the following terms: “When solving problems, GPs have to tolerate uncertainty, explore probability and marginalise danger, whereas hospital specialists have to reduce uncertainty, explore possibility and marginalise error.”¹ Although this polarises the two situations, it provides some useful pointers on how differences in approach can arise in specific clinical contexts.

Adopting appropriate decision-making principles based on a shared understanding

Learning outcomes:

• Apply rules or plans and use decision aids (such as algorithms and risk calculators) where appropriate for straightforward clinical decisions.
• Use an analytical approach to novel situations in which rules cannot be readily applied, developing your decision-making by forming and testing hypotheses.
• Use an understanding of probability, based on the prevalence, incidence, natural history and time course of illness, to aid your decision-making.
• Address early, undifferentiated presentations by integrating available information to make your best assessment of risk to the patient.
• Recognise uncertainty in general practice problem-solving, sharing uncertainty with the patient where appropriate.
• Revise hypotheses in the light of new or additional information, incorporating advice from colleagues and experts as needed.
• Develop skills in the rapid decision-making required for managing urgent, unfamiliar, unpredictable and other high-risk clinical situations.

Using best available, current, valid and relevant evidence

Learning outcomes:

• Throughout your career, you should know the science that is relevant to your role and necessary to keep up to date with progress in your field. This includes elements of:
  • epidemiology and the determinants of health and illness
  • pathology, natural history of disease and prognosis
  • therapeutics, pharmacology and non-drug therapies
  • evidence-based practice, research methodology, statistics and critical appraisal
  • health promotion, preventative healthcare and harm reduction
  • consultation and communication theory
  • adult educational and reflective learning theory
  • decision-making, reasoning and problem-solving theory
  • complexity and systems theory
  • health economics, financing, commissioning and service design
  • leadership, management and quality improvement science
  • ethical and governance principles relating to evidence-informed practice.
• Use the best available evidence in your decision-making and apply critical thinking to appraise the literature, recognising the strengths and limitations of evidence-based practice. 
• Apply knowledge of the epidemiology of disease to your decision-making. 
• Integrate science, evidence-informed practice, person-centredness and shared care planning approaches to decisions on when to initiate, review or discontinue investigations or therapeutic interventions.
• Know how to approach clinical decision-making when scientific evidence is limited or absent.
• Identify gaps in current evidence and contribute to recommendations for future research.

Progression point descriptors – Decision-making and diagnosis

This capability includes the recognition and management of common medical conditions encountered in generalist medical care, safe prescribing and approaches to the management of medicines.

General practice is primarily focused on individuals with a complex mix of problems. A key issue in the management of complex problems is that of coexisting long-term conditions, known as multimorbidity. The vast majority of management of long-term conditions rests with general practice (with 90% of NHS contacts occurring here), so facilitating and managing this process is a challenge that must be mastered. This may include educating patients and carers on how to use services most appropriately.

Providing collaborative clinical care to patients that supports their autonomy

Learning outcomes:

• Develop the knowledge and skills required to provide general medical care in the community setting to patients of all backgrounds. This includes the appropriate provision of:
  • a primary point of contact for people of all ages with unselected health problems
  • care for people with self-limiting conditions and ailments
  • care for people with chronic illnesses and long-term conditions
  • urgent, unscheduled and emergency care
  • health promotion and preventative care.
• •    Develop the knowledge and skills required to provide high-quality, holistic and comprehensive care to groups of patients who may have health and care needs that require you to adapt your clinical approach. Such groups include: 
  • infants, children and young people
  • people with mental health problems
  • acutely ill people
  • pregnant women, perinatal women and new parents
  • people with learning, physical or sensory disabilities
  • people with addictions
  • gay, lesbian, bisexual and transgender (LGBTQ+) people 
  • migrants, refugees and asylum seekers
  • older adults and those with multimorbidity
  • people nearing the end of life
  • people of different ethnicities and cultures.
• Develop the knowledge and skills required to coordinate care for patients of all life stages and backgrounds. This includes:
  • shared care planning
  • care of long-term conditions
  • treatment monitoring and surveillance
  • curative and survivorship care for people with cancer and other serious or life-changing illnesses
  • recovery and rehabilitation care
  • community-based palliative and end-of-life care.

Using a reasoned approach to clinical management that includes supported self-care

Learning outcomes:

• Develop and implement appropriate management plans for the full range of health conditions that you are likely to encounter in the community, by:
  • considering the likely causes, natural histories, trajectories and impacts of the patient’s health problems
  • differentiating between self-limiting and other conditions, encouraging appropriate self-care and reducing inappropriate medicalisation
  • integrating non-drug approaches into treatment plans, such as psychological therapies, physical therapies and surgical interventions
  • offering appropriate evidence-based management options, varying these according to the circumstances, priorities and preferences of those involved
  • monitoring the patient’s progress to identify unexpected deviations from the anticipated path quickly.
• •    Demonstrate safe and appropriate prescribing, repeat prescribing, medication review and medication management in the community context, by:
  • making safe and appropriate prescribing decisions
  • routinely using recognised sources of drug information, checking on interactions and side effects and following organisational guidance
  • prescribing cost-effectively and being able to justify your decision when you do not follow this principle
  • seeking advice on prescribing when appropriate.
• Give appropriate ‘safety-netting advice’ on what features the patient should look out for to reduce risk, as well as checking the patient’s and carer’s understanding of when and how they should seek further medical help. 
• Implement adequate follow-up arrangements, for example to facilitate the early diagnosis of evolving problems, assess response to treatment, provide safe monitoring and learn from the outcomes of interventions.
• Contribute to an organisational and professional approach that facilitates continuity of care, for example through good record-keeping and fostering long-term clinician–patient relationships.

Making appropriate use of other professionals and services

Learning outcomes:

• Refer appropriately to other professionals and services, by:
  • considering alternatives to formal referral where appropriate (such as email advice systems)
  • predicting sources of delay and taking steps to avoid these where appropriate (for example, by organising investigations in advance so that the results are available to your colleagues)
  • using referral systems and writing referral letters, using relevant information and explanations 
  • acting as an advocate for the patient and their carers as they navigate the health and care system
  • providing ongoing continuity of care for the patient while they wait for their specialist appointment, reviewing progress at suitable intervals.
• Organise the follow-up of your patients after referral through multiprofessional, team-based and structured approaches, including monitoring, reviewing and regular care planning.

Providing urgent care when needed

Learning outcomes:

• Recognise that responding to unscheduled requests for urgent care is a core part of a GP’s role as a frontline practitioner.
• Ensure that emergency care is coordinated with other members of the practice team and emergency services, giving due regard to the safety of yourself, other patients and staff.
• Develop and maintain skills in basic life support and the use of an automated defibrillator, plus any other emergency procedures specifically required in your working environment.
• Follow up patients who have experienced a medical emergency or serious illness appropriately, as well as considering the needs of their carers and family.

Progression point descriptors – Clinical management

References

1. Marinker M (1989) General practice and the social market (Social Market Foundation, London)