Area of capability: Applying clinical knowledge and skill

Particularly in the earlier stages of training (for example, ST1 and ST2), which are predominantly spent in secondary care environments, your training will focus on building the broad base of clinical knowledge and skills needed for generalist medical practice. This will include skills in first-contact patient care (for example, the assessment, diagnosis, investigation, treatment and/or referral of acutely ill patients) and the medical management of common and important long- term conditions in which the GP plays a significant role (for example, cardiovascular, metabolic and respiratory diseases in adults and common child health and mental health problems).

Early experience of the general practice environment will enable you to gain insight into the mindset, approaches and values that underpin community-based generalist practice and will make your subsequent training experiences more effective (particularly if you have limited experience of UK general practice). This will help you to demonstrate how care is applied and enhanced through an integrated and multiprofessional approach and enable you to make more effective use of the wider health and social care resources available to patients and families.

Cork wheels

Data gathering and interpretation

This is about interpreting the patient's narrative, clinical record and biographical data, investigations and examination findings.

Apply a structured 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 and items of the physical examination that 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 ability (such as by reason of a personal physical disability) 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, allowing diagnostic information to be integrated over time. This may include making a conscious decision with the patient to not undertake further investigations, when this is clinically appropriate
  • Enhance your clinical decision-making through effective and timely record-keeping, information sharing, data management and monitoring of care

Interpret findings accurately to reach a diagnosis

Learning outcomes

  • 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
  • Recognise 'red flags' and other indicators of high risk, responding promptly and effectively when these occur
  • Demonstrate proficiency in identifying the self-limiting health conditions that commonly present in an unselected population
  • Identify the mechanisms through which apparently simple health problems become chronic, complex and severe (known as 'yellow flags')

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Progression point descriptors 


Data gathering and interpretation 

This is about the gathering, interpretation, and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations

 

Generic Professional Capabilities: Professional Skills

MRCGP assessments: AKT, CSA, WPBA (CbD, CAT, COT, miniCEX, QIP, CSR)

 

Insufficient evidence - From the available evidence, the doctor’s performance cannot be placed on a higher point of this developmental scale 

Indicators of potential underperformance

 

End ST1 – Making progress at the expected rate 

End ST2 - – Making progress at the expected rate 

End ST3 - Competent for licensing

End ST3 - Excellent 

 

Has an approach which is disorganised, chaotic, inflexible or inefficient

Does not use significant data as a prompt to gather further information

Does not look for red flags appropriately

Fails to identify normality

Examination technique is poor

Fails to identify significant physical or psychological signs

Accumulates information in a formulaic way covering more than is required for the patient problem

Is aware of information in the patients notes that may be relevant

Employs examinations and investigations but not specifically focused to the patient's problem

Identifies abnormal findings and results. 

 

 

Accumulates information from the patient that is mainly relevant to their problem. 

Uses existing information in the patient records. 

Employs examinations and investigations that are broadly in line with the patient’s problems. 

Has appropriate level of knowledge of clinical norms, measurements and investigations and is aware of how these relate to the patient's conditions

Demonstrates a limited range of data gathering styles and methods.

Systematically gathers information, using questions appropriately targeted to the problem without affecting patient safety. 

Understands the importance of, and makes appropriate use of, existing information about the problem and the patient’s context. 

Chooses examinations and targets investigations appropriately and efficiently. 

Understands the significance and implications of findings and results and takes appropriate action. 

Demonstrates different styles of data gathering and adapts these to a wide range of patients and situations

 

 

Expertly identifies the nature and scope of enquiry needed to investigate the problem, or multiple problems, within a short time-frame.   

Prioritises problems in a way that enhances patient satisfaction. 

Uses a stepwise approach, basing further enquiries, examinations and tests on what is already known and what is later discovered. 

Able to gather information in a wide range of circumstances and across all patient groups (including their family and representatives) in a sensitive, empathic and ethical manner

 

 

 


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Clinical examination and procedural skills (CEPS)

This is the appropriate use of and proficient approach to clinical examination and procedural skills.

Demonstrate a proficient approach to clinical examination

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 recognise when an examination may be required but is beyond your physical ability to perform, such as by reason of your own disability, ensuring that the patient has timely and appropriate access to alternative arrangements)
  • Adopt a targeted and systematic approach to clinical examination, recognising normal and abnormal findings and tailoring further examinations accordingly
  • Recognise that a different range of examinations may be perceived as intimate by each patient, depending on individual and cultural factors
  • Demonstrate communication techniques that ensure that the patient understands the purpose of the examination, what will happen and the role of the chaperone
  • Identify cultural and ethical issues relating to examinations (such as the removal of clothing) and discuss these sensitively with the patient as appropriate
  • Provide an opportunity for the patient to give or decline consent, responding non- judgementally if consent is declined
  • Organise the place of examination to provide the patient with privacy and to respect his or her dignity, arranging for a suitable chaperone when one is requested
  • Perform and accurately interpret focused examinations in challenging circumstances (for example, 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

Demonstrate a proficient approach to the performance of procedure

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 and physical capability and the patient's preferences
  • Communicate throughout a procedure to put the patient at ease, monitor his or her condition, minimise discomfort and ensure that he or she is 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 whenever applicable
  • Demonstrate appropriate onward referral for a procedure when this falls outside your area of competence or physical capability
  • Arrange aftercare and follow-up as appropriate
  • 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 

This is about clinical examination and procedural skills. By the end of training, the trainee must have demonstrated competence in 5 mandatory skills and a range of other examination and skills relevant to General Practice.

 

Generic Professional Capabilities: Professional Skills

MRCGP assessments: CSA, WPBA (CEPS, COT, QIP, CSR)

Insufficient evidence - From the available evidence, the doctor’s performance cannot be placed on a higher point of this developmental scale 

Indicators of potential underperformance

 

End ST1 – Making progress at the expected rate 

End ST2 - Making progress at the expected rate 

End ST3 - Competent for licensing

End ST3 - Excellent 

 

 

Patient shows no understanding as to the purpose of the examination

Fails to examine when the history suggests conditions that might be confirmed or excluded by examination

Inappropriate over-examination

Fails to obtain informed consent for the procedure

Patient appears unnecessarily upset by the examination

Chooses examination with a clinically justifiable reason in line with the patient’s problem(s). 

Examination is carried out sensitively and without causing the patient harm

Elicits relevant clinical signs

Shows awareness of personal limitations and boundaries in clinical examination

Observes the professional codes of practice including the use of chaperones. 

Arranges the place of examination to give the patient privacy and respect their dignity

Demonstrates understanding of issues of consent

 

Undertakes examination when appropriate and demonstrates all the basic examination skills needed as a GP

Identifies abnormal signs 

Suggests appropriate procedures related to the patient’s problem(s). 

Performs procedures and examinations with the patient’s consent with a more focused approach.

Chooses examinations appropriately targeted to the patient’s problem(s). 

Has a systematic approach to clinical examination and able to interpret physical signs accurately? 

Varies procedures options according to circumstances and the preferences of the patient. 

Identifies and reflects on ethical issues with regard to examination and procedural skills. 

Recognises and acknowledges the patient’s concerns before and during the examination and puts them at ease

Shows awareness of the medico-legal background, informed consent, mental capacity and the best interests of the patient. 

Proficiently identifies and performs the scope of examination necessary to investigate the patient’s problem(s). 

Uses a step-wise approach to examination, basing further examinations on what is known already and is later discovered. 

Demonstrates a wide range of procedural skills to a high standard.

Engages with quality improvement initiatives with regard to examination and procedural skills. 

Recognises the verbal and non-verbal clues that the patient is not comfortable with an intrusion into their personal space, especially the prospect or conduct of intimate examinations

Is able to help the patient accept and feel safe during the examination

Helps to develop systems that reduce risk in clinical examination and procedural skills. 

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Making decisions

This is about having a conscious, structured approach to decision-making.

Decision-making in general practice is highly context specific. The skills you require relate to the context in which you encounter problems, as well as the natural history and time course of the problems themselves. They are also dependent on the personal characteristics of your patients, your own characteristics as a doctor in managing them, and the resources you have at your disposal.

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 secondary 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.'19 Although this polarises these two situations, it provides some useful pointers on how differences in approach can arise in specific clinical contexts.

  

Adopt appropriate decision-making principles

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 problems that present early and in an undifferentiated way by integrating available information to make your best assessment of risk to the patient, recognising when to act and when to defer a decision if safe and appropriate to do so
  • Recognise the inevitable 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

 

Apply a scientific and evidence-based approach

Learning outcomes

  • Throughout your career, develop and maintain a sufficiently broad and detailed knowledge of the science relevant to your role. This includes (but is not limited to) elements of:
    • epidemiology and the determinants of health and ill health
    • 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
    • health economics, financing, commissioning and service design
    • leadership, management and quality improvement science
  • Use the best available evidence in your decision-making, applying critical thinking to appraise the literature, recognising the strengths and limitations of evidence-based guidelines
  • Apply knowledge of the epidemiology of disease to your decision-making, including the age/sex distribution, risk factors, prevalence, incidence and the relevant characteristics of 'at-risk' groups
  • Integrate evidence-based and scientific approaches with patient-centred and shared care – planning approaches to inform judgements on when to initiate, review or discontinue therapeutic interventions
  • Identify gaps in current evidence and contribute to recommendations for future research

Progression point descriptors 

Making a diagnosis / decisions 

This is about a conscious, structured approach to making diagnoses and decision-making.

 

Generic Professional Capabilities: Professional Skills

MRCGP assessments: AKT, CSA, WPBA (CbD, CAT, COT, miniCEX, QIP, Leadership, Prescribing, CSR)

Insufficient evidence - From the available evidence, the doctor’s performance cannot be placed on a higher point of this developmental scale 

Indicators of potential underperformance

 

End ST1 – Making progress at the expected rate 

End ST2 - Making progress at the expected rate 

End ST3 - Competent for licensing

End ST3 - Excellent 

Is indecisive, illogical or incorrect in decision-making

Fails to consider serious possibilities

Is dogmatic / closed to other ideas

Too frequently has late or missed diagnoses

 

Demonstrates an appropriate level of clinical knowledge and skills for formulating a diagnosis giving a very broad range

Identifies possible alternative diagnoses but does not filter based on probabilty

Makes decisions by applying rules, plans or protocols. 

Aware of personal limitations in knowledge and experience

 

Generates an adequate differential diagnosis based on the information available. 

Generates and tests appropriate hypotheses. 

Justifies chosen options with evidence

Is starting to develop independent skills in decision-making and uses the support of others to confirm that these are correct. 

Makes diagnoses in a structured way using a problem-solving method. 

Uses an understanding of probability based on prevalence, incidence and natural history of illness to aid decision-making. 

Addresses problems that present early and/or in an undifferentiated way by integrating all the available information to help generate a differential diagnosis. 

Revises hypotheses in the light of additional information. 

Thinks flexibly around problems generating functional solutions. 

Has confidence in, and takes ownership of, own decisions whilst being aware of their own limitations. 

Keeps an open mind and is able to adjust and revise decisions in the light of relevant new information. 

Uses pattern recognition to identify diagnoses quickly, safely and reliably. 

Remains aware of the limitations of pattern recognition and when to revert to an analytical approach. 

No longer relies on rules or protocols but is able to use and justify discretionary judgement in situations of uncertainty or complexity, for example in patients with multiple problems. 

Continues to reflect appropriately on difficult decisions.  Develops mechanisms to be comfortable with these choices 

 

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Clinical management

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

Work as a GP is primarily focused on individuals with a complex mix of problems. A key issue in the management of complex problems is that of coexisting chronic diseases, known as multimorbidity. The vast majority of chronic disease management rests with general practice (with 90% of NHS contacts occurring here) and 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.

Provide a general clinical care to patients of all ages and backgrounds

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 (but are not limited to):
    • infants, children and young people
    • people with mental health problems
    • acutely ill people
    • pregnant women, perinatal women and new parents
    • people with intellectual, physical or sensory disabilities
    • people with addictions
    • gay, lesbian and transgender people
    • migrants, refugees and asylum seekers
    • the elderly 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 ages 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

Adopt a structured approach to clinical management

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 responsively according to the circumstances, priorities and preferences of those involved
    • monitoring the patient's progress to identify quickly unexpected deviations from the anticipated path
  • 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, checking the patient's and carer's understanding of when to seek further medical help and how they should do this
  • 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 adequate record-keeping and building long-term patient relationships)

Make appropriate use of other professionals and services

As a GP, this means that you should

  • Refer appropriately to other professionals and services, by:
    • considering alternatives to formal referral where appropriate (for example, 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)
    • writing referral letters that provide relevant information and explaining the reason for referral
    • using the appropriate referral system to avoid unnecessary delays for the patient
    • acting as an advocate for the patient and his or her carers as he or she navigates 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

Provide 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 front-line practitioner
  • Respond rapidly, skillfully and safely to emergencies
  • 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, also considering the needs of their carers and family

Progression point descriptors 

Clinical management 

This is about the recognition and management of patients’ problems.

 

Generic Professional Capabilities: Professional Knowledge; Professional Skills

MRCGP assessments: AKT, CSA, WPBA (CbD, CAT, COT, miniCEX, QIP, Leadership, CSR)

Insufficient evidence - From the available evidence, the doctor’s performance cannot be placed on a higher point of this developmental scale 

Indicators of potential underperformance

 

End ST1 – Making progress at the expected rate 

End ST2 - Making progress at the expected rate 

End ST3 - Competent for licensing

End ST3 - Excellent 

 

 

 

 

Asks for help inappropriately: either too much or too little

Does not think ahead, safety-net appropriately or follow through adequately

Uses appropriate but limited management options without taking into account the preferences of the patient. 

Suggests appropriate interventions, although with a tendency to overinvestigate.

Arranges definite appointments for follow up for patients but likely to routinely follow up rather than basing on patient need

Demonstrates an appropriate level of safe prescribing

Refers safely, acting within the limits of their competence but may over refer.

Recognises and responds safely to medical emergencies and acutely unwell patients

 

Demonstrates use of safe management plans

Understands good practice in the use of referral

Demonstrate readiness to work in an urgent care environment.

Recognises that acute management is only part of the wider care of individual patients

Ensures that continuity of care can be provided for the patient’s problem, e.g. through adequate record keeping.

Makes safe prescribing decisions, routinely checking on drug interactions and side effects. 

Varies management options responsively according to the circumstances, priorities and preferences of those involved. 

Considers a “wait and see” approach where appropriate.   

Uses effective prioritisation of problems when the patient presents with multiple issues. 

Suggests a variety of follow-up arrangements that are safe and appropriate, whilst also enhancing patient autonomy. 

In addition to prescribing safely is aware of and applies local and national guidelines including drug and non-drug therapies. 

Maintains awareness of the legal framework for appropriate prescribing. 

Refers appropriately, taking into account all available resources. 

Responds rapidly and skilfully to emergencies, with appropriate follow- up for the patient and their family.  Ensures that care is co-ordinated both within the practice team and with other services. 

Provides comprehensive continuity of care, taking into account all of the patient’s problems and their social situation. 

Provides patient-centred management plans whilst taking account of local and national guidelines in a timely manner. 

Empowers the patient with confidence to manage problems independently together with knowledge of when to seek further help. 

Able to challenge unrealistic patient expectations and consulting patterns with regard to follow up of current and future problems. 

Regularly reviews all of the patient’s medication in terms of evidence- based prescribing, cost-effectiveness and patient understanding.  

Has confidence in stopping or stepping down medication where this is appropriate. 

Identifies areas for improvement in referral processes and pathways and contributes to quality improvement. 

Contributes to reflection on emergencies as significant events and how these can be used to improve patient care in the future. 

Takes active steps within the organisation to improve continuity of care for the patients. 


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