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3 21 Knowledge and skills guide

The following learning outcomes or objectives relate specifically to the management of skin problems. These learning outcomes are in addition to those detailed in the core statement, Being a General Practitioner. The core statement and this module should be used in conjunction with the other curriculum modules. In order to demonstrate the core competences in the area of skin problems, you will require knowledge, skills and attitudes in the following areas:

Fitness to practise

This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients.

This means that as a GP you should:

  • Ensure that skin problems are not inappropriately dismissed as trivial or unimportant by healthcare professionals

Maintaining an ethical approach

This addresses the importance of practising ethically, with integrity and a respect for diversity.

This means that as a GP you should:

  • Empower patients with chronic skin problems, including managing the effects of disfigurement

Communication and consultation

This is about communication with patients, the use of recognised consultation techniques, establishing patient partnership, managing challenging consultations, third-party consulting and the use of interpreters.

This means that as a GP you should:

  • Identify symptoms that are within the range of normal and require no medical intervention, e.g. age-related changes such as dry skin/hair loss and innocent moles
  • Appreciate the feelings engendered by skin disease, which include fears about contagion (the ‘modern-day leper’) and concerns about malignancy [5]
  • Empower patients to adopt self-treatment and coping strategies, where possible, in such conditions as mild eczema and mild acne
  • Appreciate the quantities of cream/ointment/lotion that should be prescribed to enable patients to treat their skin condition appropriately, and when to use each vehicle
  • Whilst respecting dignity and observing appropriate hygiene measures, demonstrate that examining the skin and touching affected areas is acceptable
  • Describe a skin lesion or rash using dermatologically accurate terms

Data gathering and interpretation

This is about interpreting the patient’s narrative, clinical record and biographical data. It also concerns the use of investigations and examination findings, plus the adoption of a proficient approach to clinical examination and procedural skills.

This means that as a GP you should:

  • Recognise the importance of skin-specific symptoms, e.g. itching and rash distribution
  • Appreciate the importance of the social and psychological impact of skin problems on the patients’ quality of life (sleep, disfigurement, messy treatment regimens etc.)
  • Recognise the spectrum of patterns and distributions of rashes of different skin disorders
  • Understand how to carry out more detailed tests where indicated, including skin scrapings and the use of Wood’s light
  • Be prepared to carry out appropriate examination of the skin, including:
    • Addressing the need to undress the patient sufficiently but with sensitivity to dignity
    •  ‘Difficult areas’ such as the flexures, genitalia and mucous membranes

Making decisions

This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice.

This means that as a GP you should:

  • Understand the ‘alarm symptoms and signs’ for skin cancers that necessitate fast-track referral
  • Understand the different indications for patch and prick testing, and when these are appropriate
  • Understand the role of histopathology and when to recommend incision or excision biopsy
  • Know the indications for curettage, cautery and cryosurgery
  • Be aware of likely scenarios for contact dermatitis, where patch testing may be needed
  • Be able to distinguish benign from malignant skin conditions and make appropriate referrals

Clinical management

This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches.

This means that as a GP you should:

  • Demonstrate appropriate history-taking for patients with skin problems, including past personal history, family history, chemical contacts, occupation and drug usage
  • Understand how to recognise common skin conditions in primary care, e.g. eczemas, psoriasis and infections, and instigate appropriate treatment
  • Recognise rarer but potentially important conditions and know when to refer to secondary care, e.g. bullous disorders and vasculitis
  • Recognise emergency skin conditions, e.g. erythroderma, anaphylaxis and herpetic eczema, and act appropriately

Managing medical complexity

This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation.

This means that as a GP you should:

  • Appreciate that pathology in other systems may lead to skin changes, e.g. skin manifestations of internal disease
  • Know the association between psoriasis and arteriosclerosis
  • Be able to advise regarding risk of long-term exposure to ultraviolet and sunburn, especially in children
  • Be aware of inheritance of common skin diseases, such as eczema or psoriasis

Working with colleagues and in teams

This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development.

This means that as a GP you should:

  • Be aware of primary care resources and when to refer to secondary care so that patients receive appropriate treatment (such as light therapy, biological therapies or immunosuppressant therapy)
  • Be aware of local, alternative referral resources such as GPs with a Special Interest (GPwSIs) or specialist nurse practitioners
  • Provide patients with information on referral options, if appropriate (GPwSI clinic/Expert Patients Programme (EPP)/specialist nurse/secondary care)
  • Know about shared care protocols with secondary care for the follow up of patients with skin cancer/lichen sclerosis et atrophicus and, where negotiated with the secondary care provider, those on isotretinoin
  • Consider the help of ‘expert patients’ for conditions like severe childhood atopic eczema or psoriasis
  • Value the role of other members of the primary healthcare team (e.g. specialist health visitors for eczema and wet wrapping, district nurses/nurse practitioners for leg ulcers and wound management)

Maintaining performance, learning and teaching

This area is about maintaining performance and effective CPD for oneself and others, self-directed adult learning, leading clinical care and service development, participating in commissioning, quality improvement and research activity.

This means that as a GP you should:

  • Be aware of the major advances in therapy, including biological treatments such as TNF-alpha blockers and monoclonal antibodies, for severe disease that has failed to respond to standard second-line therapies
  • Understand and implement the key national guidelines that influence healthcare provision for skin problems

Organisational management and leadership

This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care planning, using new technologies to access and deliver care and developing relevant business and financial management skills.

This means that as a GP you should:

  • Consider reviewing all referrals to establish whether the input of secondary care is ‘value added’ and to establish any learning points for similar cases (i.e. meeting doctors’ educational needs (DENS))

Practising holistically and promoting health

This is about the physical, psychological, socioeconomic and cultural dimensions of health. It includes considering feelings as well as thoughts, encouraging health improvement, preventative medicine, self-management and care planning with patients and carers.

This means that as a GP you should:

  • Understand the significant quality-of-life issues regarding common skin complaints, which can also impact on the entire family. You should also be aware of:
    • Sleep disturbance from itching, especially for children with eczema (which can also cause disturbed, restless nights for parents and interfere with education)
    • Isolation and loss of confidence, especially in young people with acne or disfigurement (e.g. vitiligo)
  • Recognise how disfigurement (including problems like acne which can be seen by doctors as apparently clinically ‘trivial’) and cosmetic skin changes fundamentally affect patients’ confidence, mood, interpersonal relationships and even employment opportunities
  • Appreciate the impact of skin disease on family, friends and dependants, and on employers and employment (i.e. career choices)
  • Empower patients to self-manage their skin condition as far as practicable
  • Give advice on maintaining ‘healthy skin’, e.g. avoiding unnecessary chemicals and overexposure to sun

Community orientation

This is about involvement in the health of the local population. It includes understanding the need to build community engagement and resilience, family and community-based interventions, as well as the global and multi-cultural aspects of delivering evidence-based, sustainable healthcare.

This means that as a GP you should:

  • Understand the effect of a patient’s environment/occupation on skin conditions
  • Know how to refer to rapid access clinics in secondary care where appropriate
  • Understand that services other than the traditional secondary care, consultant-led service may be available, such as camouflage service and other patient support groups, and refer appropriately
  • Recognise the evolving trends in disease demographics, e.g. the increasing incidence of skin cancers, an aging population and the increase in ethnic minorities
  • Recognise how the cultural differences of your patient population might affect not only the spectrum of skin conditions but also their management
  • Recognise the huge prevalence of skin disease in the community and its impact on patient’s lives and healthcare resources
  • Be aware of locally determined health service priorities, e.g. restrictions on prescribing oral terbinafine/Vaniqa®/topical immunomodulators

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