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The RACGP Curriculum for Australian General Practice 2016

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Curriculum coverThe complete 2016 Curriculum consists of a number of units in addition to contextual units. All units will be available for download as a PDF shortly.

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Dermatology

Definition

General practice dermatology refers to the assessment, treatment and referral of disorders that affect the skin, nail, hair and mucous membranes.

Curriculum in practice

Typical cases that illustrate how the dermatology curriculum applies to general practice include:

  • Ian, 58 years of age, is a pig farmer. He rarely presents to the practice but today he comes in nursing one hand, which he has wrapped in a bandage. He can't remember injuring the hand, but it has now developed a large vesiculated lesion on the right thumb. Ian says he cannot work because his hand is too tender and that last night he felt 'shivery' cold. Today he is febrile with tender axillary nodes. Ian is surprised how rapidly the lesion developed, saying it was barely visible just 3 days ago. A culture is obtained and the result is Streptococcus pyogenes. Ian wants to know how long it will take to recover.
  • Jack, 17 years of age, is a high school student. He presents for review of a rash on his face that 'just won't get better'. The rash started just a few days after returning from an intensive training camp and began with a few spots on his forehead which then spread rapidly to cover the right cheek. He thought it might be a friction rash from the mats they used at the camp. He had tried topical antiseptic creams without success. Jack was commenced on antibiotics a week ago, but today, the lesions appear to be more ulcerated in nature and consistent with Herpes gladiatorum.
  • Katie, 6 years of age, has been sent home from school because she has an itchy rash. The school were worried it might be scabies. The rash is dry and scaly and predominantly involves the antecubital and popliteal fossa. There is hypo-pigmentation of the skin and her mother reports that Katie has had it on and off since she was a baby. There is a family history of atopy.

Rationale and general practice context

Skin conditions account for 14.8 out of every 100 patient encounters in general practice and 10.4% of the total reasons for encounters, making them one of the most common presentations in Australian general practice.1 In addition to being a major source of patient morbidity, skin conditions can be the first presentation of serious systemic disease, including infection and malignancy, with skin cancers being the second commonest reason for medical specialist referral in general practice.1 Skin cancers are a major and increasing source of premature death in Australia,{2 3 highlighting the importance of prompt diagnosis and management.

While each patient presenting with a skin condition is unique, some significant skin conditions are more common among particular patient groups. For example, Aboriginal and Torres Strait Islander Australians are prone to streptococcal skin disease and to secondary renal disease. Also, the vulnerability to skin cancers, including melanoma, is increased in the highly immunosuppressed, especially transplant recipients.

General practitioners also see skin conditions or dermatological manifestations of systemic diseases that, although uncommon in Australia, are seen in travellers, refugees and other people who have been to areas outside of Australia.

General practice has a significant role in participating in public health measures aimed at reducing the significant health burden of adverse outcomes, including patient education, about the avoidance of environmental hazards that may cause skin problems and other public health measures such as disease notification. This includes screening for skin cancers according to evidence based guidelines and targeting specific high risk populations.

Related curriculum areas

Refer also to the curriculum statements:

Training Outcome of the five domains of general practice

1. Communication skills and the patient-doctor relationship

PDERT1.1

Must be able to take an accurate and complete history, as skin conditions may reflect serious systemic or psychiatric disturbance. This incorporates the need to assess skin diseases that may be influenced by lifestyle, work, psychological state, cultural practices, ethnicity, geography and travel.

PDERT1.2

Need to assess how skin conditions affect the patient's family and community.

PDERT1.3

Need to provide ongoing full assessment of skin conditions, especially chronic conditions, with close attention to the long term physical, psychological and social impact of the disease on the patient. This includes the patient's own conception of their disease, which can markedly affect management and outcomes.

2. Applied professional knowledge and skills

PDERT2.1

Require knowledge of regional anatomy relevant to skin surgery. Need to be able to describe skin lesions using standard dermatological terms.

PDERT2.2

Require knowledge of clinical and historical features of major common diseases including:

  • eczema: atopic, contact and seborrhoeic
  • psoriasis
  • acne
  • rosacea
  • urticaria
  • bacterial infections: cellulitis, erysipelas, impetigo
  • viral infections: herpes simplex, herpes zoster, warts, pityriasis rosea, exanthems, enanthems
  • fungal infections: dermatophytes, pityriasis versicolor, candidiasis
  • insect infections: lice, scabies
  • benign growths: epidermoid cysts, seborrhoeic keratoses, solar lentigos
  • malignancy and premalignant conditions: solar keratosis, basal cell carcinoma, squamous cell carcinoma, Bowen's disease (squamous carcinoma in situ) keratoacanthoma, melanoma
  • pruritus
  • hair diseases: alopecia areata, androgenic alopecia, telogen effluvium
  • nail diseases: fungal, psoriatic, neoplastic nail disease
  • ulcers: including venous, arterial, malignant and pressure ulcers
  • systemic lupus erythematosus, lichen planus, purpura, keratosis pilaris, sarcoidosis.
PDERT2.3

Perform a competent skin examination, choose appropriate investigations and perform appropriate dermatological procedures. Such procedures may include:

  • biopsy: shave, punch, and excisional biopsy
  • cryotherapy
  • diathermy
  • curettage
  • skin and nail scrapings for fungal disease
  • skin swabs for bacterial or viral disease
  • dermoscopy.
PDERT2.4

Must be able to recognise life threatening dermatological emergencies including:

  • meningococcal septicaemia
  • ocular herpes simplex and zoster
  • toxic epidermal necrolysis and Stevens-Johnson syndrome
  • erythroderma: exfoliative dermatitis and pustular psoriasis
  • Kawasaki disease
  • scalded skin syndrome
  • angioedema/anaphylaxis
  • pemphigus vulgaris
  • necrotising fasciitis
  • polyarteritis nodosum
  • eczema herpeticum
  • periorbital cellulitis
  • spider and snake bites.
PDERT2.5

Recognise unusual skin conditions or dermatological manifestations of systemic diseases.

PDERT2.6

Recognise skin conditions related to drug reactions and environmental exposures.

3. Population health and the context of general practice

PDERT3.1

Educate patients about the avoidance of environmental hazards such as solar radiation, workplace or household exposures that may cause skin problems.

PDERT3.2

Practise public health measures that aim to reduce the health burden of adverse outcomes such as disease notification requirements.

PDERT3.3

Screen for skin cancers according to evidence based guidelines including targeting specific high risk populations.

PDERT3.4

Integrate knowledge of significant skin conditions which are more common among particular groups within Australia including Indigenous Australians.

PDERT3.5

Recognise unusual skin conditions or dermatological manifestations of systemic diseases uncommon in Australia that may present in travellers, refugees or other people who have been in areas outside of Australia.

4. Professional and ethical role

PDERT4.1

Manage skin conditions using a team approach that involves specialist colleagues in dermatology, plastic surgery or skilled nursing staff.

PDERT4.2

Acknowledge the limitations for treating dermatological conditions within general practice and refer patients in a timely and appropriate manner when necessary.

PDERT4.3

Use an empathetic and nonjudgmental approach that recognises the potential for psychological distress from skin conditions for the patient and others, including the potential lifelong misery and stigma of some skin conditions such as visible birthmarks, psoriasis, alopecia and acne.

5. Organisational and legal dimensions

PDERT5.1

Ensure that organisational strategies are in place for referring patients unsuitable for general practice management.

PDERT5.2

Ensure the accurate documentation of examinations, care and patient outcomes.

PDERT5.3

Ensure that the practice complies with the standards required for practical procedures (eg. infection control).

Learning objectives across the GP professional life

Medical student

1. Communication skills and patient-doctor relationship

PDERLM1.1

Demonstrate how to establish rapport with a patient, carer and/or parent.

PDERLM1.2

Describe the impact of skin disease on work, daily life and psychological wellbeing.

PDERLM1.3

Demonstrate how to take a history of skin problems without neglecting other health issues.

PDERLM1.4

Describe patient concerns and understanding about their skin problem.

PDERLM1.5

Describe the impact of patient concerns and understanding on the individual and their family.

PDERLM1.6

Demonstrate patient friendly explanations of the pathological process, natural history and treatment of the patient's condition.

2. Applied professional knowledge and skills

PDERLM2.1

Describe skin anatomy, physiology and function.

PDERLM2.2

Describe the manner in which skin disease manifests.

PDERLM2.3

Describe the aetiology, symptoms, examination and investigative techniques required to diagnose and manage common dermatological diseases

PDERLM2.4

Identify skin signs of serious or life threatening illness including HIV infection.

PDERLM2.5

Demonstrate the ability to clearly summarise the history of a presenting skin problem.

PDERLM2.6

Describe the skin condition using standard dermatological terms.

PDERLM2.7

Demonstrate how to perform a sensitive, thorough skin examination which includes hair, nails and mucous membranes.

PDERLM2.8

Describe the investigative techniques useful for diagnosis.

PDERLM2.9

Outline the commonly used topical and systemic therapies available for common skin conditions.

PDERLM2.10

Describe the major side effects of the most commonly used medications, especially topical steroids.

PDERLM2.11

Outline the principles of basic skin surgery.

PDERLM2.12

Describe the difference between 'cure' and 'control' of skin disease.

3. Population health and the context of general practice

PDERLM3.1

Describe the infectious nature of some skin diseases and the infection control measures needed for patients, siblings, parents and the school or work environment.

PDERLM3.2

Describe how some occupations, hobbies and lifestyle choices influence and cause some skin diseases.

PDERLM3.3

Outline the genetics and familial aspects of some skin diseases including atopic dermatitis and psoriasis.

PDERLM3.4

Describe the impact of complementary therapies, such as herbal cream allergies, on skin conditions (eg. calendula cream in eczema can cause severe allergic reaction).

PDERLM3.5

Describe screening for skin cancers according to evidence based guidelines including targeting specific high risk populations.

PDERLM3.6

Describe the goals and relevance of public health campaigns (eg. 'slip, slop, slap').

4. Professional and ethical role

PDERLM4.1

Demonstrate the skills needed to explain conditions, their treatment and prognosis to colleagues and patients.

PDERLM4.2

Demonstrate empathy for people with skin diseases.

PDERLM4.3

Recognise that not all treatments are available, cost effective or equally preferred by all patients with the same skin condition.

5. Organisational and legal dimensions

PDERLM5.1

Describe the importance of informed consent for procedures.

PDERLM5.2

Describe the need for accurate and contemporaneous notes for skin conditions.

Prevocational doctor

1. Communication skills and patient-doctor relationship

PDERLP1.1

Describe the patient's experience of the skin disease.

PDERLP1.2

Integrate a comprehensive patient centred approach into the assessment and management of people with skin disease.

2. Applied professional knowledge and skills

PDERLP2.1

Distinguish between what is primarily a skin disease and a dermatological manifestation of systemic disease (eg. a face rash may be a manifestation of systemic lupus erythematosus).

PDERLP2.2

Manage emergency dermatological presentations.

PDERLP2.3

Demonstrate the appropriate selection and use of local anaesthetic agents.

PDERLP2.4

Describe best practice use of skin antiseptics.

PDERLP2.5

Describe and perform basic skin surgery, including the excisional biopsy of small skin lesions.

PDERLP2.6

Manage skin wounds through primary and secondary intention healing.

PDERLP2.7

Manage safe and appropriate use of diathermy and cryotherapy.

3. Population health and the context of general practice

PDERLP3.1

Describe the relationship between skin disease and the physical environment.

PDERLP3.2

Describe the impact of skin disease in psychological, social and financial terms.

PDERLP3.3

Demonstrate that the promotion and practise of the principles of preventive care is highly relevant to the skin, including sun protection measures and the prevention of occupational dermatoses.

PDERLP3.4

Demonstrate screening for skin cancers according to evidence based guidelines including targeting specific high risk populations.

4. Professional and ethical role

PDERLP4.1

Demonstrate that the potential risks and complications of procedures undertaken in the hospital environment are acknowledged when counselling patients for informed consent.

PDERLP4.2

Demonstrate provision of information for skin problems for patients.

PDERLP4.3

Demonstrate up-to-date knowledge about clinical decision making for general practice skin conditions and their management.

PDERLP4.4

Demonstrate the processes involved in informing other treating doctors, especially the patient's GP, of the patient's course, outcome and clinical needs in a timely and accurate way.

5. Organisational and legal dimensions

PDERLP5.1

Describe the notification requirements of major diseases and the mechanisms through which notification occurs.

PDERLP5.2

Demonstrate compliance with hospital protocols on infectious disease control. For example managing multiple resistant organisms such as methicillin resistant Staphylococcus aureus (MRSA).

PDERLP5.3

Demonstrate accurate and contemporaneous recording of skin symptoms, signs and treatments undertaken.

PDERLP5.4

Describe clear referral pathways for patients with skin symptoms.

PDERLP5.5

Demonstrate unambiguous and appropriate discharge plans for patients.

PDERLP5.6

Describe personal limitations in knowledge and the importance of seeking appropriate advice.

PDERLP5.7

Demonstrate the adoption of a team approach to patient care.

Vocational registrar

1. Communication skills and patient-doctor relationship

DERLV1.1

Demonstrate how patients are allowed to communicate their concerns, fears and expectations.

DERLV1.2

Demonstrate patient engagement about their understanding of their skin condition, including reinforcing helpful beliefs and correcting any troubling misconceptions (eg. 'is my psoriasis contagious?').

DERLV1.3

Demonstrate how the results of patients' current and past treatments, including any complementary medicines, are recorded and reviewed.

DERLV1.4

Integrate the negotiation of an effective long term management plan (especially important in the management of chronic illness).

DERLV1.5

Demonstrate how to reinforce patient understanding of the difference between control and cure.

DERLV1.6

Confirm patient understanding of the condition and the agreed management plan.

2. Applied professional knowledge and skills

PDERLV2.1

Demonstrate how to take an appropriate history and conduct a thorough skin examination.

PDERLV2.2

Effectively use a dermatoscope, where appropriate, for additional help in assessing pigmented and nonpigmented lesions (this may involve specific training).

PDERLV2.3

Demonstrate diagnosis of common general practice dermatological problems.

PDERLV2.4

Demonstrate the ability to critically interpret investigations including biopsy.

PDERLV2.5

Demonstrate the ability to diagnose and manage major dermatological problems, particularly in paediatrics, pregnancy and the aged.

PDERLV2.6

Describe medication side effects that may manifest as skin symptoms, effectively mimicking other dermatological diseases including viral exanthems.

PDERLV2.7

Describe the major disorders of the hair and nails including fungal diseases and local malignancy.

PDERLV2.8

Demonstrate writing prescriptions for useful extemporaneous preparations.

PDERLV2.9

Demonstrate recognition of serious dermatological conditions, including rare conditions and arrange management.

PDERLV2.10

Demonstrate, where appropriate, competency in performing basic procedures such as obtaining skin scrapings, sampling for bacterial microscopy and culture, viral sampling, punch biopsy and formal excisional biopsy.

3. Population health and the context of general practice

PDERLV3.1

Describe the financial and time burden of some skin treatments for patients and their families.

PDERLV3.2

Describe how exposure to irritants and allergens at home and in the workplace may precipitate skin disease (eg. eczema, contact dermatitis).

PDERLV3.3

Outline the prevention of skin cancer, including patient discussion of sun protection, and the general practice surveillance of high risk groups including familial forms of dysplastic naevi and melanoma.

PDERLV3.4

Demonstrate prevention education of sun skin damage by participating in community and workplace related education and policy strategies.

PDERLV3.5

Describe how the implications of skin disease outbreaks in the general community demand unique strategies in management beyond treating the individual patient (eg. scabies, lice, impetigo, herpes zoster and meningococcal disease) especially in schools, nursing homes and hospitals.

PDERLV3.6

Describe skin conditions which are notifiable, how they are notified and school/work exclusion periods.

4. Professional and ethical role

PDERLV4.1

Outline personal limitations in dermatology skills or knowledge and describe how to be prepared to ask for help.

PDERLV4.2

Demonstrate how to avoid vulnerable anatomical structures during skin surgical procedures (eg. temporal branch of facial nerve).

PDERLV4.3

Demonstrate the important surface landmarks for the facial, accessory and marginal mandibular nerves.

PDERLV4.4

Demonstrate sensitivity to the potential lifelong misery and stigma of some skin conditions, including visible birthmarks, psoriasis, alopecia and acne

5. Organisational and legal dimensions

PDERLV5.1

Demonstrate that a reliable record system is in place for all biopsies, investigations and excisions sent from the practice.

PDERLV5.2

Outline clear practice mechanisms for the transmission of relevant information to patients about their test results.

PDERLV5.3

Demonstrate a clear paper or computer record of the flow of information.

PDERLV5.4

Demonstrate the ability to make contemporaneous, legible and accurate notes.

PDERLV5.5

Describe potential work related compensation issues with respect to skin disease (eg. allergic contact dermatitis).

PDERLV5.6

Where appropriate, demonstrate how patients can access reliable information about skin diseases, which may include printed brochures from recognised authorities.

PDERLV5.7

Demonstrate compliance with practice standards when performing dermatological procedures. For example, infection control standards including sterilisation of instruments.

Continuing professional development

1. Communication skills and patient-doctor relationship

PDERLC1.1

Describe the personal impact of visible and, possibly, stigmatising skin conditions on a person.

PDERLC1.2

Demonstrate the ability to assess the emotional and financial impact of skin disease.

PDERLC1.3

Describe how mental illness can be associated with, or exacerbated by, skin disease.

PDERLC1.4

Describe the importance of counselling patients who have unrealistic expectations; it is important to be realistic about expectations with regard to timeframes and treatment outcomes (eg. acne treatment).

PDERLC1.5

Describe methods to improve counselling skills for patients with complex management needs (eg. managing acne, psoriasis, eczema and vitiligo).

2. Applied professional knowledge and skills

PDERLC2.1

Demonstrate review of ongoing skills and methods to confidently diagnose and manage skin diseases commonly arising within the local practice population and community (eg. a patient audit may provide guidance as to what the common local diseases are).

PDERLC2.2

Describe the long term management of depression in chronic skin disease.

PDERLC2.3

Demonstrate confident and competent use of a dermatoscope.

PDERLC2.4

Demonstrate confident and competent performance of skin procedures.

PDERLC2.5

Describe dermatological treatment complications.

PDERLC2.6

Demonstrate increasing knowledge in skin complications of systemic disease (eg. diabetes, peripheral vascular disease, immunocompromised, obesity).

PDERLC2.7

Describe the psychiatric manifestation of skin disease such as trichotillomania, body dysmorphism, delusions of infestation (parasitophobia).

PDERLC2.8

Demonstrate improvement in ulcer management skills.

3. Population health and the context of general practice

PDERLC3.1

Describe the particular skin problems of immunosuppressed patients including organ transplant patients.

PDERLC3.2

Demonstrate ready access to recommended exclusion periods for childhood exanthems.

4. Professional and ethical role

PDERLC4.1

Demonstrate regular participation in dermatology updates.

PDERLC4.2

Where appropriate, demonstrate further and higher learning in dermatology, including learning advanced surgical techniques (eg. skin flaps, grafts and complex repairs), advanced diagnostic skills of pigmented lesions, and diploma and masters courses in dermatology.

PDERLC4.3

Demonstrate regular reflection of personal limitations in dermatology and refer when appropriate

PDERLC4.4

Demonstrate informed consent for all dermatological procedures.

5. Organisational and legal dimensions

PDERLC5.1

Demonstrate practice processes for reliable and sterile equipment for all dermatological procedures.

PDERLC5.2

Demonstrate compliance with sterilisation methods and maintain instruments and sterilisation procedures to RACGP Infection control standards for office based practices.

PDERLC5.3

Demonstrate the provision of patient space and privacy for disrobing, examination and treatment.

PDERLC5.4

Describe the establishment of links with dermatology and surgical colleagues for ongoing patient dermatologic treatments.

PDERLC5.5

Demonstrate processes for staff training and protocols for tray presentations, equipment, waste disposal, cleaning and sterilisation.

PDERLC5.6

Demonstrate appropriate follow up policies are in place for patient recall, result notification and action required, and that these policies are enacted.

PDERLC5.7

Demonstrate compliance with communicable notification requirements.

References

  1. Britt H, Charles J, Henderson J, et al. General practice activity in Australia 2000–01 to 2009–10 10 year data tables. Canberra: Australian Institute of Health and Welfare; 2010.
  2. Australian Institute of Health and Welfare. Australia's health 2010. Canberra: Australian Institute of Health and Welfare; 2010.
  3. Australian Bureau of Statistics. 3303.0 – Causes of death, Australia, 2009; 2011.

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