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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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Philosophy and foundation of general practice

Definition

The foundation of general practice includes the philosophy, concepts and principles that define the roles of general practitioners and the discipline of general practice.

This foundation defines:

  • what is involved in being a GP
  • how this role is different from other disciplines within medicine
  • the role of general practice in the lives of individual patients, their personal context, their communities, and the health system.

For medical students and prevocational doctors, an understanding of this foundation will improve understanding of the place and significance of general practice in their working life.

For vocational trainees, this foundation will provide a framework for building a detailed and comprehensive understanding of their chosen profession of general practice.

For established GPs, this foundation provides an external reference as a basis for reflection on the knowledge, skills and attitudes developed in training and from clinical experience.

The philosophies, concepts and principles of general practice permeate all aspects of general practice. The learning objectives of this statement should therefore be borne in mind in relation to all the priority learning areas.

Curriculum in practice

The following case illustrates how the philosophy and foundation of general practice curriculum applies to general practice:

  • As an experienced GP supervisor you have been invited to address the graduating year of the University Centre of Excellence. Positioned on either side of you are professors whose names you recognise from journal articles as international experts. Your topic is the changing role of general practice and you see this as an opportunity to inspire the next generation. As you wait your turn to speak, you reflect on the highs and lows of 25 plus years of practice. You are well aware of the changes that have already taken place, yet cannot help but think that the core elements of general practice have remained the same. Listening to one of the other specialists talking about exciting new technology, you decide to focus your talk, as you have your career, on the care of each person who walks through your door. 'Let me tell you the story of Mikaela ...'

Rationale and general practice context

General practice is the primary focus of the Australian healthcare system.

General practitioners provide ongoing patient centred healthcare for all members of the community based on an understanding of health and illness as a uniquely personal experience, shaped by past experience, cultural, social and contextual dimensions.

General practice manages patient health and illnesses grounded in knowledge from biomedical, psychosocial, intrapersonal and interpersonal perspectives.

At both a systemic and consultation level, general practice is the interface between medicine and the community, science and humanity, evidence and creativity.

Australian general practice in the 21st century is the continuation of a millennium-long tradition of caring for the sick, and the central place of general practice will continue to evolve as part of a dynamic, diverse society, which it will reflect and influence.

The discipline of general practice has evolved through historical, cultural, social, political and contextual influences, but certain core characteristics relating to the relationship between patient and doctor, and doctor and community, have remained immutable over time. These include:

  • the patient as the centre of concern
  • the patient-doctor relationship as the basis of the therapeutic process
  • the distinctive problem solving skills of GPs
  • primary care management
  • a holistic perspective to care
  • comprehensive scope
  • a community based context.

The patient-centred approach to general practice care

General practitioners have the breadth and depth of knowledge of disease as covered by this curriculum, but integrate this knowledge with an understanding that the presence or absence of disease does not necessarily correlate with a health-to-illness continuum, being patient focused, rather than disease focused.

'... the kind of commitment I am speaking of implies that the physician will "stay with" a person whatever his problem may be, and he will do so because his commitment is to people more than to a body of knowledge or a branch of technology. To such a physician, problems become interesting and important not only for their own sake but because they are Mr Smith's or Mrs Jones's problem. Very often in such relations there is not even a very clear distinction between a medical problem and a nonmedical one. The patient defines the problem.'1

Managing complexity and uncertainty in general practice

The relationship GPs have with their patients, together with the importance of the context in which patients and their doctors live, mean that GPs need to be skilled in managing complexity and uncertainty.

The challenge of managing complexity and uncertainty is also increased by the natural epidemiology of disease in the community and changes in medical care technology.

Issues contributing to complexity and uncertainty in these areas include:

  • early presentation of disease
  • relatively infrequent occurrence of serious illness
  • recognition, integration and management of multiple issues, often in a single consultation, but also over time
  • influence of comorbidities on each individual health problem
  • ongoing management of the increasing prevalence of chronic illness in the community
  • ability to manage complex illness based on advanced and developing technologies
  • constantly evolving boundaries between other healthcare providers and general practice based care, including issues of access and affordability, which may be practice and/or location specific
  • understanding of the structure and the dynamics of the community
  • collaboration with patients in drawing on and developing their self care skills.

General practitioners as patient advocates in complex health systems

In contrast to specialist practice, in which patients are selected to match the service provided, GPs need to be flexible and able to draw on an extensive range of knowledge and skills in meeting the health needs of individual patients, both in the short term and over a long professional relationship. General practitioners incorporate the expertise of other healthcare providers as appropriate, and this includes the essential role of acting as patient guide and advocate in an increasingly fragmented healthcare system.

Good general practice primary care improves the health of populations

Health systems firmly based on primary healthcare have been shown to achieve better health outcomes, improve health equality and be cost effective.2

Integrating the foundation skills of general practice into a comprehensive care approach - key principles

The foundations of general practice need to be understood in the context of a complex, integrated totality that reflects the whole patient, their environment, and how these interact with each other.

The following key principles are the specific skills necessary for quality general practice care.

The quotes after the key foundation principle expresses this concept as a GP might describe them, followed by the key skills required to demonstrate these principles.

While the skills are listed individually, every element needs to be integrated into the whole of general practice to meet the aim of comprehensive care.

The patient is the centre of concern

'It is important to know my patients. I am more concerned about patients as individuals than about the disease. I take my patients' beliefs, circumstances and concerns into account when deciding what to prescribe or when and where to refer them.'

This principle requires GPs to:

  • demonstrate respect for patient autonomy
  • work in partnership with the patient as determined by the needs of the patient
  • negotiate management plans in terms of the patient's preferences and priorities.

The patient-doctor relationship is the basis of the therapeutic process

'It is important that patients can trust their GP. Sometimes more good is done by just listening.'

This principle requires GPs to:

  • develop communication skills to underpin effective diagnosis and management (eg. listening, reassuring, explaining, interpreting)
  • develop effective communication skills to build and maintain a therapeutic relationship
  • develop more specific counselling skills in different situations
  • foster continuity of care as determined by the needs of the patient
  • develop self awareness and boundaries.

Distinctive problem solving skills

'I know the community. I know the "horses and zebras". I often need to juggle several problems at a time. General practice is an art and a science.'

This principle requires GPs to:

  • relate the diagnostic process to the community context (eg. disease prevalence)
  • recognise serious and urgent problems
  • use time as a tool
  • tolerate uncertainty
  • collaborate with patients on acceptable management plans
  • integrate comorbidities into management decisions
  • use investigations and technology appropriately
  • integrate scientific evidence and other relevant factors toward a solution
  • move from one mode or role to another (eg. diagnostician, counsellor) as required by the problem at hand or by the patient's needs
  • engage in reflective practice.

Primary care management

'I am the first port-of-call. I have colleagues I can call on when I need to and I know the available services in the community.'

This principle requires GPs to:

  • deal with unselected and undifferentiated presentations
  • triage appropriately
  • work in teams
  • integrate the expertise of other healthcare providers
  • practise ongoing management of patients with chronic health problems.

Holistic perspectives

'I know this patient's background and it really influences how he is suffering now. I also know whether he can afford treatment.'

This principle requires GPs to:

  • take into account social, psychological, cultural and existential dimensions
  • be integrative rather than reductionist.

Comprehensive scope

'You never know who walks through the door. General practice care is more than dealing with the presenting complaint. At times it's difficult to know where to start.'

This principle requires GPs to:

  • recognise that the range of patients are not limited by age, gender, culture or health problem
  • diagnose and manage disease at any chronological stage in the process including:
    • health promotion
    • prevention
    • case finding
    • acute presentations
    • chronic illness
    • palliative care
  • know how to diagnose and manage a broad range of health conditions across multiple systems
  • diagnose and manage multiple morbidities or concerns in the one patient.

Community based context

'I meet patients where they live and take our community into account when planning their care.'

This principle requires GPs to:

  • be limited only by what may be managed in the particular community (not just primary care)
  • respond to the needs of community
  • adapt to the political context
  • mediate between medicine and community
  • understand the private practice context
  • work effectively within the healthcare system (eg. legal requirements for prescribing and legislative regulations).

Related curriculum areas

Refer also to the curriculum statement:

Training Outcome of the five domains of general practice

1. Communication skills and the patient-doctor relationship

PHIT1.1

Demonstrate respect for patient autonomy.

PHIT1.2

Work in partnership with the patient as determined by the needs of the patient.

PHIT1.3

Negotiate patient centred management plans that consider the patient's preference of treatment and priority of treatments.

PHIT1.4

Use communication skills to underpin effective diagnosis and management of the patient (eg. listening, reassuring, explaining, interpreting).

PHIT1.5

Use communication skills to build and maintain a therapeutic relationship between patient and doctor.

PHIT1.6

Apply specific counselling skills in different situations.

PHIT1.7

Foster continuity of care as determined by the needs of the patient.

PHIT1.8

Move from one mode to another (diagnostician, counsellor) as required by the problem at hand or the patient's needs

2. Applied professional knowledge and skills

PHIT2.1

Relate the diagnostic process to the community context when problem solving.

PHIT2.2

Recognise serious and urgent problems.

PHIT2.3

Use problem solving skills to collaborate with patients on acceptable management plans.

PHIT2.4

Integrate comorbidities when problem solving.

PHIT2.5

Use investigations and technology appropriately when problem solving.

PHIT2.6

Integrate scientific evidence and other relevant factors when problem solving.

PHIT2.7

Manage unselected and undifferentiated presentations.

PHIT2.8

Manage patients with chronic health problems.

PHIT2.9

Have a holistic perspective that is integrative rather than reductionist.

PHIT2.10

Be able to diagnose and manage a broad range of health conditions across multiple systems.

3. Population health and the context of general practice

PHIT3.1

Have a holistic perspective, taking into account the patient's social, psychological, cultural and existential dimensions.

PHIT3.2

Treat a wide range of patients not limited by age, gender, ethnicity or health problem.

PHIT3.3

Be able to diagnose and manage disease at any chronological stage in the process, including health promotion, prevention, case finding, acute presentations, chronic illness and palliative care.

PHIT3.4

Be limited only by what may be managed in the particular community (not just primary care).

PHIT3.5

Respond to the needs of the community.

PHIT3.6

Adapt to political priorities.

PHIT3.7

Mediate between medicine and community.

4. Professional and ethical role

PHIT4.1

Tolerate uncertainty when problem solving.

PHIT4.2

Have a capacity for self awareness and recognise boundaries in the patient-doctor relationship.

PHIT4.3

Practise reflective thinking when problem solving.

5. Organisational and legal dimensions

PHIT5.1

Use time as a tool when problem solving.

PHIT5.2

Triage appropriately when working in teams or integrating the expertise of other healthcare providers.

PHIT5.3

Work effectively within the healthcare system and know the rules for procedures (eg. prescribing).

PHIT5.4

Understand the private practice context.

Learning objectives across the GP professional life

Medical student

1. Communication skills and patient-doctor relationship

PHILM1.1

Describe the role of respect for patient autonomy in patient-doctor relationships when communicating with patients, and differences between hospital and primary care settings.

PHILM1.2

Describe the importance of working in partnership with patients, including negotiating patient centred management plans as determined by patient need, preferences and priorities, and differences between hospital and primary care settings.

PHILM1.3

Demonstrate the basic communication skills required to underpin effective diagnosis and management of the patient (listening, reassuring, explaining, interpreting) and fostering whole patient care, and describe differences in the hospital and primary care setting.

PHILM1.4

Describe the need to adapt counselling skills to the needs of different situations.

PHILM1.5

Describe the basis of continuity of patient care based on patient determined needs.

PHILM1.6

Outline the various roles of the clinician according to patient needs (eg. diagnostician, counsellor).

2. Applied professional knowledge and skills

PHILM2.1

Outline how to use problem solving skills to collaborate with patients on acceptable management plans.

PHILM2.2

Describe the skills required to recognise serious and urgent problems.

PHILM2.3

Outline the integration of comorbidities when problem solving.

PHILM2.4

Describe the appropriate role of investigations and technology in problem solving.

PHILM2.5

Outline how to integrate scientific evidence and other relevant factors when problem solving.

PHILM2.6

Outline how to deal with unselected and undifferentiated presentations.

PHILM2.7

Outline the management of patients with chronic health problems.

PHILM2.8

Describe the differences between an integrative and a reductionist holistic perspective.

PHILM2.9

Outline the skills required to diagnose and manage a broad range of health conditions across multiple systems.

3. Population health and the context of general practice

PHILM3.1

Outline how diagnostic processes relate to community context (eg. disease prevalence).

PHILM3.2

Describe a holistic perspective of primary healthcare that takes into account social, psychological, cultural and existential dimensions

PHILM3.3

Outline issues involved in treating a range of patients not limited by age, gender, ethnicity or health problem.

PHILM3.4

Outline the skills required to diagnose and manage disease at any chronological lifecycle stage, including health promotion, prevention, case finding, acute presentations, chronic illness and palliative care.

PHILM3.5

Describe how doctors can be responsive to community health needs.

4. Professional and ethical role

PHILM4.1

Outline how to manage uncertainty when problem solving in patient care settings.

PHILM4.2

Describe the role of capacity for self awareness and recognition of boundaries in the patient-doctor relationship.

PHILM4.3

Outline processes for reflective practice when problem solving.

5. Organisational and legal dimensions

PHILM5.1

Outline appropriate triage processes when working in teams or integrating the expertise of other healthcare providers.

PHILM5.2

Outline the structural elements of the health system that impact on clinical practice (eg. regulations for prescribing, other relevant medical legislation).

Prevocational doctor

1. Communication skills and patient-doctor relationship

PHILP1.1

Demonstrate respect for patient autonomy in patient-doctor communications with patients in the hospital setting.

PHILP1.2

Demonstrate the ability to work in partnership with patients, including negotiating patient centred management plans as determined by patient need, preferences and priorities in the hospital setting.

PHILP1.3

Demonstrate effective communication skills required to underpin effective diagnosis and management of the patient (listening, reassuring, explaining, interpreting) and fostering whole patient care in the hospital setting.

PHILP1.4

Demonstrate the ability to adapt counselling skills to different situations.

PHILP1.5

Demonstrate continuity of patient care based on patient determined needs in the hospital setting.

PHILP1.6

Demonstrate the ability to move between various roles of the clinician according to patient needs (eg. diagnostician, counsellor) in the hospital setting.

2. Applied professional knowledge and skills

PHILP2.1

Demonstrate the ability to recognise serious and urgent problems in the hospital setting.

PHILP2.2

Demonstrate how to use problem solving skills to collaborate with patients on acceptable management plans in the hospital setting.

PHILP2.3

Demonstrate the integration of comorbidities when problem solving in the hospital setting.

PHILP2.4

Demonstrate the appropriate use of investigations and technology in problem solving in the hospital setting.

PHILP2.5

Demonstrate the integration of scientific evidence and other relevant factors when problem solving in the hospital setting.

PHILP2.6

Demonstrate how to deal with unselected and undifferentiated presentations in the hospital situation.

PHILP2.7

Demonstrate the management of patients with chronic health problems in the hospital setting.

PHILP2.8

Demonstrate the use of an integrative holistic perspective in the hospital setting.

PHILP2.9

Demonstrate the ability to diagnose and manage a broad range of health conditions across multiple systems in the hospital system.

3. Population health and the context of general practice

PHILP3.1

Demonstrate diagnostic processes that relate to community context in the hospital setting (eg. disease prevalence).

PHILP3.2

Demonstrate the use of a holistic perspective that takes into account social, psychological, cultural and existential dimensions in the hospital setting.

PHILP3.3

Demonstrate the appropriate treatment of a range of patients not limited by age, gender, ethnicity or health problem in the hospital setting.

PHILP3.4

Demonstrate the diagnosis and management of diseases at any chronological stage in the process, including health promotion, prevention, case finding, acute presentations, chronic illness and palliative care in the hospital setting.

4. Professional and ethical role

PHILP4.1

Demonstrate diagnostic processes that relate to community context in the hospital setting (eg. disease prevalence).

PHILP4.2

Demonstrate tolerance of uncertainty when problem solving in the hospital setting.

PHILP4.3

Demonstrate self awareness and recognition of boundaries in the patient-doctor relationship.

PHILP4.4

Outline processes for reflective practice when problem solving in the hospital setting.

5. Organisational and legal dimensions

PHILP5.1

Demonstrate appropriate triage processes when working in teams or integrating the expertise of other healthcare providers in the hospital setting.

PHILP5.2

Demonstrate adherence to the structural elements of the health system that impact on hospital clinical practice (eg. regulations for prescribing and other relevant medical legislation).

Vocational registrar

1. Communication skills and patient-doctor relationship

PHILV1.1

Demonstrate respect for patient autonomy in patient-doctor communications with patients in the primary care setting.

PHILV1.2

Demonstrate the ability to work in partnership with patients, including negotiating patient centred management plans as determined by patient need, preferences and priorities in the primary care setting.

PHILV1.3

Demonstrate communication skills required to underpin effective diagnosis and management of the patient (listening, reassuring, explaining, interpreting) and fostering whole patient care in the primary care setting.

PHILV1.4

Demonstrate the ability to adapt counselling skills to different situations.

PHILV1.5

Demonstrate continuity of patient care based on patient-determined needs in the primary care setting.

PHILV1.6

Demonstrate the ability to move between various roles of the clinician according to patient needs (eg. diagnostician, counsellor) in the primary care setting.

2. Applied professional knowledge and skills

PHILV2.1

Demonstrate the ability to recognise serious and urgent problems in the primary care setting.

PHILV2.2

Demonstrate how to use problem solving skills to collaborate with patients on acceptable management plans in the primary care setting.

PHILV2.3

Demonstrate the integration of comorbidities when problem solving in the primary care setting.

PHILV2.4

Demonstrate the appropriate use of investigations and technology in problem solving in the primary care setting.

PHILV2.5

Demonstrate the integration of scientific evidence and other relevant factors when problem solving in the primary care setting.

PHILV2.6

Demonstrate how to deal with unselected and undifferentiated presentations in the primary care setting.

PHILV2.7

Demonstrate the management of patients with chronic health problems in the primary care setting.

PHILV2.8

Demonstrate the use of an integrative holistic perspective in the primary care setting.

PHILV2.9

Demonstrate the ability to diagnose and manage a broad range of health conditions across multiple systems in the primary care setting.

3. Population health and the context of general practice

PHILV3.1

Demonstrate diagnostic processes that relate to community context in the primary care setting (eg. disease prevalence).

PHILV3.2

Demonstrate use of a holistic perspective that takes into account social, psychological, cultural and existential dimensions in the primary care setting.

PHILV3.3

Demonstrate appropriate treatment of a range of patients not limited by age, gender, ethnicity or health problem in the primary care setting.

PHILV3.4

Demonstrate diagnosis and management of diseases at any chronological stage in the process including health promotion, prevention, case finding, acute presentations, chronic illness and palliative care in the primary care setting.

PHILV3.5

Demonstrate responsiveness to the local community health needs.

4. Professional and ethical role

PHILV4.1

Demonstrate tolerance of uncertainty when problem solving in the primary care setting.

PHILV4.2

Outline processes for reflective practice when problem solving in the primary care setting.

5. Organisational and legal dimensions

PHILV5.1

Demonstrate appropriate triage processes when working in teams or integrating the expertise of other healthcare providers in the primary care setting.

PHILV5.2

Demonstrate adherence to the structural elements of the health system that impact on primary care clinical practice (eg. regulations for prescribing and other relevant medical legislation).

Continuing professional development

1. Communication skills and patient-doctor relationship

PHILC1.1

Demonstrate regular reflection and skill review of understanding the foundation basis of patient communication skills.

2. Applied professional knowledge and skills

PHILC2.1

Demonstrate regular reflection and skill review of understanding the foundation basis of professional knowledge and skills.

3. Population health and the context of general practice

PHILC3.1

Demonstrate regular reflection and skill review with respect to changing population health and local community needs.

4. Professional and ethical role

PHILC4.1

Demonstrate regular reflection and skill review with respect to professional and ethical roles.

PHILC4.2

Consider ongoing education in conceptual basis of general practice, including more formal academic qualifications.

5. Organisational and legal dimensions

PHILC5.1

Demonstrate review of patient continuity issues according to patient-determined needs.

PHILC5.2

Demonstrate adherence to the structural elements of the health system that impact on hospital clinical practice (eg. regulations for prescribing and other relevant medical legislation).

PHILC5.3

Demonstrate knowledge of changes to structural elements of the health system that impact on hospital clinical practice (eg. regulations for prescribing and other relevant medical legislation).

References

  1. MacWhinney IR. Family medicine in perspective. N Engl J Med 1975;293(4):176–81.
  2. Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970–1998. Health Serv Res 2003;38(3):831–65.

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