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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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Undifferentiated condititions

Definition

Undifferentiated conditions refer to ambiguous, uncertain, unexplained and undiagnosed symptoms, problems, conditions and illnesses presenting to the clinician.

The causes and management of undifferentiated conditions may become clearer through history, examination or investigations, or may become clearer over time as a disease process progresses. For example, a connective tissue disease such as systemic lupus erythematosus may first present as tiredness, but further investigation or the passage of time may result in the diagnosis becoming clearer. Similarly, the cause of an initial presentation of undiagnosed chest pain would become apparent if a dermatomal rash developed after 1 day, ie. herpes zoster.

Some undifferentiated conditions remain undiagnosed despite thorough assessment and investigation.

Some undifferentiated conditions may have a psychological origin, which presents potential challenges to patient safety because of the potential for missed, delayed or wrong diagnosis.

Curriculum in practice

The following presentation illustrates how the undifferentiated conditions curriculum applies to general practice:

  • Mary, 55 years of age, presents feeling tired and run down but vaguely suggests that she may be lonely now that her children have left home. She finds herself heading to bed around 9 pm and sleeping through until 8 am but without feeling refreshed. With no family to cook for, she has lost her appetite, has began to skip meals and thinks she may have lost weight. She thinks that is why she now feels the cold more. Her periods have become progressively lighter and she has noticed she doesn't need to shave her armpits as often and puts it down to 'change of life'. She thinks she will take up exercise and has begun walking every morning and although her skin has become quite tanned she remains feeling unfit and lacking in energy. At work it is hard to concentrate and she catches herself just staring vacantly. She is wondering if she might be depressed. Her blood pressure is BP 95/60 mmHg and physical examination is unremarkable.

Rationale and general practice context

Undifferentiated conditions are very likely to present in general practice. For example, the presentation of nonspecific weakness or tiredness is common in general practice and is the fifth commonest reason for initiating further pathology investigations in Australian general practice.1

General practitioners are primarily diagnosticians2 and are highly experienced at managing undifferentiated conditions.

These conditions challenge diagnostic skills and clinical decision making processes, which aim to discover serious illness at an appropriately early stage while minimising over-investigation of patients.3 The expertise in dealing with undifferentiated conditions places general practitioners in an ideal situation to educate and train other clinicians in this skill area, especially patient safety and situations of missed diagnoses.

Important differences exist between primary care and secondary/tertiary care medicine, with distinct differences between the patients, pathologies and presentations encountered by the GP compared to a specialist colleague.

Conditions seen in general practice are often evolving, and text book descriptions and classifications often do not apply.

Early presentations of many illnesses defy categorisation because they may be transient and self limiting, or are treated early, before reaching the stage of traditional diagnosis.

General practitioners may also have a different focus from specialists, with a management plan often having to be formulated without a precise diagnosis. A diagnosis may be framed in terms of dichotomous decisions: treatment versus nontreatment, referral versus nonreferral, and serious versus nonserious. For example, back pain may be successfully treated empirically in the absence of 'red flags', without an expectation of ever investigating further or confirming a diagnosis.2

The range of common undifferentiated conditions in general practice is large and includes such presentations as fatigue, insomnia, stress, dizziness, headache, anorexia, nausea, sexual difficulty, weight loss, apathy and abdominal discomfort.4

Understanding the role of the passage of time and knowledge of the natural history of these conditions are key in managing undifferentiated conditions.3

Undifferentiated conditions are commonly associated with clinical uncertainty and ambiguity, which presents management challenges for the clinician, including how to communicate these uncertainties to patients.2 5

The role of uncertainty in clinical outcomes is not clear. Uncertainty in clinical decision making has been linked to potential and actual adverse outcomes in patient care in the prevocational setting.6 While one study of uncertainty in primary care physicians did not demonstrate differences in patient outcomes, physicians changed their approaches to information seeking.7

Clinical strategies for managing undifferentiated conditions need to adopt a 'fail-safe' strategy,8 including regular review of the presentation, and recognising that some symptoms and presentations may never be attributed to specific conditions.

The potential for diagnostic uncertainty is compounded by somatisation, when psychological conditions present as physical symptoms. Clinicians need to remain alert to this potential and develop clear strategies for delineating physical and psychological components of the presenting conditions. Effective and appropriate management of somatisation may also require a multidisciplinary approach and professional support to ensure that diagnoses are not being missed.9 10

Being clear about decisions and referring to evidence during the history taking, examination and investigations help maximise diagnostic effectiveness and patient safety and minimise over-investigation. This includes familiarity with serious conditions that must not be missed, conditions commonly missed and conditions that may present with unusual or elusive symptoms. Evidence based approaches to assessment and management10 can help to clarify and strengthen decision making.

Develop familiarity with the disease patterns specific to the geographical areas of practice may help discern local variations in disease presentations and diagnoses compared with other regions. For example, higher than average presentations of hay fever in spring may be due to local pollen conditions.

Communication skills are critical to characterising undifferentiated conditions and to communicating management outcomes to patients.

Patients with limited capacity to give complete histories, for example, children, patients with dementia or some patients with disabilities, may need family, friends and carers to be consulted for further clarification. Clinicians need to observe confidentiality and the legal status of carers or guardians, and the potential for carers or guardians to abuse or misuse of the position by deliberately providing incorrect and misleading information concerning the patient.

Uncertainty can be a source of considerable anxiety for patients, and learning to manage this is a key general practice skill. Communication skills are the key to successful outcomes in managing undifferentiated conditions of a psychogenic origin.

Related curriculum areas

Undifferentiated conditions affect many other curriculum statement areas, but in particular:

Training Outcome of the five domains of general practice

1. Communication skills and the patient-doctor relationship

UNDT1.1

Communicate clearly to help characterise symptoms as part of a diagnostic and management strategy for undifferentiated conditions in the general practice setting.

UNDT1.2

When appropriate, take a history from family, carers and others, for example when patients are unable to give clear histories.

UNDT1.3

Counsel patients safely and appropriately when managing uncertainty in diagnosis and management.

2. Applied professional knowledge and skills

UNDT2.1

Use skilful history taking, examination processes and appropriate investigations when managing undifferentiated conditions in the primary care setting.

UNDT2.2

Be familiar with early presentations of evolving conditions, their natural history and the impact of early treatment to help characterise undifferentiated conditions in the general practice setting.

UNDT2.3

Manage any uncertainties that may arise in undifferentiated conditions that remain unexplained and undiagnosed despite thorough assessment and investigation.

UNDT2.4

Use safe diagnostic strategies to minimise the risk of missed, delayed or wrong diagnoses.

UNDT2.5

Understand how appropriate diagnostic tests reduce diagnostic uncertainty and help minimise inappropriate investigations.

UNDT2.6

Diagnose and manage psychological factors in undifferentiated conditions.

UNDT2.7

Implement periodic review of the undifferentiated problem to be alert to potential changes and development of symptoms and signs.

3. Population health and the context of general practice

UNDT3.1

Understand that undifferentiated conditions are common in the general practice setting.

UNDT3.2

Be familiar with common patterns of presentations of undifferentiated illnesses including transient and self limiting diseases and new complaints in patients with chronic disease.

UNDT3.3

Be familiar with the patterns of serious ('red flag') conditions that should not be missed, difficult to diagnose conditions and common conditions that present as undifferentiated conditions.

UNDT3.4

Understand that some undifferentiated conditions may have a psychological origin, and the potential challenges this may present to patient safety because of the potential for diagnostic errors.

4. Professional and ethical role

UNDT4.1

Be aware of clinical decision making processes and the potential pitfalls in the diagnosis of undifferentiated conditions.

UNDT4.2

Understand that primary care patients present with differing patterns of undifferentiated conditions compared to those presenting in the secondary/tertiary setting.

UNDT4.3

Consider the role of experienced general practitioners in training registrars and others in the management of undifferentiated conditions. This includes teaching patient safety approaches to prevent missed, delayed or wrong diagnoses.

5. Organisational and legal dimensions

UNDT5.1

When appropriate, work with multidisciplinary teams to successfully characterise and manage undifferentiated conditions.

UNDT5.2

Consider the legal implications of potential diagnostic errors and seek appropriate and timely advice.

Learning objectives across the GP professional life

Medical student

1. Communication skills and patient-doctor relationship

UNDLM1.1

Discuss the ability to clearly characterise symptoms of undifferentiated conditions.

UNDLM1.2

Discuss the ability to counsel patients when managing uncertainty of diagnosis and management.

2. Applied professional knowledge and skills

UNDLM2.1

Describe the role of history, examination and appropriate investigations in managing undifferentiated conditions.

UNDLM2.2

Discuss the decision making processes involved in making a diagnosis.

UNDLM2.3

Discuss fail-safe diagnostic strategies.

UNDLM2.4

Describe the role of appropriate diagnostic tests in reducing diagnostic uncertainty.

UNDLM2.5

Describe the role of diagnosis in patient management when dealing with undifferentiated conditions.

UNDLM2.6

Describe the factors that affect the presentation of undifferentiated conditions such as patient and environmental factors, and the natural history of a disease including transient and self limiting conditions.

UNDLM2.7

Describe how early treatment can influence the natural history and presentations of disease.

UNDLM2.8

Describe how psychological factors impact on undifferentiated conditions and their potential challenges to patient safety including diagnostic errors.

UNDLM2.9

Outline management options when undifferentiated conditions remain undiagnosed despite thorough assessment and investigation.

UNDLM2.10

Describe processes for counselling a patient when there is uncertainty regarding diagnosis and management.

3. Population health and the context of general practice

UNDLM3.1

Outline the pattern of common presentations of undifferentiated conditions in the hospital and general practice setting.

UNDLM3.2

Describe important presentations in undifferentiated conditions that should not be missed.

UNDLM3.3

Describe the differences in disease presentations and management between primary care and secondary/tertiary care medicine.

UNDLM3.4

Describe common patterns of psychological conditions that relate to the presentation of undifferentiated conditions.

4. Professional and ethical role

UNDLM4.1

Describe appropriate professional behaviours when managing undifferentiated conditions.

UNDLM4.2

Describe professional differences in diagnostic and management decision making between GPs and specialists.

UNDLM4.3

Describe the impact of uncertainty for the patient and doctor in clinical decision making, and the potential for missed, delayed or wrong diagnosis.

5. Organisational and legal dimensions

UNDLM5.1

Describe the multidisciplinary approaches managing undifferentiated conditions.

UNDLM5.2

Describe the legal pitfalls and implications of managing undifferentiated conditions.

Prevocational doctor

1. Communication skills and patient-doctor relationship

UNDLP1.1

Demonstrate the ability to clearly characterise symptoms of undifferentiated conditions.

UNDLP1.2

Demonstrate the ability to counsel patients when managing uncertainty of diagnosis and management.

2. Applied professional knowledge and skills

UNDLP2.1

Demonstrate the ability to take a history, examine and appropriately investigate in managing undifferentiated conditions.

UNDLP2.2

Demonstrate fail-safe diagnostic strategies.

UNDLP2.3

Request appropriate diagnostic tests to reduce diagnostic uncertainty.

UNDLP2.4

Identify specific factors that affect the presentation of undifferentiated conditions.

UNDLP2.5

Identify psychological factors in undifferentiated conditions.

UNDLP2.6

Identify possible diagnoses that need to be excluded in undifferentiated conditions.

UNDLP2.7

Discuss management options when undifferentiated conditions remain undiagnosed despite thorough assessment and investigation.

UNDLP2.8

Demonstrate the ability to counsel a patient when there is uncertainty regarding diagnosis and management.

3. Population health and the context of general practice

UNDLP3.1

Describe the pattern of common presentations of undifferentiated conditions in their current workplace(s).

UNDLP3.2

Describe the patterns of commonly missed conditions in undifferentiated conditions in their current workplace(s).

UNDLP3.3

Describe the patterns of important conditions that should not be missed in undifferentiated conditions in their current workplace(s).

UNDLP3.4

Describe common patterns of psychological conditions that relate to the presentation of undifferentiated conditions in their current workplace(s).

4. Professional and ethical role

UNDLP4.1

Demonstrate appropriate professional behaviours when managing undifferentiated conditions.

UNDLP4.2

Describe the impact of uncertainty in clinical decision making and the potential for missed, delayed or incorrect diagnoses in specific cases of undifferentiated conditions currently being managed.

5. Organisational and legal dimensions

UNDLP5.1

Describe the multidisciplinary approaches for the management of undifferentiated conditions in their current workplace(s).

UNDLP5.2

Describe the legal pitfalls and implications of managing undifferentiated conditions in their current workplace(s).

Vocational registrar

1. Communication skills and patient-doctor relationship

UNDLV1.1

Demonstrate the ability to clearly characterise symptoms of undifferentiated conditions in the primary care setting.

UNDLV1.2

Demonstrate the ability to counsel patients when managing uncertainty of diagnosis and management in the primary care setting.

2. Applied professional knowledge and skills

UNDLV2.1

Demonstrate the ability to take a history, examine and appropriately investigate in managing undifferentiated conditions in the primary care setting.

UNDLV2.2

Demonstrate fail-safe diagnostic strategies in the primary care setting.

UNDLV2.3

Request appropriate diagnostic tests to reduce diagnostic uncertainty in the primary care setting.

UNDLV2.4

Identify specific factors that affect the presentation of undifferentiated conditions in the primary care setting.

UNDLV2.5

Identify psychological factors impacting upon undifferentiated conditions in the primary care setting.

UNDLV2.6

Identify possible diagnoses that need to be excluded in undifferentiated conditions in the primary care setting.

UNDLV2.7

Discuss management options when undifferentiated conditions remain undiagnosed despite thorough assessment and investigation in the primary care setting.

UNDLV2.8

Demonstrate the ability to counsel a patient when there is uncertainty regarding diagnosis and management in the primary care setting.

3. Population health and the context of general practice

UNDLV3.1

Describe the pattern of common presentations of undifferentiated conditions specific to the current primary care setting.

UNDLV3.2

Describe the patterns of commonly missed conditions in undifferentiated conditions specific to the current primary care setting.

UNDLV3.3

Describe the patterns of important conditions that should not be missed in undifferentiated conditions specific to the current primary care setting.

UNDLV3.4

Describe common patterns of psychological conditions that relate to the presentation of undifferentiated conditions in the primary care setting.

4. Professional and ethical role

UNDLV4.1

Demonstrate appropriate professional behaviours when managing undifferentiated conditions in the primary care setting.

UNDLV4.2

Describe the impact of uncertainty in clinical decision making and the potential for missed, delayed or wrong diagnosis in specific cases of undifferentiated conditions being managed in the primary care setting.

UNDLV4.3

Identify professional supports and mentors in the primary care setting for acquiring skills in the management of undifferentiated conditions (eg. colleagues, supervisors).

5. Organisational and legal dimensions

UNDLV5.1

Describe the multidisciplinary approaches for the management of undifferentiated conditions in the primary care setting.

UNDLV5.2

Describe the legal pitfalls and implications of managing undifferentiated conditions in the primary care setting.

Continuing professional development

1. Communication skills and patient-doctor relationship

UNDLC1.1

Demonstrate maintenance of competency in characterising symptoms of undifferentiated conditions in the primary care setting.

UNDLC1.2

Demonstrate maintenance of competency in counselling patients when managing uncertainty of diagnosis and management in the primary care setting.

2. Applied professional knowledge and skills

UNDLC2.1

Demonstrate maintenance of skill competencies in the assessment and management of undifferentiated conditions.

UNDLC2.2

Request appropriate diagnostic tests to reduce diagnostic uncertainty in the primary care setting.

3. Population health and the context of general practice

UNDLC3.1

Describe any trends in patterns of common presentations of undifferentiated conditions specific to their current primary care setting.

UNDLC3.2

Describe any trends in commonly missed conditions in undifferentiated conditions specific to their current primary care setting.

UNDLC3.3

Describe any trends in patterns of important conditions that should not be missed in undifferentiated conditions specific to their current primary care setting.

4. Professional and ethical role

UNDLC4.1

Demonstrate appropriate professional behaviours when managing undifferentiated conditions in the primary care setting.

UNDLC4.2

Outline professional processes for dealing with uncertainty in clinical decision making and the potential for missed, delayed or wrong diagnosis in specific cases of undifferentiated conditions currently being managed in the primary care setting.

UNDLC4.3

Identify professional supports and mentors within the primary care setting for acquiring skills in the management of undifferentiated conditions (eg. colleagues, supervisors).

UNDLC4.4

Consider a role in training registrars and others in the management of undifferentiated conditions in the general practice setting, for example, colleagues, supervisors and others. This includes teaching patient safety approaches to prevent missed, delayed or wrong diagnoses.

UNDLC4.5

Consider further training in psychological management of undifferentiated conditions (eg. somatisation disorders).

5. Organisational and legal dimensions

UNDLC5.1

Describe current practice processes for the multidisciplinary management of undifferentiated conditions.

UNDLC5.2

Describe the legal pitfalls and risk management processes in place in the current workplace with respect to undifferentiated conditions.

References

  1. Britt HMG, Charles J, Henderson J, et al. General practice activity in Australia 2009–10. Canberra: Australian Institute of Health and Welfare; 2010.
  2. Summerton N. Diagnosis and general practice. Br J Gen Pract 2000;50(461):995–1000.
  3. Green C, Holden J. Diagnostic uncertainty in general practice. A unique opportunity for research? Eur J Gen Pract 2003;9(1):13–5.
  4. Frith J, Knowlden S. Undifferentiated illness. Med J Aust 1992;156(7):472–6.
  5. Seaburn DB, Morse D, McDaniel SH, Beckman H, Silberman J, Epstein R. Physician responses to ambiguous patient symptoms. J Gen Intern Med 2005;20(6):525–30.
  6. Farnan JM, Johnson JK, Meltzer DO, Humphrey HJ, Arora VM. Resident uncertainty in clinical decision making and impact on patient care: a qualitative study. Qual Saf Health Care 2008;17(2):122–6.
  7. McKibbon KA, Fridsma DB, Crowley RS. How primary care physicians' attitudes toward risk and uncertainty affect their use of electronic information resources. J Med Libr Assoc 2007;95(2):138–46, e49–50.
  8. Murtagh J. A safe diagnostic strategy. Murtagh's General Practice. 5th edn. North Ryde: McGraw-Hill Australia, 2011.
  9. Stone L. Reasoning for registrars: an overview for supervisors and medical educators. Aust Fam Physician 2008;37(8):650–3.
  10. Stone L, Clarke DM. Somatising disorders: untangling the pathology. Aust Fam Physician 2007;36(4):234–9.

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