Assessment Objectives for Certification in

Family Medicine

2nd Edition

May 2020
© 2020 The College of Family Physicians of Canada

All rights reserved. This material may be reproduced in full for educational, personal, and non-commercial use
only, with attribution provided according to the citation information below. For all other uses permission must
be acquired from the College of Family Physicians of Canada.

Suggested citation: Crichton T, Schultz K, Lawrence K, Donoff M, Laughlin T, Brailovsky C, Bethune C, van
der Goes T, Dhillon K, Pélissier-Simard L, Ross S, Hawrylyshyn S, Potter M. Assessment Objectives for
Certification in Family Medicine. Mississauga, ON: College of Family Physicians of Canada; 2020
Contents

Preface to the Second Edition....................................................................................................................................... 1

Executive Summary ......................................................................................................................................................... 6
Part I—The evaluation objectives: what are they, where do they come from, and how can they be
used? ..................................................................................................................................................................................... 8
Part II—Essential Skills, Themes, and Observable Behaviours .......................................................................30
Part III: Priority Topics and Key Features............................................................................................................57
Appendices .................................................................................................................................................................... 172
Preface to the Second Edition
Similar to the first edition, this second edition of the document formerly titled Defining Competence for the
Purposes of Certification by the College of Family Physicians of Canada: Evaluation Objectives in Family Medicine
describes the essential skills and observable competencies that are expected from residents at the end of their
training, and as such, serves as a major guide to both in-training assessment and the content of the Certification
Examination.

The original version of the document 1, published in 2010, was envisioned as a living document that would be
updated and enhanced to respond to the evolving nature of family medicine practice. The Working Group on
the Certification Process 2, which evolved into the Certification Process and Assessment Committee (CPAC) 3,
was tasked with the continuous maintenance of the document.

To minimize disruption on family medicine programs and residents, several updates made over the last five
years have been coalesced and are all being released in this new edition.

The following changes and additions were made in this second edition:

1. Renaming the document Assessment Objectives for Certification in Family Medicine in English (The
French name remains unchanged). This change reflects usage in English medical education literature,
where training programs are evaluated for their efficacy, but individuals in those programs are assessed
for competence.
2. Six new priority topics. The decision to add these new topics is based on responses to the 2014
validation survey, sent to 2,000 practicing family physicians across the country. Thus, we have grown
from 99 to 105 priority topics, which now include: Chronic Pain, Heart Failure, Pain, Rash, Renal
Failure, and Shortness of Breath.
3. Updated key features for 16 existing mental health related priority topics based on work completed
by the Working Group on the Assessment of Competence in Mental Health 4. Priority Topic name
Substance Abuse was changed to Substance Use and Addiction, following a change in terminology.
4. Changed French translation for 8 priority topic names, based on changes in terminology and/or
updates to their key features.
5. Three supplementary documents are now integrated into the Assessment Objectives document as
appendices. These are:
• Priority Topics and Key Features for Rural and Remote Family Medicine 5

1 Defining competence for the purposes of certification by the College of Family Physicians of Canada: Evaluation Objectives in
Family Medicine: College of Family Physicians of Canada; 2010
2 Authors of the original 2010 document: Tim Allen, MD; Cheri Bethune, MD; Carlos Brailovsky, MD; Tom Crichton, MD; Michel

Donoff, MD; Tom Laughlin, MD; Kathrine Lawrence, MD; Stephen Wetmore, MD
3 CPAC members who contributed to the updated version: Cheri Bethune, MD; Carlos Brailovsky, MD; Tom Crichton, MD; Kiran

Dhillon, MD; Michel Donoff, MD; Theresa van der Goes, MD; Steven Hawrylyshyn, MD; Tom Laughlin, MD; Kathrine Lawrence,
MD; Luce Pelissier-Simard, MD; Martin Potter, MD; Shelley Ross, PhD; Karen Schultz, MD
4 Working Group on the Assessment of Competence in Mental Health: Ellen Anderson, MD; Marie Hayes, MD; Garey

Mazowita, MD; Peter Selby, MD; Vicky Winterton, MD

5 Working Group on the Assessment of Competence in Rural and Remote Family Medicine: Elaine Blau, MD; Garth Campbell,

MD; Claudette Chase, MD; Paul Dhillon, MD; Brian Geller, MD; Fred Janke, MD; C. Stuart Johnston, MD; Mohamed Ravalia, MD;
Hélène Rousseau, MD
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 Preface

• Priority Topics and Key Features for Intrapartum and Perinatal Care 6
• Priority Topics and Key Features for Mental Health (other than those that overlap with the
existing priority topics for family medicine)
These supplementary documents are available to be used as resources that can guide in-training assessment and
design of learning opportunities for residents in family medicine residency programs.

A conscious choice has been made to keep the overall structure and purpose of this second edition the same as
the first edition. We did not change Part I and Part II of the first edition. There are language choices from the
first edition left unchanged for clarity purposes – for example the term “evaluation objectives” in Part I and Part
II. We are aware that the whole document needs to be reviewed and its terminology revised and updated. The
review will happen over time, but changes will only be made in five to seven-year cycles to minimize training
program impacts and program resource implications.

As with the first edition, this second edition provides an extensive list of competencies in family medicine,
extending far beyond the mere listing of important medical knowledge. We urge all readers to read (or re-read)
and focus on Part 1, as its framing of what is important to assess, especially the overarching Skill Dimensions of
Competence, remains crucial and relevant to the assessment of future family physicians today (namely, Clinical
Reasoning, Selectivity, Patient-Centred Approach, Communication, Professionalism and Procedures).

We continue to describe competencies in terms of their most salient key features and observable behaviours.
We emphasize that each competency is specific to the situation’s context and to the phases of the clinical
encounter; furthermore, each competency is linked back to the appropriate skill dimensions reinforcing this
essential relationship.

The CFPC’s 2018 Standards of Accreditation for Residency Programs in Family Medicine 7 indicate that the
goal of training is to produce a candidate who is competent to enter and adapt to the independent (i.e.,
unsupervised) practice of comprehensive family medicine 8 anywhere in Canada.

Through continuous observational sampling, utilising the key features and reflection on a resident’s behaviours
and performances, assessors need to be eventually satisfied that a resident displays competency in all six
essential skill dimensions of family medicine. Besides in-training assessment, the College of Family Physicians
of Canada will continue to use the document as a foundation for examination content.

Awarding Certification in the College of Family Physicians (CCFP) is the responsibility of the CFPC’s Board
of Examinations and Certification. This decision is the end result of three discrete, but linked, decisions. The
first is a candidate’s qualifying to sit the examination, either through the decision by a training program to
recommend a resident as ready to sit the Certification Examination, or by meeting the requirements of the
Practice Eligible Route. The second is obtaining a pass on the Certification Examination in Family Medicine.
The third is successfully completing all post-examination requirements, either the requirements of their

6 Working Group on the Assessment of Competence in Maternity and Newborn Care: Anne Biringer, MD; William Ehman, MD;
Shanna Fenton, MD; Lisa Graves, MD; Andrée Gagnon, MD; Kathrine J. Miller, MD; Sharon Northorp, MD
7 Standards of Accreditation for Residency Programs in Family Medicine. Mississauga, ON: College of Family Physicians of

Canada; 2018
8 Comprehensive family medicine as defined by the Family Medicine Professional Profile, Mississauga, Ontario: College of Family

Physicians of Canada; 2018

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 Preface

residency-training program or any practice eligible requirements set by the CFPC, within the Board of
Examinations and Certification’s prescribed timelines.

For further details about competence-based assessment and its components, please refer to the College’s 2018
Continuous Reflective Assessment for Training (CRAFT) document 9.

9Continuous Reflective Assessment for Training (CRAFT): A national programmatic assessment model for family medicine.
Mississauga, ON: College of Family Physicians of Canada; 2018

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 Preface

Priority Topics

New priority topics have been bolded and the ones with updated key features are marked by an asterisk. Topics
with an updated translation into French are marked by (F).

1. Abdominal Pain 39. Fatigue

2. Advanced Cardiac Life Support 40. Fever
3. Allergy 41. Fractures
4. Anemia 42. Gastro-intestinal Bleed
5. Antibiotics 43. Gender Specific Issues (F)
6. Anxiety* 44. Grief*
7. Asthma 45. Headache
8. Atrial Fibrillation 46. Heart Failure
9. Bad News 47. Hepatitis
10. Behavioural Problems* (F) 48. Hyperlipidemia (F)
11. Breast Lump 49. Hypertension
12. Cancer 50. Immigrants
13. Chest Pain 51. Immunization
14. Chronic Disease 52. In Children
15. Chronic Obstructive Pulmonary Disease 53. Infections
16. Chronic Pain 54. Infertility
17. Contraception 55. Insomnia*
18. Cough 56. Ischemic Heart Disease
19. Counselling* (F) 57. Joint Disorder
20. Crisis* 58. Lacerations
21. Croup (F) 59. Learning (Patients/Self) (F)
22. Deep Venous Thrombosis 60. Lifestyle
23. Dehydration 61. Loss of Consciousness
24. Dementia* 62. Loss of Weight
25. Depression* 63. Low-back Pain
26. Diabetes 64. Meningitis
27. Diarrhea 65. Menopause
28. Difficult Patient 66. Mental Competency* (F)
29. Disability 67. Multiple Medical Problems
30. Dizziness 68. Neck Pain
31. Domestic Violence 69. Newborn
32. Dyspepsia 70. Obesity
33. Dysuria 71. Osteoporosis
34. Earache 72. Pain
35. Eating Disorders* 73. Palliative Care
36. Elderly 74. Parkinsonism
37. Epistaxis 75. Periodic Health Assessment/Screening
38. Family Issues 76. Personality Disorder*

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 Preface

77. Pneumonia 92. Somatization*

78. Poisoning 93. Stress
79. Pregnancy 94. Stroke
80. Prostate 95. Substance Use and Addiction*
81. Rape/Sexual Assault 96. Suicide*
82. Rash 97. Thyroid
83. Red Eye 98. Trauma
84. Renal Failure 99. Travel Medicine
85. Schizophrenia* 100. Upper Respiratory Tract Infection
86. Seizures 101. Urinary Tract Infection
87. Sex* (F) 102. Vaginal Bleeding
88. Sexually Transmitted Infections 103. Vaginitis
89. Shortness of Breath 104. Violent/Aggressive Patient
90. Skin Disorder 105. Well-baby Care
91. Smoking Cessation

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 Executive Summary

Executive Summary
The Domain of Competence in Family Medicine

There are four major components in this definition:

1. Skill Dimensions of Competence
2. Phase of the Clinical Encounter
3. Priority Topics, Core Procedures, and Themes
4. Key Features and Observable Behaviours
Together they constitute the domain of competence in family medicine. Overall competence is determined
through a process of continuous sampling, observation, and reflection of learner performance with respect to
key features and observable behaviours for a series of problems (priority topics, procedures, themes),
throughout the phases of the clinical encounter, until evaluators are satisfied that the physician is competent in
all the skill dimensions.

The Components of the Evaluation Objectives:

1. Skill Dimensions of Competence: There are six essential skills that enable the family physician to deal
competently with problems in the domain of family medicine. The competent family physician has the
potential to use all the skills for any problem, but competence is also characterized by adapting the choice of
the skills used to the specific needs of the problem at hand.
a) Patient-centred approach: This is a hallmark of family medicine and represents one of the most efficient
and effective methods for dealing with problems. The details of the method are well established in the
literature, and the evaluation objectives for this dimension of competence are derived directly from this
information.
b) Communication skills: Certain skills and behaviours facilitate communication, and good
communication is essential for competence. Communication can be written or verbal, with patients or
colleagues; it also involves listening and watching as much as or more than talking and showing.
c) Clinical reasoning skills: This dimension focuses on the problem-solving skills used to deal with the
“medical aspects” of a problem. Although obviously knowledge dependent, many of the difficulties in
this dimension are related to poor process (the how and why). Assessment of these processes is more
important than assessing the final results or answers.
d) Selectivity: This dimension has not, to our knowledge, been described with respect to physician
competence. It describes a set of skills cited as characterizing the competent family physician: such a
physician does not do things in a routine fashion, but is selective in their approach, adapting it to the
situation and patient. This physician sets priorities and focuses on the most important, knowing when
to say something and when not to, gathering the most useful information without losing time on less
contributory data, or doing something extra when it will be helpful. It is perhaps a subset of all the
other dimensions, but it was used frequently enough to merit its own dimension.
e) Professionalism: This dimension was the most frequently cited in the descriptions of competence. It
includes all the responses that dealt with respect and responsibility to patients, to colleagues, to oneself,
to the profession, and to society. It includes ethical issues, as well as lifelong learning and the
maintenance of quality of care. It also includes attitudinal aspects such as caring and compassion.
f) Procedure skills: In the initial survey, specific procedures themselves were not often cited as being
characteristic of competence. It was recognized, however, that an individual about to enter independent
practice should be able to competently perform certain procedures. A working group on procedure

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 Executive Summary

skills identified 65 core procedures; assessment of competence in this dimension will be based on these
as well as general key features developed for procedure skills.

2. Phase of the Clinical Encounter: This component plays an essential role in directing assessment toward
the cognitive processes most critical to the competent resolution of a specific problem or situation. It
covers the steps or phases from the beginning to end of a clinical encounter. It includes the processes
usually identified with a hypothetico-deductive model of clinical problem solving, and with clinical
decision making.
a) Hypothesis generation (preliminary differential diagnosis)
b) History (gather the appropriate information)
c) Physical examination (gather the appropriate information)
d) Investigation (gather the appropriate information)
e) Diagnosis, including problem identification (interpret information)
f) Treatment (or management)
g) Follow-up
h) Referral

3. Priority Topics, Core Procedures, and Themes: These constitute a list of the problems or situations that
the competent family physician should be able to deal with at the start of independent practice. This list
sets out and limits the content of competence in family medicine for the purposes of certification. The
limits permit all concerned to concentrate their efforts, and the scope reassures us that overall competence
can be reasonably inferred if assessment has been based on an adequate sampling of this content.
a) Priority topics: This list was generated from the responses in the original survey. It includes diagnoses,
symptoms, presentations, and tasks; there are also roles (periodic health/screening), groups
(immigrants, newborn, elderly), issues (lifestyle), situations (family issues, difficult patients), and even
some topics (antibiotics).
b) Core procedures: Competence in this dimension is not limited to the technical skills required for the 65
core procedures. Other aspects, such as indications and contraindications, deciding to do or not to do a
procedure, and choosing among several possible approaches should also be assessed. With this in mind,
a key feature analysis was undertaken to identify the critical aspects of competence applicable to all
procedures.
c) Themes: The dimensions of the patient-centred approach, professionalism, and communication skills
were not sufficiently defined by the key feature analysis of the priority topics. An additional iterative, a
focus-group approach, using information from a variety of sources as inspiration, was used to develop a
series of themes to organize the description of competence for each of these three dimensions.
4. Key Features and Observable Behaviours: These are the operational evaluation objectives describing
competence in relatively objective and observable terms. This component is most useful for the assessment
of competence during daily clinical supervision.
a) Key features: Each priority topic underwent analysis to generate the key features for the topic. Key
features are the specific situations most determinant of competence within a topic and the critical
processes involved in dealing competently with each situation. They are determined by a group of
practicing peers using a reflective, iterative process. Each key feature identifies the skill dimensions and
phases of the clinical encounter that are to be used in assessing the competence for the situation and
task in question.
b) Observable behaviours: For each of the themes identified for communication skills and professionalism,
an iterative process analogous to the key feature analysis was used to identify behaviours indicative of
competence, or lack of it, for each theme. While the key feature analysis identifies a subset of
situations thought to be indicative of overall competence for a topic, the observable behaviour analysis
lists all behaviours potentially indicative of competence, and no particular subset is identified as being
most critical to competence for the theme or the dimension in question.
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 Part 1—The evaluation objectives

Part I—The evaluation 10 objectives: what are

they, where do they come from, and how can
they be used?

Introduction .......................................................................................................................................................................9
I. An overview of the structure and the components of this definition of competence .....................9
II. Some theoretical and further practical considerations in defining competence and in designing
successful evaluations.................................................................................................................................................... 12
III. Further details on the nature of the evaluation objectives, and how they were derived.............. 15
IV. Using the evaluation objectives ................................................................................................................... 27

10 For consistency purposes, we have decided to keep the terminology used in the first edition

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 Part 1—The evaluation objectives

Introduction
The purpose of Part I is to encourage and to help you to use the new evaluation objectives to inspire and
structure your assessment of competence in family medicine, whether this be assessment of others, or of
yourself. This will be done in four steps.

• First presented is an overview of the structure and components of this definition of competence. This
will provide some familiarity with the terms used in the definition, and how the different components
may be used to help reach the goal of the assessment or evaluation of competence for the purposes of
certification.

• Second, there is a brief discussion of some of the theoretical and practical considerations in designing
successful evaluations. These considerations were kept in mind throughout the development of the
evaluation objectives, and are the reason behind most of the choices made and the methods used.

• Third, we will discuss in more detail what the evaluation objectives are, and how they were derived.
Understanding this process and how it relates to the considerations in the previous section are essential
if the evaluation objectives are to be used as intended and with maximal usefulness and effectiveness.

• Finally, a few examples will be given of how these evaluation objectives can be used at this time,
followed by some of the additional possibilities for the near future.

Part II presents all of the evaluation objectives in detail. It should be noted that the information that follows is
presented in a somewhat heuristic fashion, so much of what may not seem clear as it is being read for the first
time should become easier to understand once all the information is obtained and digested. This definition of
competence is not linear or hierarchical; the components are, however, complementary. How they fit together
and how they work to guide the evaluation of competence will become more evident once the whole picture has
been viewed and reflected upon.

I. An overview of the structure and the components of this definition of

competence
There are four major components in this definition, which is specific to family medicine.

1. The skill dimensions of competence: There are six essential generic skills that enable the family physician to
deal competently with problems in the domain of family medicine. The competent family physician has the
potential to use all the skills for any problem, but competence is also characterized by adapting the choice of
the skills used to the specific needs of the problem at hand. The six skill dimensions are as follows:

a. The Patient-Centred Approach 11

11 We have opted to retain the use of the term “approach” rather than “method”. “Patient-centred approach”
includes the “patient-centred method”, but the inverse is not necessarily as clearly true. Making sure our whole
approach to practice is patient-centred is one of the defining characteristics of family medicine, so this term is used
when defining competence.

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 Part 1—The evaluation objectives

b. Communication Skills
c. Clinical Reasoning Skills
d. Selectivity
e. Professionalism
f. Procedure Skills
This component is most useful in summative situations, and assessment of competence in any of the skill
dimensions will be based on an adequate series of observations. Overall competence can be inferred when
competence has been demonstrated in each of the six skill dimensions, and in the preferential use of the
skills most appropriate to a particular problem.

2. The phase of the clinical encounter dimension of competence: This component is in a slightly secondary
position, but plays a critical role in directing assessment toward the cognitive processes that are most critical
to the competent resolution of a specific problem or situation. This dimension covers the steps or phases
from the beginning to the end of a clinical encounter. It includes the processes usually identified with the
hypothetico-deductive model of clinical problem solving, and with clinical decision making. It is most useful
for directing and limiting assessment to the processes that are most likely to discriminate between
competent and non-competent performances with respect to a specific problem or situation. For this reason
it is also particularly useful for orienting additional learning for a trainee who is having recurrent or ongoing
difficulty.

3. The priority topics, the core procedures, and the themes: These three, taken together, constitute a list of the
problems or situations that the competent family physician should be able to deal with at the start of
independent practice. As such, this component sets out and limits the basic content of the domain of
competence in family medicine for the purposes of certification. The domain is, of course, only completely
portrayed with the addition of the other three components, as they describe how competence is
demonstrated or achieved for each of the problems or situations on these lists. This component is most
useful for planning purposes, whether for teaching, learning, or assessment. The limits permit all concerned
to concentrate their efforts, and the scope reassures one that overall competence can be reasonably inferred
if assessment has been based on an adequate sampling of this content, from all three parts of the list. It also
facilitates a periodic review of the domain to see if there are obvious gaps or duplications that may need to
be corrected.

4. The key features and the observable behaviours: These are the operational evaluation objectives, using two
different formats, which describe competence in relatively objective and observable terms for each of a series
of specific situations that must be dealt with in family medicine. They represent the interactions between all
the components for the purposes of assessing competence. There are approximately 1300 distinct elements
in this component. This is the component that is most useful for the assessment of competence in specific
situations, during daily clinical supervision.

In summary, this definition of overall competence in family medicine provides very problem-specific definitions
of competence for a series of situations that must be dealt with by family physicians. These definitions are found

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 Part 1—The evaluation objectives

in the fourth component, the key features and the observable behaviours, which constitute the individual and
specific evaluation objectives for certification in family medicine.

The other components provide both the framework and the details necessary to make the evaluation objectives
operational and effective. Each objective includes, either implicitly or explicitly, the skills and the phases
necessary for competent resolution. Each objective is also part of a more general topic or procedure or theme.
The degree of detail of description is quite variable, but it is sufficient to direct the evaluation of performance for
the situation in question, and to make sure that the performances and processes assessed are truly reflective of
competence.

The evaluation objectives, using the term more generally, are described and defined by all four components of
this definition of competence. The evaluation objectives and the definition of competence are, for most intents
and purposes, the same thing.

Determining competence using the evaluation objectives:

It is perhaps important to emphasize at this time that this whole definition of competence was developed
without any reference to assessment tools or examination formats. This was done in order to have a definition of
competence and evaluation objectives that are free of the unfortunate biases that are often imposed by
predetermined instruments and formats.

We can, however, present both schematic and verbal representations of how this model could be used to
determine competence.
Observed in
Skill dimensions Phases Competent Physician
practice
a) b) c)
Key features • Patient-centred Exhibited Continuous sampling, observation,
approach throughout the and reflection based on (a), until
and
• Communication skills phases of the this assures and satisfies the
observable clinical evaluators that the physician is
behaviours • Clinical reasoning encounter competent in all the skills in (b)
skills
• Selectivity
• Professionalism
• Procedure skills
d) Priority topics, core procedures, themes

This can also be expressed verbally:

“The evaluation objectives provide an extensive list of competencies in family medicine, in terms of key features and
observable behaviours. Each of the competencies is specific to the situation to be dealt with and to the phases of the
clinical encounter that are involved; each competence is linked to the six skill dimensions that are essential to overall
competence in family medicine.

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 Part 1—The evaluation objectives

Competence will be determined by continuous sampling, observation, and reflection on an individual’s

performances with respect to the key features and the observable behaviours until the evaluator(s) is (are) assured
and satisfied that the individual is competent in all six of the skill dimensions essential to competence in family
medicine.”

The exact assessment tools and examination formats can be developed later.

II. Some theoretical and further practical considerations in defining competence

and in designing successful evaluations

Two concepts are briefly discussed in this section: the characteristics of successful evaluations; levels of
competence from a cognitive point of view, and the greater usefulness of the higher levels in predicting overall
competence. These two concepts were used as guiding principles during the development of the evaluation
objectives; understanding them will help one to understand the structure of the evaluation objectives, and will
improve the chances of their being used appropriately, to full advantage.

Characteristics of successful evaluations:

Any high-stakes evaluation (such as our certification process in family medicine) should strive to perform well
on five characteristics. 12 It should be

1. Valid: It should assess performances that are truly indicative of competence in the domain of
tasks for the discipline in question.

2. Reliable: The evaluation must measure performance in a consistent fashion, and distinguish
between competent and non-competent performances.

3. Cost-effective: This quality is important in terms of time, effort, and resources.

4. Acceptable: Both candidates and evaluators must feel that the evaluation is pertinent, rigorous,
and fair.

5. Positive in its effect on learning: It should drive learning toward true competence rather than toward
simply passing an examination.

The specific purpose of evaluation objectives is to provide clear direction for the development and use of
assessment or evaluation tools or situations, so that these five criteria are met. The evaluation objectives should
inform all types of evaluation: formative and summative, structured and unstructured, in-training and terminal,
written and oral, and simulated and real-life clinical situations, to name but a few.

To succeed, the evaluation objectives should clearly describe the domain of competence to be tested, as well as
competent performances for each of the tasks within the domain. As the particular nature of a competently

12Van der Vleuten CPM. The assessment of professional competence: developments, research and practical implications. Adv
Health Sci Educ. 1996;1:41-67.

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performed task is somewhat problem specific, good evaluation objectives include a definition at the level of each
problem-task interaction.

If a peer group uses a structured and validated approach to develop all of the steps above (problems in the
domain, tasks, and problem-task interactions), we can be reasonably sure that an assessment based on this
definition will test performances indicative of competence. We can feel comfortable that the test has been valid,
and that the successful candidate is competent—in our case, to start an independent family practice. This
approach also permits the identification of performances that are likely to discriminate best between competent
and non-competent candidates. Testing that concentrates on such discriminators is more efficient and more
likely to generate reliable results. Many other practical issues must, of course, be considered to ensure evaluation
reliability, but a valid definition of the competence to be tested is a prerequisite. The more its details outline the
elements of competent performances, the easier the development of reliable test instruments and specific test
items. This model therefore also tends to improve cost-effectiveness.

Acceptability is a complex issue, but for most of the players (the teachers, learners, and candidates) it has little to
do with psychometric qualities of an evaluation program. An evaluation of very high quality can be unacceptable
if it doesn’t look or feel right, if it is perceived as being too hard or too easy, or if it is perceived as being not
useful for daily activities of practice, clinical teaching, and learning. Evaluation is acceptable if it fits into these
daily activities, and if the process and the results of the evaluations are helpful to all the players in achieving their
educational goals. Evaluation for certification must also, of course, be of high psychometric quality, but this is
not sufficient if it is not first acceptable on the basis of how it looks and feels, how it fits in, and how it is useful.

The effect of evaluation on learning is closely related to acceptability, but merits a few specific comments. The
perverse effects of preparing for examinations are well known to postgraduate training programs: the trainees are
essentially lost for extensive periods to activities dedicated to preparing to pass examinations. These activities
usually concentrate on content and behaviours that have little if anything to do with real competence. Indeed,
many might say that they actually reduce competence, devaluing the skills and behaviours that are associated
with competence, as these “are not on the exam”. The undeniable value and force of examinations in driving
learning cannot be ignored, and were recognized throughout this project: the challenge was to express the
evaluation objectives (and, hopefully, the examinations that are based on them) in terms that bring the
preparation for examinations as close as possible to a preparation for true competence in family medicine.

Level of competence:

The second concept to be discussed is the difference between low and high levels of competence as far as
cognitive skills are concerned, and the reasons why higher levels of competence may be more robust and efficient
as indicators of overall competence, as well as being particularly pertinent to family medicine. This will also
allow us to look at the difference between “performance” and “competence” and explain some of the
preoccupations of the working group members as they developed this definition of competence in family
medicine.

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Evaluators really need to know what steps were taken, and why, in order to truly appreciate whether an
operator acted in a competent manner while performing a task—the end result does not tell the whole story. It
is difficult to assess competence without observing some performance, but the difference between the two terms
is important. This difference between “competence” and “performance” is nicely illustrated by language-
speaking skills. With respect to language, competence can be said to “refer specifically to the speaker’s
knowledge of a system of rules that they have assimilated in one way or another. These rules allow them to be
creative and produce an unlimited number of grammatically correct phrases. In addition it allows the speaker to
determine whether a phrase is grammatically correct or not.” 13 Performance does not necessarily require an
intimate knowledge of the preceding—many people speak a language very well without being at all aware of the
rules and the system. If we wish to truly assess competence, then we should also look at the systems and rules
being used during the performance of a task.

This is also important when considering the levels of competence to be assessed. In any profession, many daily
activities are routine and do not require a high level of competence. These might even be considered to be
routine performances, done without much thought or reflection, where the outcome depends little on the
competence of the operator. They are routine problems with clear-cut solutions. Many argue that professional
competence is more than this: it is the ability to manage ambiguous problems, tolerate uncertainty, and make
decisions with limited information. True competence is manifested in unfamiliar situations, and has been
defined as “the capacity to demonstrate cognitive flexibility and adaptability when faced with novel situations in
a given domain, rather than a ritualized set of responses to a predictable set of stimuli”. 14 Medical diagnostic
problems can be characterized as usually ill structured: not all the relevant information is available to the
problem solver, the potential causes are numerous, and there is often not a definite solution. Solving these
problems requires deliberate reasoning, not reflex reaction or simple recognition, which has been called “low-
road transfer”. Deliberate reasoning involves the conscious abstraction from one context to another, or the
“high-road transfer” 15 of knowledge and skills. The highly competent individual is able to generalize abstracted
knowledge across a wide range of situations—in essence, attaining competence involves a maximization of high-
road transfer. Low-level competence is extremely task-specific, and competence on one task does not at all
predict competence on other tasks. Higher-level competence is much more generalizable from one task to
another; this is perhaps not surprising as the skills themselves are not very task-specific. Finally, competence at
the higher levels usually predicts competence (or clear awareness of the lack of competence) with respect to
lower-level skills; the contrary is not at all true.

It is worthwhile noting at this time that the family physician must be competent to deal with many well-defined
problems, but he or she must also be especially competent at dealing with the many problems that are
undifferentiated, where diagnoses may remain uncertain for extended periods of time, and where multiple other
factors (e.g., other illnesses, psychosocial elements, preferences, resources) come into play and must be
considered. The skills required to handle these situations correspond very closely to the above definition of the
higher-level cognitive skills of true competence.

13 James L. Prolegomena to a theory of communicative competence. Champaign, IL: Center for Comparative Psycholinguistics,
University of Illinois; 1969/2003.
14 Regehr G. Chickens and children do not an expert make. Acad Med. 1994;69(12):970-1.
15 Patel V, Kaufman D. On poultry expertise, precocious kids, and diagnostic reasoning. Acad Med. 1994;69(12):971-2.

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The implications of the above for a definition of competence for evaluation purposes are three: 1) the definition
must include, either implicitly or explicitly, the how’s and the why’s of a competent performance of a task, not
just the performance itself; 2) tasks requiring use of the higher levels of competence will permit us to make
inferences about overall competence that are much more plausible than tasks requiring only the lower levels; 3)
the higher levels of competence are particularly applicable and necessary for competence in family medicine.
The working group maintained a healthy preoccupation with these three implications throughout. The key
feature approach led naturally in this direction, requiring some definition of the how’s and why’s, and selecting
tasks requiring the higher levels of competence, as these are often the ones that are most determinant of
competence when handling a particular problem. The preoccupation was equally maintained when using
approaches other than the key feature analysis.

III. Further details on the nature of the evaluation objectives, and how they were
derived
This section starts with a brief description of the rationale for the revision of the evaluation objectives for
certification, and of the methods used. Additional details on the four major components of the evaluation
objectives will follow.

Revising the evaluation objectives: 16

In 1998 the Board of Examiners 17 of the College decided to review the processes leading to certification. A
critical part of this process is the determination of competence at a level appropriate to the start of independent
practice as a family physician, so the assessment of this competence also came under review. The essential first
step in planning an assessment of competence is to define in sufficient detail that which constitutes the
competence in question. Surprisingly, perhaps, existing definitions for family medicine were found not to be
detailed enough for the purposes required. For example, the Four Principles of Family Medicine are useful as an
overview, providing general goals and guideposts, but they are nowhere near detailed enough to provide clear
direction for determining competence. This remained true even though a layer of precision had been added
under each principle.

The Board, therefore, decided to go back to the beginning and develop a competency-based definition for the
purposes of assessment for certification. It was decided to ground this definition in the experience of practicing
family physicians. The opinions of these physicians were sought through a postal questionnaire asking four
open-ended questions about how they would define competence in family medicine at the start of independent
practice. The results of this survey were analyzed by a focus group, which identified a series of headings that
could be used to describe competence. Reanalysis of the survey results according to these headings showed that
competence was described in terms of five skill dimensions, the phases of the clinical encounter, and a certain
number of priority topics. A sixth skill dimension, procedure skills, was subsequently added, for reasons
explained in the next section.

16 This is only a very brief summary of the methodology used and of the results. Complete details have been presented in a
series of reports to the College, and will also become available in a series of scholarly articles currently in preparation.
17 Renamed to the Board of Examinations and Certification in 2019

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These three components provided a clearer portrait of competence in family medicine, but it was still not
detailed enough to provide adequate direction for the assessment of competence. The Board therefore charged
other working groups to develop the detailed evaluation objectives using an appropriate combination of these
components. A focus-group analysis approach was used, developing the evaluation objectives through multiple
structured iterations, and two general formats were used for the final specific and operational evaluation
objectives: key features and observable behaviours. These two together are the operational component or layer
of the evaluation objectives: they direct how assessment of competence should be done in each situation under
consideration.

The individual evaluation objectives themselves can be found elsewhere in this document under the appropriate
headings. The next part of this section will, however, provide you with sufficient detail to understand what you
should be looking for and how this will all fit together. There is obviously overlap between these various
components—indeed a large part of competence is using them in the appropriate integrated fashion. From the
pragmatic point of view it is most useful to separate them—this is essential for assessment, and quite likely
preferable for teaching and learning at most stages of training.

Further details on the components of the evaluation objectives:

We will maintain the previous order of the components for the first parts of this section, but then discuss in
detail the key features before coming back to the core procedures, themes, and observable behaviours. This
follows more closely the order in which the components were developed, but, more important, the results of the
key feature analysis had a major influence on subsequent steps. A full understanding of the key features makes it
easier to understand why the core procedures, themes, and observable behaviours were developed as they were.

1. The skill dimensions of competence:

General definitions of each of the six skills are presented here. The operational definitions for assessment of
competence in each will be found throughout the topics, core procedures, themes, key features, and observable
behaviours.

a) The patient-centred approach: This well-known approach is a hallmark of family medicine and
represents one of the most efficient and effective methods for dealing with problems. It does this by
concentrating on the patient and his or her context rather than on the disease alone. In this way a shared
understanding and common ground can be reached between the patient and the practitioner concerning
goals for dealing with the problems at hand. This approach also helps these goals to be realistic and
achievable. The details of the method are well established in the literature, and the evaluation objectives for
this dimension of competence are derived directly from this information.

b) Communication skills: Certain skills and behaviours facilitate communication, and good
communication is essential for competence. It is a complex skill that permeates most of our other activities.
Good communication facilitates the use of the other skills when dealing with problems and improves
chances of a successful resolution, whereas poor communication is likely to be very detrimental.

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Communication can be written or verbal, with patients or colleagues; it also involves listening and watching
as much as or more than talking and showing. All of these aspects need to be assessed.

c) Clinical reasoning skills: This dimension deals with more familiar territory, and concerns the problem-
solving skills used to deal with the so-called “medical aspects” of a problem. Although obviously knowledge
dependent, knowledge alone is not sufficient. Many of the difficulties in this dimension are related to poor
process, and not to knowledge deficiency. These difficulties in process have the most impact on competence,
so assessment of the processes (how and why clinical reasoning is going on) is more important than
assessing the final results or answers.

d) Selectivity: This dimension has not, to our knowledge, been previously described with respect to
physician competence, although it is surely not an original idea. It is the term that was chosen to describe a
set of skills that was frequently cited in the survey as characterizing the competent family physician: such a
physician does not do things in a routine or stereotypical fashion, but is very selective in approach, adapting
it to the situation and the patient. Competent physicians set priorities and focus on the most important;
they know when to say something and when not to; they gather the most useful information without losing
time on less contributory data, or they do something extra when it will likely be helpful. It is perhaps a
subset of all the other dimensions, but it was used frequently enough in the descriptions of competence to
merit its own dimension. As we saw earlier, selectivity is found at the higher levels of competence, and it
could be an extremely robust indicator of overall competence when used for assessment purposes.

e) Professionalism: Acting professionally is a complex multi-faceted skill that has little effect by itself, 18 but
is an absolutely necessary complementary skill for competent practice. It facilitates the use of the other skills
when dealing with problems and improves chances of a successful resolution, whereas acting
unprofessionally is usually extremely detrimental, even when other skills are good. This dimension was the
most frequently cited in the descriptions of competence: it includes all the responses that dealt with respect
and responsibility to patients, to colleagues, to oneself, to the profession, and to society at large; it includes
ethical issues, as well as most of the issues pertaining to lifelong learning and the maintenance of the quality
of care; it also includes important attitudinal aspects such as caring and compassion.

f) Procedure skills: In the initial survey, skills around specific procedures and other psychomotor skills
themselves were not often cited as being characteristic of competence. This was not surprising because the
competence we are interested in is more a question of individuals knowing what procedures they are or are
not competent to do, and respecting these limits, rather than being able to perform an infinite and
unspecified list of procedures. On the other hand, certification does imply that the certificant is competent
to perform a certain number of procedures, at the start of independent practice. For these reasons,
procedure skills were added as the sixth skill dimension, and measures were taken to define this dimension
for the purposes of assessment.

18When everything else seems to be failing, however, acting professionally (in the widest sense, as used here) is perhaps the
greatest indicator of competence, and represents the most useful thing we can be or do.

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2. The phase of the clinical encounter:

Competence was also commonly described in terms of the phase of the clinical encounter without referring to a
specific problem, e.g., “take a focused history, generate a good differential diagnosis, refer when indicated”. All of
the survey responses of this nature were grouped together in this single dimension, using the following eight
subheadings, or phases.

i. Hypothesis generation (or early differential diagnosis)

ii. History (gather the appropriate information)
iii. Physical examination (gather the appropriate information)
iv. Investigation (gather the appropriate information)
v. Diagnosis (interpret information) (The term “diagnosis” is used in the general sense, and so includes
problem identification.)
vi. Treatment (or management)
vii. Follow-up
viii. Referral
The subheadings were chosen to start to define the principal activity in each phase. The clarifications in
parentheses after the subheadings are to remind us that the processes involved are quite different from a
cognitive point of view: interpreting a history is quite different from gathering it, and the implications are very
different for the assessment of competence. Although these subheadings are similar to those found in clinical
reasoning skills, they do in fact mainly refer to the phase, and not to the cognitive skill: all of the six skill
dimensions could be applicable in any of the eight phases. Having this separate layer of definition helps us to be
more precise when planning or doing an assessment of competence. Competent resolution of one problem may
require the use of a particular skill in a particular phase of the clinical encounter; the required skill and the
pertinent phase may be totally different for another problem.

3. The priority topics:

These topics are only one part, albeit the major one, of the situations found in our domain of competence in
family medicine, for the purposes of assessment of competence for certification; the other two parts are the core
procedures and the themes for the observable behaviours. The justification for the latter two became most
evident, however, after the development of the key features for the priority topics. For this reason this section
will first give some details on the topics and their key features. This information will be helpful in understanding
the subsequent presentation of the core procedures, the themes, and the observable behaviours.
The survey: The first question of the survey was “List the most important problems or clinical situations that a
newly practicing family physician should be competent to resolve”. The responses were compiled, retaining the
terminology and the level of specificity of the answers wherever possible. Reasonable synonyms were identified
and converted to a single form, usually selecting the one that was used most often. This resulted in a total of 99
different topics being listed. The frequencies of the responses for each topic were then calculated. The topics
and frequencies are presented on page 21 in tabular form.

Two features of this table are worthy of note:

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The table shows a skewed frequency of citation of each topic, with a few topics being cited much more
frequently than others. One could probably limit the topics used for assessment to fewer than 99: remember
we are mainly interested in the skills used to deal with the problems in each topic, and less interested in the
topics themselves. On the other hand, we do need to know that the certificant is competent to deal with a
sufficient number of specific problems, as well as having the general skills, so it does not seem unreasonable
to use all 99 topics as the domain for assessment. One might also argue that it would be more pertinent to
base assessment on topics from the top one-third of the list than on topics from the bottom one-third, as the
latter were really not cited very often at all.

The terminology used for the topics is extremely varied: practicing family physicians use an eclectic
taxonomy to describe the problems that must be dealt with. There are many diagnoses, symptoms,
presentations and tasks; there are also roles (periodic health/screening), groups (immigrants, newborn,
elderly), issues (lifestyle), situations (family issues, difficult patients), and even some topics (antibiotics).
Most of these terms are, however, quite familiar to most physicians, and will be understood quite readily.
There are a few exceptions (e.g., “in child”), but the interpretation given these can be understood by looking
at the key features for these topics.

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Frequencies of citation by topic, in the initial survey

rate of rate of
TOPICS TOPICS
citation citation

Depression 87% Behavioural problems 10%

Anxiety 87% Allergy 10%
Substance abuse 60% Multiple medical problems 9%
Ischemic heart disease 52% Dizziness 9%
Diabetes 51% Counselling 9%
Hypertension 50% Earache 9%
Pregnancy 48% Grief 8%
Headache 43% Thyroid 8%
Periodic health/screening 42% Stroke 8%
Palliative care 40% Vaginitis 7%
Family issues 37% Insomnia 7%
Abdominal pain 36% Infections 7%
Upper respiratory infection 35% Anemia 6%
Difficult patient 35% Immunization 6%
Domestic violence 33% Advanced cardiac life support 6%
Asthma 33% Gastrointestinal bleeding 5%
Chest pain 32% Obesity 5%
Dementia 32% Lacerations 5%
Low-back pain 32% Eating disorder 5%
Chronic disease 29% Antibiotics 5%
Elderly 29% Stress 4%
Contraception 28% Prostate 4%
Sex 28% Fracture 4%
Menopause 27% Newborn 4%
Joint disorder 26% Immigrant issues 4%
Sexually transmitted infections 24% Deep venous thrombosis 4%
Well-baby care 24% Hepatitis 3%
Schizophrenia 23% Atrial fibrillation 3%
Skin disorder 23% Parkinsonism 3%
Disability 20% Learning 3%
Personality disorder 19% Seizure 3%
Fatigue 18% Infertility 3%
Lifestyle 18% Loss of weight 2%
Urinary tract infection 16% Mental competency 2%
Chronic obstructive pulmonary disease 16% Osteoporosis 2%
Trauma 16% Loss of consciousness 2%
Cancer 16% Red eyes 2%
Vaginal bleeding 15% Croup 2%
Fever 15% Poisoning 2%
Smoking cessation 15% Meningitis 2%
Bad news 14% Travel medicine 2%
Violent/aggressive patient 14% Dehydration 1%
Suicide 14% Diarrhea 1%
Breast lump 14% Neck pain 1%
Dyspepsia 13% Crisis 1%
Hyperlipidemia 13% Dysuria 1%
Pneumonia 13% Rape/sexual assault 1%
In child 13% Gender-specific issues 1%
Cough 12% Epistaxis 1%
Somatization 12%

Three frequent questions are asked concerning the priority topics, and can be answered here.

1. Is this list valid? Clearly the answer is yes. A second survey was completed with a different
representative group of family physicians. The correlation was extremely high between both the topics
cited and the relative frequencies of citations.
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2. Should other topics be on the list? It is much more important to exclude topics or material that is not
demonstrably valid from an evaluation than it is to include all possible valid material. The topics currently
on the list have been validated, and they do cover a lot of territory. Demonstrable competence in dealing
with these topics will let us infer that the candidate is competent to practice all aspects of family medicine,
and that is what evaluation and certification need to do. There is no need to add further topics, although a
mechanism should be established to regularly review the list in a structured and valid fashion.

3. Aren’t these topics a bit too broad to direct the design of evaluations? This is a correct observation.
Evaluation objectives that stop at this level (as many do) are not detailed enough to help us reach the five
goals for successful evaluation, as stated earlier. In dealing with these topics in the specific context of
family medicine, we need to identify the critical elements, the higher levels of competence, and the skills
needed to deal with the situations under each topic. This was first done using the key feature analysis, as
described both above and below.

4. Key features:

A key feature analysis identifies two things: it first identifies the specific situations that are most determinant of
competence within a topic; it then identifies the critical steps and the critical processes involved in dealing
competently with each situation. The key feature is the interaction between the problem and the dimensions of
competence necessary to deal with it; the key feature also clarifies, either implicitly or explicitly, both how and
why things should be done in a competent fashion for this particular problem.
As a rule, key features are observable actions: They are processes or skills, not simple knowledge. In this respect
they fit very well with the current trend toward “competency”-based teaching and assessment. Key features are
not only problem or situation specific; they are also discipline specific. By developing the key features specific to
each topic we can add the problem-task interaction layer to our definition of competence.
Key features are generated according to clinical experience, not theoretical considerations or literature searches.
The number of key features will vary greatly from one problem to another. This number is essentially
determined by the various elements considered essential to the competent resolution of that clinical problem.
They are determined by a group of practicing peers, using a reflective, iterative process. The approach is
intentionally selective; it covers only what is distinctive of competence.

How, then, do these characteristics of key features lend themselves particularly well to the task at hand:
assessing competence in family medicine? Key features permit this assessment by promoting validity and
reliability in testing. They are valid for two main reasons:

• They are generated by a group of practicing physicians, who base their analysis on the real-life
solution of problems in family medicine.

• They identify the higher levels of competence, and these are the levels that distinguish best
between the competent and the not-yet-competent practitioner during the certification
process.

Key features help to improve reliability by permitting assessment to be selective, concentrating on skills that are
likely to discriminate between candidates, and by identifying criteria that can be used to assess performances

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objectively in test situations. The key features are not themselves test items, but they are signposts that clearly
suggest both the content and the format of the test items that would be most appropriate.

In short, key features permit assessment to be concentrated on skills that discriminate between competent and
not-yet-competent physicians in a fair, valid, and objective fashion. Experience elsewhere has shown that
reliable results can be achieved in a relatively short testing time when test construction is based on key features.
Key features are also quite intuitive (although the process of developing them is much less so); for this reason,
evaluations based on key features are usually well accepted by all concerned as valid or authentic. In addition,
because they reflect the performances related to true competence, key feature-based evaluations tend to
stimulate appropriate learning.

The key features for the priority topics: As stated in the initial section of this report, a key feature specifies a
particular clinical or situational starting point within a topic, and then identifies a task or action to be done that
is critical to the competent resolution of the problem at hand. It specifies, implicitly or explicitly, the skill and
the phase dimensions that are involved. It is important to emphasize that as a key feature is being developed
there is no preconceived determination of the skills or phases to be included—these are determined by the
problem itself, and by the processes required for its competent resolution. Each key feature is therefore a mini-
competence, specific to the problem in question, and contains sufficient detail to be used as an evaluation
objective that will clearly direct assessment in the intended direction. All the key features, by topic, are listed in
Part II.

An assessment based on all the key features for one topic should determine whether competence has been
reached for that topic; an assessment based on the key features of all the priority topics should determine
whether competence has been achieved for this definition of the domain of competence of family medicine. It is
important to know, therefore, whether such an assessment would adequately cover all the dimensions (skills
and phases) of competence that we have previously identified as essential. To this end, the last step in the
development of every key feature was to code it for the skill and phase dimensions that it assessed, permitting a
maximum of two skills and two phases per key feature. These codes are not yet visibly attached to their key
features in this current posting, although they are available in working files. The overall compilation is available,
however, for all the key features of all 99 priority topics, and is given in the following table.

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Descriptive coding of the key features:

A total of 773 key features were generated for the 99 topics, for an average of 7.8 key features per topic. The
implications of the relative frequencies in the boxes are discussed below.

Skill dimensions % of key Phase dimension % of key

features features

Patient-centred approach 14% Hypothesis generation (= early DDx) 22% Gather

Communication skills 4% History 14% = Diagnose

Clinical reasoning skills 60% Physical 4% 47% =

Selectivity 16% Investigation 7% 63%

Professionalism 5% Diagnosis 16% Interpret

(includes problem identification)
= 16%

Psychomotor 1% Treatment 30% Manage Manage

Follow-up 5% = =

Referral 2% 37% 37%

1080 codes for 773 key features = 1.4 1128 codes for 773 key features = 1.5 codes/key feature
codes/key feature

Relative percentages for the skill dimensions: These percentages in no way reflect the relative importance of
these dimensions; it simply means that key feature analysis of the priority topics identifies many opportunities
to assess three of the skill dimensions, but few opportunities for three others, namely communication skills,
professionalism, and procedure skills. We must define these latter three by a complementary process and plan
their assessment by parallel means.

As already mentioned, a core procedures list (analogous to the priority topics list) was developed, and the
general key features for procedure skills were developed. The latter can be used to guide the assessment of
competence for the individual procedures. Both the list of core procedures and their general key features are
found later in this document.

For professionalism and communication skills, the definitions were completed using our “observable behaviour”
approach. The method was briefly introduced earlier in this report, and is expanded upon below under “The
themes and observable behaviours”.

One other important point is not evident in this table—even though ample opportunity is provided for the
assessment of the patient-centred method, the key features do not provide much specific direction as to how to
assess or judge this competence objectively. For this reason we also generated some observable behaviours to
help guide the assessment of this dimension. They were derived directly from the excellent already-published
material on this dimension, and they are listed with the other evaluation objectives in Part II. If further detail is

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felt to be necessary, this could be generated de novo, but it could also probably be done using the same published
material.

Relative percentages for the phase dimension: The three columns show progressive groupings of frequencies in
terms of the different clinical tasks, which do require somewhat different cognitive skills. Once again, all the
phases are important to overall competence, but we do interpret these figures to indicate the relative importance
of the various cognitive skills in dealing with our priority topics in family medicine, in contradistinction to the
skill dimensions. We see that the essential skills for the majority of the key features deal with diagnosis (63%),
and that nearly half (47%) deal with the active process of gathering the pertinent data to make an adequate
diagnosis. Sixteen percent deal with making a diagnosis given certain data, and slightly more than one-third deal
with management. These figures are important for two reasons. First, data-gathering skills in this context
represent a higher cognitive level of competence than data-interpretation skills or management choices. Second,
traditional evaluations have often concentrated more on management, and have neglected the diagnostic phases
as being too difficult to evaluate or too basic to be important. The opposite is actually true. The higher cognitive
levels of competence (as represented here by diagnostic skills) are much better predictors of overall competence
than are the lower levels, such as management choices, which are usually quite problem specific. While
competence obviously requires the demonstrated ability to manage many problems in family medicine, it is
much more important for us to concentrate our efforts on the higher levels if we wish our evaluation process to
be valid and efficient.

Are we sure that these key features are the right ones? Similar questions can be asked about the validity and
inclusiveness of the key features as were asked of the topics: Would other groups of physicians develop
different key features, and would the inclusion of others improve the evaluation process?

The answer to the first question is yes, and to the second, no. The key features method has been validated
elsewhere, and a validation study of our key features showed that a different group of physicians agreed
with over 95% of the key features. This other group did suggest some additional key features, but these
usually addressed the same concepts with different examples. We therefore are confident that the current
key features are more than sufficient, even though they are not absolutely complete. Once again, the
establishment of a mechanism for the ongoing review of key features is important, but we do not expect
them to change significantly over the short term.

How does one get from key features to evaluations? Key features are the starting point for developing
various evaluation instruments or situations, both formal and informal, which can be used throughout a
certification process. Key features serve as reference points and signposts throughout all evaluation
activities, as they are a major component of our operational definition of competence. They are one of the
“keys” to maintaining validity throughout the certification process.

There remain for presentation the three areas not well defined by the key feature analysis: procedure skills,
communication skills, and professionalism.

5. The core procedures and their key features:

Procedure skills are a good example of the different levels of competence. As far as an individual procedure is
concerned, cognitive skills are generally low level: the technique is learned and practiced and becomes routine.

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Indications and contraindications, deciding to do or not to do a procedure, and choosing among several possible
approaches to a problem are examples of the higher levels of competence. As a general rule, the individual at the
higher levels of competence
• will not perform a procedure at which he or she is not skilled and
• will arrange to learn a procedure that he or she is going to need in his or her particular
practice.
This is surely the most important aspect of competence to assess for certification.
Certification cannot, however, limit itself to this level. An independent practice requires a certain level of
experiential competence; the practitioner is assumed to have the technical skills to perform a certain number of
procedures. The challenge is to define what these essential, or basic, procedures are. Very few (1%) of the key
features for the priority topics involved procedure skills in their resolution. It was therefore decided to use a
parallel process to better define competence in this skill dimension.
Another working group assumed this task, surveying a group of practicing family physicians to identify and
validate a list of core procedures for the start of an independent practice. This group identified 65 core
procedures and 15 enhanced procedures. The 65 core procedures are the procedures upon which the
assessment of competence will be based—these procedures are listed in Part II. It must be remembered that not
only the technical aspects of individual procedures are important. The higher levels of competence will also be
assessed, as always, in the context of family medicine: the details of these were defined by a key feature analysis,
and these can also be found with the core procedures in Part II.

6. The themes and the observable behaviours:

The other two skill dimensions that were not well defined by the key feature analysis of the priority topics are
not the least important—indeed the dimensions of professionalism and communication skills are often
neglected as far as rigorous assessment is concerned, even though a lack of competence in these dimensions will
have negative effects throughout all the other dimensions as well. These dimensions were defined through a
focus-group approach, using information from various sources as inspiration, first developing a series of themes
under each dimension. This was followed by a multiple-iteration process to identify behaviours that were
indicative of competence, or lack of it, under each theme. The process was continued until satisfaction and
saturation were achieved. The behaviours had to be observable (= potentially assessable in a fairly objective
fashion); hence the term “observable behaviours”.

This process is analogous to the key feature analysis, but differs in two important ways. First, it is dimension
based rather than topic based; we started with the dimension, identifying observable behaviours that are
indicative of competence (or lack of it) in that dimension in certain situations in family medicine. Second,
whereas the key feature analysis identifies a subset of situations and competencies thought to be indicative of
overall competence in the topic in question, the observable behaviour analysis does not attempt to do this: all
potentially indicative behaviours are listed, both major and minor, and no particular subset has been identified
at this time as being most critical to competence. This could well be a useful exercise at a future date.

The themes of the two dimensions are presented here—the observable behaviours themselves are listed in Part
II.

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Communication skills:
The themes or skill subsets are as follows. Noteworthy for this dimension is that observable behaviours under
each subset were developed twice, once for communication with colleagues, and once for communication with
patients. There is considerable overlap, but there are some major differences.
1. Listening skills
2. Language skills
i. Verbal
ii. Written
iii. Charting skills
3. Non-verbal skills
i. Expressive
ii. Receptive
4. Cultural and age appropriateness
5. Attitudinal

Professionalism:
Knowing how to act professionally and actually doing it in a consistent fashion are not one and the same, and
this has major implications for the context of any evaluation. Assessment should probably be based on
observations of real-life, real-time behaviours—it does not really lend itself to assessment in simulated
situations. In this dimension, competence was defined as being demonstrated by a series of observable
behaviours that have been grouped under 12 themes. The themes are listed below. The observable behaviours
are listed in Part II.
1. Day-to-day behaviour reassures one that the physician is responsible, reliable, and trustworthy.
2. The physician knows his or her limits of clinical competence and seeks help appropriately.
3. The physician demonstrates a flexible, open-minded approach that is resourceful and deals with
uncertainty.
4. The physician evokes confidence without arrogance, and does so even when needing to obtain
further information or assistance.
5. The physician demonstrates a caring and compassionate manner.
6. The physician demonstrates respect for patients in all ways, maintains appropriate boundaries, and
is committed to patient well-being. This includes time management, availability, and a willingness
to assess performance.
7. The physician demonstrates respect for colleagues and team members.
8. Day-to-day behaviour and discussion reassure one that the physician is ethical and honest.
9. The physician practices evidence-based medicine skillfully. This implies not only critical appraisal
and information-management capabilities, but incorporates appropriate learning from colleagues
and patients.
10. The physician displays a commitment to societal and community well-being.

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11. The physician displays a commitment to personal health and seeks balance between personal life
and professional responsibilities.
12. The physician demonstrates a mindful approach to practice by maintaining
composure/equanimity, even in difficult situations, and by engaging in thoughtful dialogue about
values and motives.

IV. Using the evaluation objectives

The main target audience of this section at this time consists of trainees and their preceptors, and the use of the
evaluation objectives during training and daily supervision. They are already being used in other contexts, but
these are dealt with elsewhere.

The first piece of advice may seem paradoxical, but should improve the chances of getting started and eventually
using the evaluation objectives to their full potential:

1) Do not read the evaluation objectives in any great detail: Both preceptors and trainees should start by
getting into the habit of using some type of field note after most supervised clinical encounters to
stimulate discussion, identify the critical steps in the resolution (or not) of the situation in question,
reflect on the performance with respect to these, and document one or two points that seem to be most
useful. Start to concentrate as much or more on the process (why and how) as on the results, paying
particular attention to diagnostic reasoning and decision making. Many of these steps are already being
done, but often without an awareness of the cognitive processes involved, and without always being
able to articulate the judgments, reflection, and feedback that will be most useful in moving toward
competence. Such a repetitive analytical approach will gradually become intuitive, for both trainees and
preceptors. This would now be the time, if it has not already been done, to get to know the evaluation
objectives in detail.

2) Consult the evaluation objectives to help to articulate the analysis, reflection, and feedback on clinical
performances, either by supervision or by self-assessment: Much of the difficulty experienced with in-
training evaluations comes from not being able to articulate clearly and objectively why a certain
performance does or does not meet the standards of competence, and what might need to be changed
to reach competence. The “does not” situation is particularly problematic, as the result is often a vague
response from a preceptor, or no comment and no useful documentation at all of a series of subpar
performances, with no useful constructive feedback for change. Similarly, the apparently competent
performance often deserves a more insightful analysis and feedback, so that any continuing minor
weaknesses can be identified and corrected, or if all truly seems well, then future teaching and learning
can be concentrated on other areas.

The evaluation objectives provide this articulation for most of the situations that will be met during
training in family medicine. They also depersonalize, in a useful way, the judgments and feedback,
making them easier to accept by providing clear reference points and justified descriptions of
competence in a pragmatic fashion.

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3) Use the evaluation objectives to help to structure, organize, and document progress toward competence:
The evaluation objectives provide a frame of reference and clear guideposts for achieving and
demonstrating competence in family medicine. They are equally applicable for regular unstructured
daily clinical supervision, for planned direct observations, or for any structured assessment activity.
They are particularly useful for a trainee in some difficulty—the areas of weakness can be better
defined, thus permitting specific educational prescriptions and further assessment in these specific
areas as necessary.

Some may prefer more structured field notes, even for the unstructured supervisions. The components
of the evaluation objectives may be used to develop these: the skill dimensions, the phase of the clinical
encounter, the priority topics, and the procedures. Whatever structure is used, the feedback and
documentation should be inspired by the key features or the observable behaviours. It is also important
to remember that for most preceptor-trainee clinical interactions, the analysis and feedback should be
limited to one or two specific areas or points.

The evaluation objectives are designed for an individual, but can also obviously be used to plan group-
learning activities—topics can be reviewed through the key features. Prototypical critical incidents tend
to be identified, so they can be discussed ahead of time—wisdom and experience cannot really be
taught, but some of the lessons learned can be passed on ahead of time.

Future developments may include topic- and dimension-specific field notes, perhaps computer
generated on demand. Electronic filing and compilation would permit ready revision of progress and
help with planning of future training. There is perhaps no limit at this time on how the evaluation
objectives might be used—it is hoped that experiences and new ideas will be shared, so that all may
benefit.

4) Other uses of the evaluation objectives: The evaluation objectives are already being used to design and
develop the certification examinations. They could also be used in several other ways.

Levels of competence, core competence: The expected performances at certain levels of training can be defined
using the evaluation objectives. This would be useful for deciding on promotion, equivalence of previous
training, needs for additional training, etc.

Curriculum design: Curriculum design is a complex issue, with many limiting factors. The measure of the
pertinence of an activity should, however, no longer be its name and its duration. The measure should be
the contribution of the activity to the progressive acquisition of competencies, and the degree to which it
can demonstrate that it is fulfilling this objective. The evaluation objectives provide a pragmatic reference
tool to which a curriculum and its parts may be compared and against which they may be judged. They are
structured so that the comparisons should be quite straightforward and the judgments transparent,
leading to changes within an existing activity or to a new activity. In this way, they can be used for
continuous quality improvement and help to ensure that our curricula in family medicine evolve in a
dynamic fashion as we strive to make sure that our training programs promote, in an efficient and
predictable manner, the acquisition of all the competencies required of the family physician in today’s
society.

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Defining the specialty of family medicine, with comments on postgraduate and undergraduate training: A
medical specialty or discipline is defined by many characteristics, and may include many variants or even
subspecialties. There usually is, however, an identifiable central competence common to all these variants
and subspecialties within one specialty. This situation applies to family medicine, and the evaluation
objectives do represent an operational definition of this central competence, one that should be common
to all family physicians. As such they can be used to determine the resources needed to provide the
necessary common training and assessment of competence, and to justify these needs to academic
institutions, licensing bodies, provincial governments, and society at large. This competency-based
definition of family medicine is quite transparent, and the link between the desired result (competent
family physicians) and the postgraduate training required (in which clinical milieu, with which kind of
preceptors, to what level of desired competence) should be just as transparent. It is also quite detailed and
factual or objective, so both inadvertent redundancies and gaps can be identified, and specific limited
corrective modifications can be made, without changing the whole curriculum.

This competency-based definition also permits those involved with undergraduate training to look ahead
to what competencies are required for family medicine. Curricular modifications at this level may then
better prepare students for postgraduate training in family medicine, and they may well be able to justify
even more significant curricular changes to achieve objectives that move toward competencies common to
more than one specialty. Our evaluation objectives define the nature of competence at the point of entry
into independent practice in family medicine. Nothing in our definition states, however, when these
competencies must be acquired or in what order. This is more properly the domain of the educators, those
who look after the training at all levels, by designing curricula and supervising activities, and by assessing,
on a regular basis, progress toward the desired competencies and overall competence. Once again, the
evaluation objectives are an essential reference point and a useful tool for achieving this result in family
medicine.

End of Part I

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 Part II—Essential Skills, Themes, and Observable Behaviours

Part II—Essential Skills, Themes, and

Observable Behaviours

Introduction .................................................................................................................................................................... 31
The Patient-Centred Approach ................................................................................................................................ 32
Communication Skills.................................................................................................................................................. 34
Professionalism............................................................................................................................................................... 43
Clinical Reasoning Skills.............................................................................................................................................. 53
Selectivity ......................................................................................................................................................................... 55
Procedure Skills.............................................................................................................................................................. 56

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Introduction
Part I of the evaluation objectives document provides a fairly detailed description of the processes used for the
development of these evaluation objectives, as well as the rationale for the choices made. It can be found on pages
10-30 of this document (see menu).
Part II of the document, which is the subject of the following pages, is the operational level, containing all the
details necessary to assess performances in family medicine, to make objective judgments about competence in
specific situations, and to stimulate reflection than can lead to interpretive feedback and suggestions for future
learning and changes that will help the trainee or the practitioner to move toward competence. These objectives
should also help to concentrate efforts on those elements that are most determinant of competence, both in general
and with respect to specific situations. In this way, time spent on evaluation will be both more effective and more
efficient. Finally, as these objectives are entirely competency based, their use should drive learning toward
competency, rather than toward simply passing examinations at various times.
They are organized according to the six essential skill dimensions of competence. The format varies with the
dimension, but in each case it should be sufficient to clearly orient evaluation of the dimension in the context of
daily clinical practice and supervision. Each dimension could be considered a menu of useful items to be selected
according to the specific needs of the situation. As such it is helpful to be familiar with the whole menu before
making the selections that fit the needs. The dimensions are followed by the priority topics and key features: they
are not cross-referenced at this time, and so searching for the right combinations may require several steps. The
next version of these objectives will be cross-referenced and searchable by various parameters.
These objectives do not contain any test instruments or examinations or scoring scales or performance levels or
forms, nor any prescription for developing these tools. This omission is intentional, as was explained in Part I of
the objectives. As these tools are developed, these evaluation objectives will provide the primary matter that will
direct both the content and the format of the instruments used, and increase the chances that any evaluation will
do well according to the five parameters associated with successful evaluations.
Could these evaluation objectives be used as a study guide or a curriculum, and should they be? The answer is
mixed. As a curriculum, the evaluation objectives are incomplete. They will represent one set of terminal objectives,
but a curriculum must also pay attention to the intermediate and enabling objectives necessary to learning, as well
as to other possible end points. As a study guide, these evaluation objectives are more usable, as long as the reader
remembers that performances will be assessed in the context of all the layers of our definition of competence in
family medicine. This means that assessment will concentrate as much on the skills and processes used to deal with
problems as it does on the actual answers or solutions to specific problems. With this caveat, it can be said that a
physician who can show competence in dealing with an adequate sample of the topics, procedures, and themes on
this list, demonstrating the higher levels of competence in each of the six essential skill dimensions, in all phases of
the physician-patient encounter, and in the context of the Four Principles of Family Medicine, probably does
indeed deserve certification to start independent practice.

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The Patient-Centred Approach

This dimension encompasses the clinical method established by the Centre for Studies in Family Medicine at The
University of Western Ontario.

The method sets out to understand a patient’s presenting problem through learning about the disease and how the
individual experiences it. One must learn what patients feel in connection to their symptoms, how they explain
what they are experiencing, the effect it is having on their lives, and how they hope the physician will be able to
help to address the problem.

This is connected to the process of gaining a greater understanding of the whole person— “who the patient is”, his
or her “context”. Who the people in their lives are and how they relate to them, who or what their supports are,
and what social factors exist all play a role in understanding patients’ context. This context weaves through the
patient’s “disease” and how he or she experiences it.

In attempting to address a concern, the patient and the physician work to come to a common understanding of the
problem and their roles in addressing it. Understanding a patient and his or her context is also important in
effective health promotion and prevention, which are incorporated into this method.

It is a realistic approach and, like care in family medicine, a longitudinal one. The priorities of the patient and
physician are respected and balanced. The resources of individuals and the community are considered in the
process.

This method is considered an essential tool in building the patient-physician relationship. The working group felt
that the details of the method are clearly articulated in Patient-Centered Medicine: Transforming the Clinical
Method by Stewart, Brown, Weston, McWhinney, McWilliam, and Freeman. We did not attempt to redefine the
method, but have instead tried to express the various components of the method as specific actions that can be
observed during the clinical encounter. The patient-centred approach permeates all of our clinical encounters, but
there are specific instances in which skill in this dimension may be better assessed. Many examples of these
instances can be found within the priority topics and key features.

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Observable Behaviours:

1. Actively explores patients’ experience with a problem by inquiring about:

• what they feel in connection with their problem (feelings)

• how they explain what they are experiencing (ideas)
• the effect it is having on their life (impact on function)
• how they hope the physician will be able to help them address the problem (expectations)

2. In assessing a clinical problem, attempts to gain a greater knowledge and understanding of the whole person by
asking about his or her context (i.e., who else is in his or her life [family, partner, children], who or what
supports are, other social factors [work, finances, education, etc.])

3. In moving toward developing a management plan for a patient’s problem, integrates a patient’s context with his
or her illness experience in a clear and empathetic way

4. In attempting to address a problem, works with the patient to come to a shared understanding of it and each
person’s role in addressing it by

• encouraging discussion
• providing the patient with opportunities to ask questions
• encouraging feedback
• seeking clarification and consensus
• addressing disagreements

5. In finding common ground around the management of a problem, incorporates relevant health promotion and
prevention.

6. Approaches a patient’s problems with a realistic and longitudinal view, which respects and appropriately
balances the priorities of the patient and physician; considers the resources of individuals and the community.

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Communication Skills

Communication skills were clearly identified as one of the skill dimensions essential for the competent practice of
family medicine. There is a large body of literature on communication and the working group did not attempt to
redefine communication or develop a theoretical definition. We chose instead to articulate a pragmatic approach
focused on skills and behaviours that facilitate communication.

We began by identifying those themes or skill subsets that are essential to good communication. We then used an
interactive focus-group approach to define the themes and observable behaviours that should predict competence
for entry to the independent practice of family medicine. Other observable behaviours may be added to this list;
however, those identified below should be more than sufficient to determine competence.

These are the themes identified:

1. Listening skills
2. Language skills
a) Verbal
b) Written
c) Charting skills
3. Non-verbal skills
a) Expressive
b) Receptive
4. Cultural and age appropriateness
5. Attitudinal

The working group felt there were tangible differences between communication with health team members and
with patients. Physicians may be able to communicate effectively with one group and not with the other; therefore
we chose to separate these areas in our definition. For each group we have identified observable behaviours for each
type of interaction. Some behaviours appear in both sections. They have been duplicated in order to be
comprehensive.

For each subset of skills we have identified behaviours, expressed either positively ( ) or negatively ( ), that reflect
competence. Positive behaviours are listed first, followed by negative behaviours. We have not placed the
behaviours in any order of priority. For the most part, only the positive or negative expression of the behaviour was
described.

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Effective Communication with Patients

1. Listening Skills
Uses both general and active listening skills to facilitate communication

Observable Behaviours:

Appropriately looks at the patient while the patient is talking

Allows the time for appropriate silences
Feeds back to the patient what he or she has understood from the patient
Provides appropriate non-verbal responses to patient’s statements
At all times responds to verbal cues (e.g., does not go on with regular questioning when the patient reveals
major life or situation changes like “I just lost my mother”)
Clarifies jargon when used by the patient
Comprehends what the patient says
Lets the patient tell his or her story (does not interrupt the patient inappropriately)

Does other things while the patient is talking (e.g., looks at computer chart, takes phone calls)

2. Language Skills

a) Verbal:
Adequate to be understood by the patient; able to converse at an appropriate level for the patient’s age and
educational level; appropriate tone for the situation—to ensure good communication and patient comfort

Observable Behaviours:

Asks open- and closed-ended questions appropriately

Checks back with the patient to ensure understanding (e.g., “If I say this, am I understanding you correctly?”)
Facilitates the patient’s story (e.g., “Can you clarify that for me?”)
Provides clear and organized information in a way the patient understands (e.g., test results, pathophysiology,
side effects) and checks back to ensure the patient understands
Provides explanations to accompany examinations and/or procedures
When first meeting a patient, clarifies how the patient would like to be addressed

Fails to greet the patient

Interrupts patients inappropriately
Uses inappropriate word choices for the individual’s level of understanding (e.g., use of scientific language that
the patient cannot understand, overuse of jargon)
Displays inappropriate anger
Uses inappropriate humour
Uses paternalistic language (e.g., use of “dear”)
Uses offensive language (e.g., swearing)
Shouts or uses excessively loud speech

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Asks multiple questions without awaiting the answers

Has language skills that are insufficient to be easily understood by the majority of patients (i.e., patients can’t
understand what the physician is saying)

b) Written:
Clearly articulates and communicates thoughts in a written fashion (e.g., in a letter to a patient, educational
materials for the patient, instructions for a patient)

Observable Behaviours:

Writes legibly
Written material is organized so the patient can understand (spelling, grammar, and punctuation must be
sufficient to permit understanding)
When providing written information, chooses materials that are appropriate to the patient’s level of
understanding

Uses abbreviations that are not understood by the patient

3. Non-Verbal Skills

a) Expressive:
Being conscious of the impact of body language on communication with the patient and adjusting it appropriately
when it inhibits communication

Observable Behaviours:

Sits while interviewing the patient (in order to convey the feeling of providing the patient with more time and
attention)
Eye contact is appropriate for the culture and comfort of the patient
Is focused on the conversation
Adjusts demeanour to be appropriate to the patient’s context (e.g., is pleasant, appropriately smiles, is
appropriately serious, is attentive, is patient and empathetic)
Communicates at eye level (e.g., with children, patients who are bedridden)
Physical contact is appropriate for the patient’s comfort

Fidgets
Hygiene or dress that inhibit communication
Gets too close (not respectful of other’s personal space)

b) Receptive:
Aware of and responsive to body language, particularly feelings not well expressed in a verbal manner (e.g.,
dissatisfaction, anger, guilt)

Observable Behaviours:

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Responds appropriately to the patient’s discomfort ( e.g., gets a tissue for a patient crying, shows appropriate
empathy with the patient’s difficulties )
Verbally checks the significance of body language (e.g., “You seem nervous/upset/uncertain/in pain; is that
right?”)
Comments on behaviour/non-verbal actions of the patient when appropriate (e.g., “You seem
quiet/unhappy/angry/worried/in pain”)
Modifies actions during examination or history-taking in response to the patient’s discomfort (e.g., adjusts
angle of exam table when patients are short of breath during an abdominal exam)

Misses signs that the patient does not understand what is being said (e.g., blank look, look of astonishment,
puzzlement)

4. Culture and Age Appropriateness

Adapts communication to the individual patient for reasons such as culture, age, and disability (e.g., the young
child or teenager, or someone with speech deficits, hearing deficits, or language difficulties)

Observable Behaviours:

Uses appropriate communication skills with adolescents (e.g., offers to see them independently, respects the
capacity to make decisions, acknowledges issues of confidentiality, specifically directs questions to the
adolescent, is not judgmental)
Adapts communication style to the patient’s disability (e.g., writes for deaf patients)
Asks about the need for an interpreter and arranges for one
Speaks at a volume appropriate for the patient’s hearing
Adapts communication style based on the patient’s cultural expectations or norms (e.g., other family members
in the room)
Uses appropriate words for children and teens (e.g., “pee” vs. “void”)

Ignores the patient while exclusively engaging the caregiver, especially with children, the elderly, those with
cognitive impairment (e.g., no questions to the patient, patient not involved in management plan)
Makes assumptions based on the patient’s appearance or dress (i.e., stereotyping the patient)
Uses colloquialisms that the patient does not understand

5. Attitudinal
This permeates all levels of communication. This includes the ability to hear, understand, and discuss an opinion,
idea, or value that may be different from your own while maintaining respect for the patient’s right to decide for
himself or herself. Communication conveys respect for the patient.

Observable Behaviours:

Shows interest in the patient’s opinion

Is empathetic
Maintains an appropriate attitude in response to inappropriate/offensive language or comments made by the
patient

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Appears rude
Appears impatient
Displays irritation or anger
Belittles the patient
Trivializes or dismisses the patient’s ideas or concerns
Is sarcastic
Appears intimidating
Appears arrogant (e.g., ignores the patient’s concerns or opinions about the management plan)

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Effective Communication with Colleagues

(“Colleague”, for our purposes, means all members of the health care team.)

1. Listening Skills
Many specific listening skills are better assessed in the context of communication with patients. Some are well
assessed in the context of communication with colleagues.

Observable Behaviours that Can Be Assessed with Colleagues:

Is attentive
Stops and takes the time to listen respectfully to colleagues
Appropriately maintains eye contact while discussing issues with all members of the health care team
Allows sufficient time for colleagues to articulate their concerns

Does other tasks that interfere with listening

2. Language Skills

a) Verbal:
Adequate to be understood in face-to-face communication, and with all other commonly used methods (e.g.,
phone, video conferencing, etc.); adequate to understand complex profession-specific conversation; appropriate for
colleagues with different backgrounds, professions, and education; appropriate tone for the situation, to ensure
good communication and colleague comfort

Observable Behaviours:

Introduces self when meeting a colleague for the first time

When asking colleagues to do something, makes a clear request and ensures that it is understood
Offers rationale for a plan or an approach to improve understanding
Adjusts tone to be appropriate to circumstances
Asks rather than demands
Uses non-blaming, appropriate, and specific observations when addressing difficult circumstances

Case presentations are poorly organized or incomplete

Is not specific with requests
Interrupts colleagues
Asks multiple questions without awaiting the answers
Does not target language to the individual’s professional background and level of understanding
Displays inappropriate anger
Uses inappropriate humour
Uses condescending language
Shouts or uses excessively loud speech
Swears or uses offensive language

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 Part II—Essential Skills, Themes, and Observable Behaviours

b) Written:
(e.g., hospital and office charting, consultant letter, lawyer letter)
• Clearly articulates and communicates thoughts in a written fashion
• Has spelling, grammar, legibility, and punctuation that are adequate to facilitate understanding

Observable Behaviours:

Writes legibly
Written material is organized
When writing to request consultation, is specific about questions/reasons and provides relevant information

Patient-care plans (e.g., test requests, follow-up orders) are:

a) clearly written and
b) securely transmitted to the appropriate recipient

Uses abbreviations that are not universally known or are prone to misinterpretation

c) Charting Skills
Assessment should concentrate mainly on the charting of individual encounters. Overall organization and
structure of the ongoing clinical record are important, but these are often predetermined and outside the control of
the individual—they can be assessed, but in a different context. Note that these charting skills are formatted as a
set of key features.

a) A clinical note must

a) be legible.
b) avoid using acronyms or abbreviations that may be misunderstood or confusing (e.g., “U” for
“units”).
c) be organized so as to facilitate reading and understanding.
d) follow an agreed-upon structure within a practice setting.

b) Charting must be done in a timely fashion, so as to minimize inaccuracies and lost information, and to
ensure that the information is available for others involved in care. It should usually be done
immediately after the encounter; if delayed, notes must be made to direct the later charting.

c) Corrections or changes to the note must be clearly visible as such, and dated if not made at the time of
the original entry.

d) Should not write anything in the chart that you would not want the patient to read (e.g., disparaging
remarks)

e) Must not falsify data (e.g., don’t include data in the note that has not been gathered)

f) The clinical note must

a) reflect all the phases of the clinical encounter that are relevant to the presenting situation.
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b) show an obvious and logical link between the data recorded and the conclusions and plan.
c) include the relevant negative findings, as well as the relevant positive findings.
d) avoid inappropriate verbatim reporting of the encounter (it should synthesize the data gathered).

g) As part of ongoing care, acknowledge additional received data (e.g., test results, consultation reports)
and document follow-up action when appropriate.

h) As new information is gathered during an encounter, maintain the chart according to the expectations
of the work milieu (e.g., flow sheets, summary page).

i) Structure and use the clinical record as a tool to try to improve comprehensiveness and continuity of
care.

3. Non-Verbal Skills

a) Expressive:
Appropriate eye contact, respectful of others’ personal space, appropriate demeanour (e.g., pleasant, smiles
appropriately, appropriately serious, attentive, patient and empathetic), and conscious of the impact of body
language on the colleague

Observable Behaviours:

Is focused on the conversation

Eye contact is appropriate for the culture and comfort of the colleague
Adjusts demeanour to be appropriate to the colleague’s context
Physical contact is appropriate for the colleague’s comfort

b) Receptive:
Aware of and responsive to body language, especially as seen with dissatisfaction; correctly interprets signs of
feelings not expressed, such as anger and frustration

Observable Behaviours:

When a colleague is manifesting signs of distress, demonstrates awareness by actions such as modifying
demands, exploring concerns, seeking resolution

4. Culture and Age Appropriateness

There may be instances where communication with colleagues and other team members from different cultural
backgrounds can be problematic. Awareness of these potential problems and subsequent adjustments to
communication are elements of competence. This, however, is better assessed in the context of communication
with patients and in professionalism.

5. Attitudinal
This permeates all levels of communication. Competent family physicians possess an attitude that allows them to
respectfully hear, understand, and discuss an opinion, idea, or value that may be different from their own.

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Observable Behaviours:

Seeks to understand rather than judge

Returns the focus to effective patient care when interprofessional conflicts occur
Attempts to resolve difficulties before ending the discussion or walking away
Apologizes when appropriate

Appears rude
Appears impatient
Belittles colleagues or their field of work
Trivializes or dismisses ideas or concerns of colleagues
Appears arrogant
Displays anger or irritation
Uses derogatory language when describing a patient’s circumstances or case
Appears threatening or intimidating

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 Part II—Essential Skills, Themes, and Observable Behaviours

Professionalism

The key feature analysis of the priority topics for evaluation did not lead to the required detailed operational
definition of competence in the dimension of professionalism. It was therefore necessary to use a different process
to define this dimension. The working group used a process analogous to the priority topic–key feature approach,
more or less simply inverting it. We went from the general behaviours characteristic of professionalism to specific
behaviours in certain situations, rather than the other way round.

Twelve general behaviours or themes were identified following analysis of the terms used to describe
professionalism by the practicing family physicians who replied to our initial survey. We then used small groups
and multiple iterations to generate lists of behaviours in certain situations that reflect on competence in each of the
12 general behaviours and so on the dimension of professionalism as a whole. These 12 themes and examples of
behaviours under each theme make up most of the content of this section.

We do not think that it will be pertinent to assess the 12 themes individually as they are rather interdependent,
and any separation risks becoming artificial. For example, from the point of view of competence, how can we draw
a clear line between ethics and professionalism? For the same reason, even though there is considerable overlap
between the behaviours listed under the 12 themes, we made little effort to eliminate this overlap: better to have
too many concrete examples from which to develop assessment tools and programs than not enough. Any
necessary conciliation can be done when this next step (assessment tools and programs) is reached.

There was one other major difference in our approach to the definition of competence in professionalism.
Throughout the process of developing evaluation objectives we had intentionally stayed away from test
instruments and specific examination scenarios, not wishing to bias the evaluation objectives toward that which is
testable by existing instruments or examinations. The process of developing test instruments and examinations has
been intentionally left to a second independent step. We soon realized that this was not entirely possible for
professionalism, as the nature and structure of our detailed evaluation objectives for this dimension must make
some assumptions about the context of the ultimate assessments. Before giving these assumptions, we will first list
the observations that justify this slight deviation from our usual approach:

1. Professionalism is perhaps the most multi-faceted dimension of competence; it is essentially subjective,

determined by all those working around the individual (e.g., patients, colleagues, employees, employers,
occasional contacts) and the cultural environment in which we find ourselves.

2. Although there is a considerable body of knowledge on “professionalism”, the demonstration of the

possession of this knowledge itself is not sufficient for competence, as it does not seem to predict, in any
way, adequate professional behaviour. We are, therefore, more interested in specific behaviours that are
indicative of acting professionally than in knowledge about professionalism.

3. Examples of professional behaviour may be quite context specific, and may depend on local expectations.
Expectations in any evaluation situation should, therefore, be quite explicit, and any apparently
unprofessional behaviour should first be discussed and explored before any final judgment is made.

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4. There are many circumstances during practice and training that may demonstrate, to a greater or lesser
degree, whether an individual is acting in a professional manner. Professional behaviour is the sum of an
appropriate mix of all these. In this sense, there is no one set of key features for professionalism.

5. No one is expected to be perfect all the time, but we expect certification of competence to imply that the
individual acts in a professional manner. Competence in this domain is absent when there is a pattern of
repeated unprofessional behaviour that cannot be readily justified or explained. There may also be a single
incident of behaviour that is fundamentally incompatible with certification of competence in this
dimension.

Professionalism can be defined in theoretical terms or in a pragmatic fashion. We have opted again for the
pragmatic fashion, starting with input from practicing family physicians, then using a focus group to identify
common themes, and then listing specific examples of behaviours (positive or negative) that reflect on
professionalism.

For these reasons we feel that our working definition of competence in professionalism requires the assessment to
have certain characteristics:

a) It must be done on real-life performances, either immediately or at a distance. It would appear to be

easiest to do this during residency training; it is just as important, however, to be able to do the
equivalent for those already in practice.

b) Many performances, in many situations, over an extended period of time, must be included in the
evaluation. This also implies the involvement of many different assessors or judges of the different
performances.

c) All judgments will be based on certain criteria specific to the situation at hand, but the judgment will
still be subjective, made by the observer-assessor most appropriate for the situation and performance.

d) All initial judgments of unprofessional behaviour must be subject to discussion, and possible
resolution, before being maintained. Staff or preceptors may not always behave professionally.

e) The criteria for certification remain to be established, but it is unlikely that certification of
professionalism will be based on scores or averages. Competence is essentially the absence of
unprofessional behaviour over a period of sufficient exposure and observation.

Twelve Themes that Define Professionalism in Family Medicine

(Examples of observable behaviours related to each theme can be found on the following pages.)

1. Day-to-day behaviour reassures one that the physician is responsible, reliable, and trustworthy.
2. The physician knows his or her limits of clinical competence and seeks help appropriately.
3. The physician demonstrates a flexible, open-minded approach that is resourceful and deals with
uncertainty.
4. The physician evokes confidence without arrogance, and does so even when needing to obtain further
information or assistance.
5. The physician demonstrates a caring and compassionate manner.
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6. The physician demonstrates respect for patients in all ways, maintains appropriate boundaries, and is
committed to patient well-being. This includes time management, availability, and a willingness to assess
performance.
7. The physician demonstrates respect for colleagues and team members.
8. Day-to-day behaviour and discussion reassure one that the physician is ethical and honest.
9. The physician practices evidence-based medicine skillfully. This implies not only critical appraisal and
information-management capabilities, but incorporates appropriate learning from colleagues and patients.
10. The physician displays a commitment to societal and community well-being.
11. The physician displays a commitment to personal health and seeks balance between personal life and
professional responsibilities.
12. The physician demonstrates a mindful approach to practice by maintaining composure/equanimity, even
in difficult situations, and by engaging in thoughtful dialogue about values and motives.

A few remarks on the organization and wording of the behaviours listed under each theme:
Although the behaviours are listed under 12 different themes, they could be considered as one list, to be used in
the most general sense as a menu from which to draw concrete examples that can be used when giving feedback on
professional or unprofessional behaviour, or when assessing the same in a more structured fashion.

We have not placed the behaviours under each theme in any order of priority. For each theme, positive behaviours
are listed first, with negative behaviours second. The choice of positivity or negativity in the formulation was
spontaneous—it might be advantageous to generate the opposite formulation when using a particular behaviour in
an assessment, but that can be done at the appropriate moment. Some behaviours are quite similar to others, some
are opposites, but no conscious effort was made to determine the latter. In general, only the positive or the negative
manifestation of the behaviour was described. At the moment, in this list, there are about 80 behaviours expressed
positively, and about 50 behaviours expressed negatively.

No standard structure or formulation was used. Some are quite general and others very specific. Taken together,
however, we do feel that they provide a sufficient and clear operational definition that can serve as the basis for the
development of a structured evaluation of professionalism in most of the contexts applicable to family medicine.
The user will make both the selection and the refinements appropriate to the situation.

1. Day-to-day behaviour reassures one that the physician is responsible, reliable, and trustworthy.

Observable Behaviours:

Comes to clinic when expected

Answers pages when on call
Notifies attending colleague if he or she is going away and has a maternity patient due or is following an in-
patient
Notifies others when away for illness or emergencies as soon as possible
Sets up systems for follow-up of patients
Does not lie

Does not look up questions after specific requests

Leaves early, arrives late, without advising
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Inappropriately double schedules activities

Switches schedules to personal advantage
Does not do patient rounds appropriately i.e., too infrequent, too cursory
Is unavailable for clinical responsibilities for personal reasons, without consideration of the needs of the
patient or team
Allows chart completion to back up unreasonably
Does not document lab results as normal or abnormal; does not document follow-up
Does not do letters, summaries
Cheats on exams or quizzes (e.g., ALSO, NRP)
Goes into SOOs with foreknowledge of cases (i.e., cheats on exams)
Does not check allergies or interactions when prescribing
Fails to follow up in a timely fashion with patients when investigations are pending (e.g., a skin biopsy), or in
potentially serious clinical situations (e.g., a depressed adolescent who does not show up for an appointment)
Lies about prior experience with a procedure to get to do it
Signs in for others when attendance is taken at academic events
Plagiarizes on projects

2. The physician knows his or her limits of clinical competence and seeks help appropriately.

Observable Behaviours:

Seeks opportunities to address limitations to improve knowledge and skills (electives/continuing education)
Does not use the excuse of limited clinical competence to avoid challenging clinical problems

Argues about deficiencies in clinical competence in spite of examples to illustrate concerns

Ignores clinical problems to mask clinical limitations
Refers cases even when he or she has the skills and resources to perform the tasks (does not take the time to do
appropriate medical procedures)
Does not initiate the management of complex/difficult problems when a patient presents— defers to an
attending physician or a consultant
Does not prepare adequately for a procedure

3. The physician demonstrates a flexible, open-minded approach that is resourceful and deals with
uncertainty.

Observable Behaviours:

In patient encounters, consistently demonstrates a willingness to explore the patient’s ideas of cause and take
steps to include or exclude these from the ensuing differential diagnosis
Is willing to adapt diagnosis/plan when provided with an alternative view/information/perspective (willing to
change his or her mind)
Provides time to deal with the emotion related to an uncertain diagnosis
Does not unnecessarily limit patient options (i.e., does not display paternalism)
Is satisfied with “symptom diagnosis” (e.g., says “dyspepsia”, not “peptic ulcer disease”) when information is
limited or diagnosis is not confirmable
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Formulates a patient-centred stepwise plan to deal with a situation even when he or she doesn’t know the
answer

Cuts patients off

Refuses to deal with a major problem during an office visit because of time
Refuses to see a patient who arrives slightly late for an appointment
Shows anger/rigidity when patients don’t follow a prescribed course of action
Becomes dismissive of patient ideas when they don’t fit his or her own
Uses manipulative techniques to influence patient behaviour (“I won’t be able to take care of you if you choose
to do…”)

4. The physician evokes confidence without arrogance, and does so even when needing to obtain further
information or assistance.

Observable Behaviours:

Says, “I don’t know but I know how I am going to find out”

Management discussions with patients are clearly helpful to the patient with “value added”, even without a
certain diagnosis or final opinion about available treatment
Projects appropriate confidence in non-verbal communication: looks patients in the eye when he or she says,“I
don’t know”

Uses own experience to devalue the patient’s experience (e.g., “I didn’t have to have an epidural”)
Tells patients what to do without understanding their circumstances (displays arrogance, paternalism)

5. The physician demonstrates a caring and compassionate manner.

Observable Behaviours:

Allows patients time to verbalize their concerns without cutting them off; listens for a while before talking—
actively listens before talking
Does not belittle the patient’s losses/fears
Asks patients about their feelings, worries, hopes
Sits down with patients whenever possible while communicating
Addresses issues or behaviours with patients rather than confronting them personally or judgmentally
Expands on healthy options or choices with patients
Keeps patients’ needs foremost when faced with own personal concerns about medical
errors/disasters/accusations
Is willing to acknowledge the patient’s emotions within the encounter
Does not blame patients for difficult situations they encounter
When dealing with a difficult patient, recognizes his or her own feelings and avoids expressing anger
inappropriately
Despite time and workload pressure, maintains a pleasant, compassionate approach

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6. The physician demonstrates respect for patients in all ways, maintains appropriate boundaries, and is
committed to patient well-being. This includes time management, availability, and a willingness to assess
performance.

Observable Behaviours:

Respects the patient’s time as if it were his or her own: does his or her best to be on time; acknowledges when
he or she is not
Does not impose personal religious, moral, or political beliefs on a patient
Does not ask for or accept offers of dates from patients
Does not ask patients for favours
Does not accept inappropriate gifts
Does not make jokes at a patient’s expense
Respects a patient’s lifestyle choices as his or hers to make
Appreciates the power differential in the physician-patient interaction
Maintains personal appearance to facilitate patient comfort and confidence for individual patients, or for
specific patient populations
Comments and behaviours reinforce and enhance the patient’s abilities and capabilities
Does not lend patients money (or borrow money from patients)
Recognizes the difference between maintaining confidentiality and seeking appropriate professional advice
when needed in difficult situations
Actively looks at his or her practice with assessment tools, and implements appropriate changes
Thinks and speaks about patients in a positive manner
Attempts to understand the patient’s issues that precipitate difficult behaviour or non-compliance, and adapts
his or her response accordingly

Always seems rushed or burdened by too many demands

Complains about other team members in front of patients
Blames others for a personal lack of organization or harried approach (“Who took my stethoscope this time?”,
“Where’s my pen?”, “I’m late because there are no parking spots”, “The secretary didn’t remind me I had to be
there”, “My charts weren’t out”)
Is reluctant or refuses to see some patients

7. The physician demonstrates respect for colleagues and team members.

Observable Behaviours:

Does not undermine and avoids making negative comments about other providers, especially those who may
have seen patients in different settings or contexts
When consulted or asked for help, listens to concerns and tries to respond positively and to be available
(“How can I help?” vs. “I don’t need to see this patient”)
When needing to talk to someone unexpectedly, waits and picks the right moment; does not interrupt unduly
Thinks and speaks about colleagues in a positive manner; respects their time as if it were his or her own
Arrives on time

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Pays attention when others are speaking

Lets others speak/continue; hears them out and stays respectful even if he or she may not agree with topics or
points of view

Provides inappropriate feedback in an insensitive manner (non-specific, wrong place, wrong time)
Leaves early, picks the easy tasks, leaves tasks unfinished, etc., such that others have more work
Discusses contentious issues in public, or gossips
Avoids the discussion of contentious issues that are having or may have a major impact on team dynamics and
outcomes
Argues with other team members
Does not make personal adjustments in spite of repeated messages from others about performance in the
workplace
A male trainee does not accept feedback from a female colleague or faculty
Does other things (i.e., does not pay attention) while a colleague is speaking (e.g., text messages, reads paper,
does charts)

8. Day-to-day behaviour and discussion reassure that the physician is ethical and honest.

Observable Behaviours:

When an error has been made, acknowledges his or her own contribution, discusses it with the appropriate
parties, tries to clarify why the error was made and apply corrective action for the future
Obtains informed consent, asks about privacy/communication/confidentiality
Respects patient autonomy, and assesses whether patient decision making is impaired
Provides honest estimates concerning time, services, and billing

Discloses patient information against his or her expressed wishes, especially with respect to adolescents, the
elderly, and patients with different cultural issues
Discusses patients in “public” places
Provides medical treatment inappropriately to colleagues, including writing prescriptions
Claims (to colleagues, patients, others) to have done something that has not been done (e.g., history, physical
exam, lab tests, phone calls, follow-up)
Takes credit for work done by others (for monetary reasons, for prestige, for any reason)
Has inappropriate prescribing practices:
o Puts in the name of someone with a drug plan instead of the patient
o Prescribes inappropriately for self-gain
o Prescribes without sufficient assessment
Makes unjustifiable claims on insurance or other forms

9. The physician practices evidence-based medicine skillfully. This implies not only critical appraisal
and information-management capabilities, but incorporates appropriate learning from colleagues and
patients.

Observable Behaviours:

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Does not give undue weight to evidence-based medicine: incorporates the patient’s and family’s expertise about
the uniqueness of their situation; incorporates the experience and expertise of colleagues and team members,
as well as his or her own
When a patient questions care or makes suggestions, is open to respectful discussion; responds positively to
patients who bring materials from the Internet
When using guidelines or the results of clinical trials (on large populations), customizes and adapts them to
ensure applicability to the individual patient in question
Does not change a current treatment plan when temporarily dealing with someone else’s patient; if thinks
changes are desirable, discusses them first with the regular provider
Checks as to whether practice is consistent with recent evidence, and makes changes consistent with this
evidence
Identifies knowledge gaps in own clinical practice, and develops a strategy to fill it; frames clinical questions
that will facilitate the search for “answers” to these gaps

Does not use resources to acquire up-to-date information about specific cases
Following a group discussion and decision, does not incorporate agreed-upon changes into clinical practice
Relies too much on a limited set of inappropriate information resources (e.g., drug company representatives,
unselected Internet material, The Medical Post, “expert” opinion)
Does not critically question information

10. The physician displays a commitment to societal and community well-being.

Observable Behaviours: **

Does not dismiss concerns raised by patients on local issues that have an impact on their health (e.g., safe
walking areas, pollution)
Tries to empower the patient who raises concerns about community issues; acts in a confidential manner
Responds positively to community requests for participation: will dedicate some time and experience, some
resources (e.g., put a poster up)

Does not respect the duty to report in situations where there is a clear danger to others (e.g., meningococcal
disease, capacity to drive, child abuse)
Does not report inappropriate behaviour (e.g., substance abuse) of professional colleagues to the appropriate
supervisor or authority

** Although many examples around this theme may be found later in practice, we do not think it practical or fair
to assess this theme in great detail at the time of certification, namely during training or at the very beginning of
independent practice. The other themes of professionalism provide better opportunities for the appropriate
assessment of this dimension.

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11. The physician displays a commitment to personal health and seeks balance between personal life and
professional responsibilities.

Observable Behaviours:

Takes appropriate time to fulfill personal needs

Is willing to discuss observations from colleagues or team members when behaviour suggests difficulty because
of stress
When a conflict between professional and personal activities is brought to his or her attention, discusses it,
makes an appropriate adjustment or not
Sometimes puts the patient first, ahead of personal need, and demonstrates satisfaction and appreciation of
the value of this action
Has a healthy lifestyle: does not smoke, does not drink to excess, drives reasonably

Takes frustration, etc., out on colleagues/staff (e.g., is rude and inappropriate)

Fails or refuses to recognize or deal with significant illness or a condition that may have an impact on
professional activities, especially when concerns are identified by others
Stays overtime inappropriately, comes to work sick, is unwilling to take time off
Burdens co-workers when taking care of own needs (i.e., leaves many things undone without communicating
with colleagues)
Transfers tasks to colleagues without clear justification, without adequate communication; changes availability
for professional tasks “frequently”, “at the last minute”
Seeks medical care from friends or colleagues outside of a normal physician-patient relationship; acts as own
physician

12. The physician demonstrates a mindful approach to practice by maintaining composure/equanimity,

even in difficult situations, and by engaging in thoughtful dialogue about values and motives.

Observable Behaviours:

Given a difficult situation, maintains composure and is able to act appropriately (e.g., with angry patients, an
unexpected clinical turn of events, an overwhelming demand, examinations)
Is consistently attentive to a patient or colleague throughout any interaction
Tries to understand the behaviour of others without getting mad or being hurt
Does not display anger, inappropriate humour, or other emotions when this could undermine constructive
work with patients or colleagues
When emotions are intense or visible, can nevertheless explain or suggest a constructive plan of action
Does not lose his or her cool—even when the other person in the room loses it
Can allow for multiple perspectives from various participants in complex situations; entertains or solicits other
viewpoints
Is willing to engage in dialogue, in order to learn from experience and others, when
o a bad/unexpected outcome occurs
o there are conflicting ideas

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o he or she is asked questions (does not perceive these as a threat; makes time to discuss them vs. being
“too busy to talk about it”)
When a mistake appears to have been made, acknowledges it and looks first for personal responsibility rather
than directing blame elsewhere

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 Part II—Essential Skills, Themes, and Observable Behaviours

Clinical Reasoning Skills

This dimension of competence is one of two that are currently almost entirely defined by and within the key
features of the priority topics.

Each key feature suggests, explicitly or implicitly, the dimensions of competence as well as the phase of the clinical
encounter, and, hence, the specific cognitive skills, that are characteristic of competence when dealing with the
problem in question. All the key features have been individually coded as to the skills and phases assessed, but
these codes are not yet visible in this version of the evaluation objectives document—the majority of the key
features (60%), however, involve clinical reasoning skills, so using them in an unselected fashion will certainly
touch on this dimension.

Clinical reasoning is a more familiar territory and the framework used is that of clinical problem solving using the
hypothetico-deductive model, with particular emphasis, however, on using it in an expert fashion. The skilled
physician will use this model efficiently, in a manner adapted to the patient’s needs, as well as to those of the
problem at hand and the context of the encounter, to deal with a patient’s problems.

What are some of the characteristics of expert clinical reasoning, as opposed to the not-yet-expert? Repeated studies have
shown that the history is the most important part of the clinical encounter and that it is usually sufficient to suggest the
correct diagnoses. We use the term “diagnosis” in its widest sense, including problem identification at all levels, not just
medical diagnoses. The experienced clinician often generates the diagnostic possibilities or hypotheses within the first
minute of the clinical encounter. The expert then uses these hypotheses to direct the subsequent data gathering: he may
collect less information than a non-expert, but the information selected is often much more detailed around the
important points—he or she gathers the data necessary to deal with the problem, and does not lose time gathering non-
contributory information for the problem at hand. The data is interpreted as it is obtained, to finish with a second round
of diagnostic hypotheses—this step certainly requires expertise, but it is often self-evident if the initial diagnostic
hypotheses and the data gathering have been done in a skilled fashion. The physical examination and investigation phase
often play minor roles—indeed it is often a question of confirming or eliminating diagnostic possibilities generated by the
history.

Is it reasonable to almost equate clinical reasoning skills (and medical problem solving) with skill in arriving at an
accurate diagnosis? Most would agree with this assumption, for two reasons. First, management and treatment certainly
require skill, but they are heavily knowledge dependent, so they are situated closer to the lower cognitive levels of clinical
competence, as well as being particularly dependent on an accurate set of diagnoses. Second, with a few domain-specific
exceptions, the various cognitive and non-cognitive skills required in the later phases of the clinical encounter are all
required to a higher degree in making an accurate and pertinent diagnosis.

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Of course, although skill at making accurate diagnoses is a necessary element of competence in clinical reasoning skills, it
is probably not sufficient by itself. A well-planned assessment of competence in clinical reasoning skills will put great
emphasis on taking the history and making diagnoses, but it will also include some tasks situated in the later parts of the
clinical encounter. It will not do this in a random fashion, however. This brings us back to the concept of the interaction
between the patient, the physician, and the problem. Each interaction will itself determine which steps are most critical:
for some it may well be the treatment or the physical examination, and, if this is so, then this is where competence lies for
this interaction, and this is what should be assessed. The challenge, for valid assessment, is to match the evaluation with
the interaction. The key feature analysis did this, so the best definition of competence in clinical reasoning skills can be
found in the Priority Topics and Key Features List.

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 Part II—Essential Skills, Themes, and Observable Behaviours

Selectivity

This dimension has not, to our knowledge, been previously described with respect to physician competence,
although it is surely not an original idea. It is the term that was chosen by the initial focus group to describe a set of
skills that was frequently cited in the survey as characterizing the competent family physician: such a physician
does not do things in a routine or stereotypical fashion but is very adaptable and selective in approach, modifying it
to suit both the situation and the patient. Some of the ways in which a physician demonstrates competence in this
dimension are as follows:

• Sets priorities and focuses on the most important

• Knows when to say something and when not to
• Gathers the most useful information without losing time on less contributory data
• Does something extra when it will likely be helpful
• Distinguishes the emergent from the elective and intervenes in a timely fashion
• Acts when necessary, even though information may be incomplete
• Determines the likelihoods, pertinence, and priorities in his or her differential diagnoses
• Distinguishes the sick from the not sick
• Selects and modifies a treatment to fit the particular needs of a patient and a situation

Selectivity could perhaps be considered a subset of all the other dimensions, but it was used frequently enough in
the descriptions of competence to merit its own dimension. As we saw earlier, selectivity is found at the higher
levels of competence, and it could be an extremely robust indicator of overall competence when used for assessment
purposes. It could also be considered to be one of the operational levels that go to make up clinical judgment, and
provides a way to assess this important concept.

This dimension of competence is one of two that are currently almost entirely defined by and within the key
features of the priority topics. Each key feature suggests, explicitly or implicitly, the dimensions of competence, as
well as the phase of the clinical encounter, and, hence, the specific cognitive skills that are characteristic of
competence when dealing with the problem in question. Sixteen percent of the key features involve selectivity as an
essential skill, most often (although not exclusively) associated with clinical reasoning skills. It may be sufficient to
assess selectivity only in this context, but we could also envisage its assessment in other dimensions, if necessary.
The concept surely applies. It would simply remain to develop a further operational definition of selectivity as it is
expressed in the other dimensions.

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Procedure Skills

Certification for independent practice requires a certain level of experiential competence: this includes the technical
skills to perform a certain number of procedures. Sixty-five core procedures are listed below, and these are the
procedures upon which the assessment of competence will be based 19. It should be remembered that it is not only
the technical aspects of the individual procedures that are important. The higher levels of competence must also be
assessed, as always, in the context of family medicine—the key features describe this aspect.

The General Key Features of Procedure Skills*

1. In order to decide whether or not you are going to do a procedure, consider the following:
a) The indications and contraindications to the procedure
b) Your own skills and readiness to do the procedure (e.g., your level of fatigue and any personal distractions)
c) The context of the procedure, including the patient involved, the complexity of the task, the time needed,
the need for assistance, and location
2. Before deciding to go ahead with the procedure:
a) Discuss the procedure with the patient, including a description of the procedure and possible outcomes,
both positive and negative, as part of obtaining their consent.
b) Prepare for the procedure by ensuring the appropriate equipment is ready.
c) Mentally rehearse the following:
o The anatomic landmarks necessary for procedure performance.
o The technical steps necessary in sequential fashion, including any preliminary examination.
o The potential complications and their management.
3. During performance of the procedure:
o Keep the patient informed to reduce anxiety.
o Ensure patient comfort and safety always.

4. When the procedure is not going as expected, re-evaluate the situation, and stop and/or seek assistance as
required.
5. Develop a plan with your patient for after care and follow-up after completion of a procedure.

* Apply to all procedures. These can be used to guide the development of specific evaluation tools for specific
procedures.

19 19
Wetmore SW, Rivet C, Tepper J, Tatemichi S, Donoff M, Rainsberry P. Defining core procedure skills for
Canadian family medicine training. Can Fam Physician. 2005; 51(10): 1364-5.

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 Part III: Priority Topics and Key Features

Part III: Priority Topics and Key Features

Priority Topics

Abdominal Pain .................................................................................................................... 60

Advanced Cardiac Life Support ................................................................................................ 61
Allergy ................................................................................................................................ 62
Anemia................................................................................................................................ 63
Antibiotics ........................................................................................................................... 64
Anxiety................................................................................................................................ 65
Asthma................................................................................................................................ 66
Atrial Fibrillation................................................................................................................... 67
Bad News............................................................................................................................. 68
Behavioural Problems ............................................................................................................. 69
Breast Lump ......................................................................................................................... 70
Cancer................................................................................................................................. 71
Chest Pain............................................................................................................................ 72
Chronic Disease .................................................................................................................... 73
Chronic Obstructive Pulmonary Disease..................................................................................... 74
Chronic Pain ........................................................................................................................ 75
Contraception ....................................................................................................................... 76
Cough ................................................................................................................................. 77
Counselling .......................................................................................................................... 78
Crisis .................................................................................................................................. 79
Croup.................................................................................................................................. 81
Deep Venous Thrombosis ....................................................................................................... 82
Dehydration ......................................................................................................................... 83
Dementia ............................................................................................................................. 84
Depression ........................................................................................................................... 86
Diabetes............................................................................................................................... 88
Diarrhea .............................................................................................................................. 89
Difficult Patient..................................................................................................................... 90
Disability ............................................................................................................................. 91
Dizziness ............................................................................................................................. 92
Domestic Violence ................................................................................................................. 93
Dyspepsia............................................................................................................................. 94
Dysuria................................................................................................................................ 95
Earache................................................................................................................................ 96
Elderly................................................................................................................................. 98
Epistaxis .............................................................................................................................. 99
Family Issues ...................................................................................................................... 100
Fatigue .............................................................................................................................. 101
Fever................................................................................................................................. 102
Fractures............................................................................................................................ 103
Gastro-intestinal Bleed.......................................................................................................... 104
Gender Specific Issues .......................................................................................................... 105
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 Part III: Priority Topics and Key Features

Grief ................................................................................................................................. 106

Headache ........................................................................................................................... 107
Heart Failure ...................................................................................................................... 108
Hepatitis............................................................................................................................ 109
Hyperlipidemia ................................................................................................................... 110
Hypertension...................................................................................................................... 111
Immigrants......................................................................................................................... 112
Immunization ..................................................................................................................... 113
In Children......................................................................................................................... 114
Infections ........................................................................................................................... 115
Infertility ........................................................................................................................... 116
Insomnia............................................................................................................................ 117
Ischemic Heart Disease ......................................................................................................... 118
Joint Disorder ..................................................................................................................... 119
Lacerations......................................................................................................................... 120
Learning (Patients/Self)........................................................................................................ 121
Lifestyle ............................................................................................................................. 122
Loss of Consciousness........................................................................................................... 123
Loss of Weight .................................................................................................................... 124
Low-back Pain .................................................................................................................... 125
Meningitis .......................................................................................................................... 126
Menopause ......................................................................................................................... 127
Mental Competency ............................................................................................................. 128
Multiple Medical Problems.................................................................................................... 130
Neck Pain .......................................................................................................................... 131
Newborn ........................................................................................................................... 132
Obesity.............................................................................................................................. 133
Osteoporosis....................................................................................................................... 134
Pain .................................................................................................................................. 135
Palliative Care ..................................................................................................................... 136
Parkinsonism...................................................................................................................... 137
Periodic Health Assessment/Screening .................................................................................... 138
Personality Disorder............................................................................................................. 139
Pneumonia......................................................................................................................... 140
Poisoning ........................................................................................................................... 142
Pregnancy .......................................................................................................................... 143
Prostate ............................................................................................................................. 145
Rape/Sexual Assault............................................................................................................. 146
Rash ................................................................................................................................. 147
Red Eye ............................................................................................................................. 148
Renal Failure ...................................................................................................................... 149
Schizophrenia ..................................................................................................................... 150
Seizures ............................................................................................................................. 151
Sex ................................................................................................................................... 152
Sexually Transmitted Infections.............................................................................................. 153
Shortness of Breath .............................................................................................................. 154
Skin Disorder ..................................................................................................................... 155
Smoking Cessation............................................................................................................... 156
Somatization ...................................................................................................................... 157
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 Part III: Priority Topics and Key Features

Stress ................................................................................................................................ 158

Stroke ............................................................................................................................... 159
Substance use and addiction ................................................................................................... 160
Suicide .............................................................................................................................. 162
Thyroid ............................................................................................................................. 163
Trauma ............................................................................................................................. 164
Travel Medicine .................................................................................................................. 165
Upper Respiratory Tract Infection .......................................................................................... 166
Urinary Tract Infection......................................................................................................... 167
Vaginal Bleeding.................................................................................................................. 168
Vaginitis ............................................................................................................................ 169
Violent/Aggressive Patient .................................................................................................... 170
Well-baby Care ................................................................................................................... 171

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 Part III: Priority Topics and Key Features

Abdominal Pain
Key Feature Skill Phase

1 Given a patient with abdominal pain, paying particular attention to

its location and chronicity:
Clinical Reasoning History
a) Distinguish between acute and chronic pain.
b) Generate a complete differential diagnosis (ddx). Clinical Reasoning Hypothesis generation
Diagnosis

c) Investigate in an appropriate and timely fashion. Clinical Reasoning Selectivity Investigation

2 In a patient with diagnosed abdominal pain (e.g., gastroesophageal Clinical Reasoning Treatment
reflux disease, peptic ulcer disease, ulcerative colitis, Crohn’s
disease), manage specific pathology appropriately (e.g., with.
medication, lifestyle modifications).
3 In a woman with abdominal pain: Hypothesis generation
a) Always rule out pregnancy if she is of reproductive age. Clinical Reasoning Investigation

b) Suspect gynecologic etiology for abdominal pain. Clinical Reasoning Hypothesis generation

c) Do a pelvic examination, if appropriate. Clinical Reasoning Physical

Diagnosis

4 In a patient with acute abdominal pain, differentiate between a Clinical Reasoning Selectivity Physical
surgical and a non-surgical abdomen. Diagnosis

5 In specific patient groups (e.g., children, pregnant women, the Clinical Reasoning Selectivity Hypothesis generation
elderly), include group-specific surgical causes of acute abdominal Diagnosis
pain in the ddx.
6 Given a patient with a life-threatening cause of acute abdominal
pain (e.g., a ruptured abdominal aortic aneurysm or a ruptured
ectopic pregnancy):
Selectivity Diagnosis
a) Recognize the life-threatening situation.
b) Make the diagnosis. Clinical Reasoning Diagnosis

c) Stabilize the patient. Selectivity Treatment

Clinical Reasoning

d) Promptly refer the patient for definitive treatment. Selectivity Diagnosis

Referral

7 In a patient with chronic or recurrent abdominal pain:

a) Ensure adequate follow-up to monitor new or changing
Clinical Reasoning Follow-up
symptoms or signs.
b) Manage symptomatically with medication and lifestyle Clinical Reasoning Treatment
modification (e.g., for irritable bowel syndrome). Communication

c) Always consider cancer in a patient at risk. Clinical Reasoning Hypothesis generation

Diagnosis

8 Given a patient with a diagnosis of inflammatory bowel disease Clinical Reasoning Hypothesis generation
(IBD) recognize an extra intestinal manifestation. Diagnosis

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 Part III: Priority Topics and Key Features

Advanced Cardiac Life Support

Key Feature Skill Phase

1 Keep up to date with advanced cardiac life support (ACLS) Professionalism Treatment
recommendations (i.e., maintain your knowledge base).
2 Promptly defibrillate a patient with ventricular fibrillation (V fib), Clinical Reasoning Selectivity Treatment
or pulseless or symptomatic ventricular tachycardia (V tach).
3 Diagnose serious arrhythmias (V tach, V fib, supraventricular Clinical Reasoning Diagnosis
tachycardia, atrial fibrillation, or second- or third-degree heart Treatment
block), and treat according to ACLS protocols.
4 Suspect and promptly treat reversible causes of arrhythmias (e.g., Clinical Reasoning Selectivity Hypothesis generation
hyperkalemia, digoxin toxicity, cocaine intoxication) before Treatment
confirmation of the diagnosis.
5 Ensure adequate ventilation (i.e., with a bag valve mask), and secure Clinical Reasoning Selectivity Treatment
the airway in a timely manner.
6 In patients requiring resuscitation, assess their circumstances (e.g., Clinical Reasoning Diagnosis
asystole, long code times, poor pre-code prognosis, living wills) to Treatment
help you decide when to stop. (Avoid inappropriate resuscitation.)
7 In patients with serious medical problems or end-stage disease, Patient-centred Approach Treatment
discuss code status and end-of-life decisions (e.g., resuscitation, Follow-up
feeding tubes, levels of treatment), and readdress these issues
periodically.
8 Attend to family members (e.g., with counselling, presence in the Professionalism Treatment
code room) during and after resuscitating a patient. Communication

9 In a pediatric resuscitation, use appropriate resources ( e.g., Clinical Reasoning Treatment

Braeslow tape, the patient’s weight) to determine the correct drug
doses and tube sizes.

Note: Shock is not dealt with in this topic.

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 Part III: Priority Topics and Key Features

Allergy
Key Feature Skill Phase

1 In all patients, always inquire about any allergy and clearly Clinical Reasoning History
document it in the chart. Re-evaluate this periodically. Follow-up

2 Clarify the manifestations of a reaction in order to try to diagnose a Clinical Reasoning History
true allergic reaction (e.g., do not misdiagnose viral rashes as Diagnosis
antibiotic allergy, or medication intolerance as true allergy).
3 In a patient reporting allergy (e.g., to food, to medications, Clinical Reasoning Treatment
environmental), ensure that the patient has the appropriate
medication to control symptoms (e.g., antihistamines,
bronchodilators, steroids, an EpiPen).
4 Prescribe an EpiPen to every patient who has a history of, or is at Clinical Reasoning Treatment
risk for, anaphylaxis.
5 Educate appropriate patients with allergy (e.g., to food, Clinical Reasoning Treatment
medications, insect stings) and their families about the symptoms of Patient-centred Approach Follow-up
anaphylaxis and the self-administration of the EpiPen, and advise
them to return for immediate reassessment and treatment if those
symptoms develop or if the EpiPen has been used.
6 Advise patients with any known drug allergy or previous major Clinical Reasoning Treatment
allergic reaction to get a MedicAlert bracelet. Patient-centred Approach

7 In a patient presenting with an anaphylactic reaction:

a) Recognize the symptoms and signs. Selectivity Diagnosis
Clinical Reasoning

b) Treat immediately and aggressively. Selectivity Treatment

Clinical Reasoning

c) Prevent a delayed hypersensitivity reaction through Clinical Reasoning Treatment

observation and adequate treatment (e.g., with steroids).
8 In patients with anaphylaxis of unclear etiology refer to an allergist Clinical Reasoning Referral
for clarification of the cause.
9 In the particular case of a child with an anaphylactic reaction to
food:
a) Prescribe an EpiPen for the house, car, school, and daycare.
Clinical Reasoning Treatment

b) Advise the family to educate the child, teachers, and Clinical Reasoning Treatment
caretakers about signs and symptoms of anaphylaxis, and about
when and how to use the EpiPen.
10 In a patient with unexplained recurrent respiratory symptoms, Clinical Reasoning Hypothesis Generation
include allergy (e.g., sick building syndrome, seasonal allergy) in the
differential diagnosis.

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 Part III: Priority Topics and Key Features

Anemia
Key Feature Skill Phase

1 Assess the risk of decompensation of anemic patients (e.g., volume Clinical Reasoning Selectivity Diagnosis
status, the presence of congestive heart failure [CHF], angina, or Treatment
other disease states) to decide if prompt transfusion or volume
replacement is necessary.
2 In a patient with anemia, classify the anemia as microcytic, Clinical Reasoning Diagnosis
normocytic, or macrocytic by using the MCV (mean corpuscular Investigation
value) or smear test result, to direct further assessment and
treatment.
3 In all patients with anemia, determine the iron status before Clinical Reasoning Investigation
initiating treatment. Diagnosis

4 In a patient with iron deficiency, investigate further to find the Clinical Reasoning Investigation
cause.
5 Consider and look for anemia in appropriate patients (e.g., those at Clinical Reasoning Selectivity Hypothesis Generation
risk for blood loss [those receiving anticoagulation, elderly patients Investigation
taking a nonsteroidal anti-inflammatory drug]) or in patients with
hemolysis (mechanical valves), whether they are symptomatic or
not, and in those with new or worsening symptoms of angina or
CHF.
6 In patients with macrocytic anemia:
a) Consider the possibility of vitamin B12 deficiency. Clinical Reasoning Hypothesis Generation

b) Look for other manifestations of the deficiency (e.g., Clinical Reasoning History
neurologic symptoms) in order to make the diagnosis of pernicious Physical
anemia when it is present.
7 As part of well-baby care, consider anemia in high-risk populations Clinical Reasoning Selectivity Hypothesis Generation
(e.g., those living in poverty) or in high-risk patients (e.g., those who
are pale or have a low-iron diet or poor weight gain).
8 When a patient is discovered to have a slightly low hemoglobin Clinical Reasoning Selectivity Hypothesis Generation
level, look carefully for a cause (e.g., hemoglobinopathies, Diagnosis
menorrhagia, occult bleeding, previously undiagnosed chronic
disease), as one cannot assume that this is normal for them.
9 In anemic patients with menorrhagia, determine the need to look Clinical Reasoning Hypothesis Generation
for other causes of the anemia.

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 Part III: Priority Topics and Key Features

Antibiotics
Key Feature Skill Phase

1 In patients requiring antibiotic therapy, make rational choices (i.e., Clinical Reasoning Selectivity Treatment
first-line therapies, knowledge of local resistance patterns, patient’s
medical and drug history, patient’s context).
2 In patients with a clinical presentation suggestive of a viral infection, Clinical Reasoning Treatment
avoid prescribing antibiotics.
3 In a patient with a purported antibiotic allergy, rule out other Clinical Reasoning Hypothesis Generation
causes (e.g., intolerance to side effects, non-allergic rash) before History
accepting the diagnosis.
4 Use a selective approach in ordering cultures before initiating Selectivity Investigation
antibiotic therapy (usually not in uncomplicated cellulitis,
pneumonia, urinary tract infections, and abscesses; usually for
assessing community resistance patterns, in patients with systemic
symptoms, and in immunicompromised patients).
5 In urgent situations (e.g., cases of meningitis, septic shock, febrile Selectivity Treatment
neutropenia), do not delay administration of antibiotic therapy (i.e.,
do not wait for confirmation of the diagnosis).

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 Part III: Priority Topics and Key Features

Anxiety
Key Feature Skill Phase

1 For a patient with multiple unexplained symptoms or behaviours, look for Clinical Reasoning Hypothesis Generation
anxiety as a primary or contributing cause. Patient-centred Approach Diagnosis

2 When a patient presents with symptoms of anxiety, clearly distinguish Clinical Reasoning History
between distress (e.g. fear, nervousness, worry) and an anxiety disorder. Patient-centred Approach Diagnosis

3 In a patient presenting with acute symptoms of panic (e.g., shortness of Selectivity Hypothesis Generation
breath, palpitations, hyperventilation), do not attribute the symptoms to Clinical Reasoning Diagnosis
anxiety without first excluding serious medical pathology (e.g., pulmonary
embolism, myocardial infarction) from the differential diagnosis, especially
in patients with established anxiety disorder.
4 When working up a patient with symptoms of anxiety, and before making
the diagnosis of an anxiety disorder, Selectivity Hypothesis generation
Clinical reasoning Diagnosis
a) Exclude serious medical pathology
b) Identify: Clinical reasoning History
• other co-morbid psychiatric conditions
• abuse
• substance use
c) Assess the risk of suicide Clinical reasoning History

d) Discuss functional impact with the patient Patient-centred Approach History

5 When an anxiety disorder is suspected, assess and classify according to Clinical reasoning Diagnosis
established diagnostic criteria, as treatment will vary according to the
classification.
6 In patients with known anxiety disorders, do not assume all new symptoms Selectivity Hypothesis generation
are attributable to the anxiety disorder. Clinical reasoning

7 When planning management of anxiety, offer appropriate treatment, which Patient-centred Approach Treatment
may include one or a combination of the following: Referral
t Self-management techniques
t Regular office follow-up
t Community resources
t Structured therapies (Cognitive Behavioral Therapy,
psychotherapy)
t Judicious use of pharmacotherapy
t Referral to other health professionals with ongoing shared
care
8 When managing anxiety or an anxiety disorder do not use medication as a Patient-centred Approach Treatment
sole treatment. Clinical reasoning

9 When assessing and managing anxiety, discuss the use of alcohol and Patient-centred Approach Treatment
substances as harmful self-medication. Communication

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 Part III: Priority Topics and Key Features

Asthma
Key Feature Skill Phase

1 In patients of all ages with respiratory symptoms (acute, chronic,

recurrent):
Clinical Reasoning Hypothesis generation
a) Include asthma in the differential diagnosis.
Diagnosis

b) Confirm the diagnosis of asthma by appropriate use of: Clinical Reasoning History
- history. Physical
- physical examination.
- spirometry.
2 In a child with acute respiratory distress, distinguish asthma or Clinical Reasoning Selectivity History
bronchiolitis from croup and foreign body aspiration by taking an Physical
appropriate history and doing a physical examination.
3 In a known asthmatic, presenting either because of an acute Clinical Reasoning Diagnosis
exacerbation or for ongoing care, objectively determine the severity
of the condition (e.g., with history, including the pattern of
medication use), physical examination, spirometry). Do not
underestimate severity.
4 In a known asthmatic with an acute exacerbation:
a) Treat the acute episode (e.g., use beta-agonists repeatedly Clinical Reasoning Selectivity Treatment
and early steroids, and avoid under-treatment).
b) Rule out co-morbid disease (e.g., complications, congestive Selectivity Hypothesis generation
heart failure, chronic obstructive pulmonary disease). Clinical Reasoning Diagnosis

c) Determine the need for hospitalization or discharge (basing Selectivity Treatment

the decision on the risk of recurrence or complications, and on the Clinical Reasoning
patient’s expectations and resources).
5 For the ongoing (chronic) treatment of an asthmatic, propose a Clinical Reasoning Treatment
stepwise management plan including: Patient Centered
- self-monitoring.
- self-adjustment of medication.
- when to consult back.
6 For a known asthmatic patient, who has ongoing or recurrent
symptoms:
Clinical Reasoning History
a) Assess severity and compliance with medication regimens.
Patient Centered Diagnosis

b) Recommend lifestyle adjustments (e.g., avoiding irritants, Clinical Reasoning Treatment

triggers) that may result in less recurrence and better control. Patient Centered

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 Part III: Priority Topics and Key Features

Atrial Fibrillation
Key Feature Skill Phase

1 In a patient who presents with new onset atrial fibrillation, look for Clinical Reasoning Hypothesis generation
an underlying cause (e.g., ischemic heart disease, acute myocardial
infarction, congestive heart failure, cardiomyopathy, pulmonary
embolus, hyperthyroidism, alcohol, etc.)
2 In a patient presenting with atrial fibrillation,
a) Look for hemodynamic instability, Clinical Reasoning Selectivity Hypothesis generation

b) Intervene rapidly and appropriately to stabilize the patient. Clinical Reasoning Selectivity Treatment

3 In an individual presenting with chronic or paroxysmal atrial

fibrillation,
Patient-centred Approach Diagnosis
a) Explore the need for anticoagulation based on the risk of
Clinical Reasoning Treatment
stroke with the patient,
b) Periodically reassess the need for anticoagulation. Clinical Reasoning Hypothesis generation
Follow-up

4 In patients with atrial fibrillation, when the decision has been made Clinical Reasoning Treatment
to use anticoagulation, institute the appropriate therapy and patient Follow-up
education, with a comprehensive follow-up plan.
5 In a stable patient with atrial fibrillation, identify the need for rate Clinical Reasoning Hypothesis generation
control. Treatment

6 In a stable patient with atrial fibrillation, arrange for rhythm Clinical Reasoning Selectivity Hypothesis generation
correction when appropriate. Treatment

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 Part III: Priority Topics and Key Features

Bad News
Key Feature Skill Phase

1 When giving bad news, ensure that the setting is appropriate, and Patient-centred Approach Treatment
ensure patient’s confidentiality. Communication

2 Give bad news: Communication Treatment

• in an empathic, compassionate manner
• allowing enough time.
• providing translation, as necessary
3 Obtain patient consent before involving the family. Patient-centred Approach Treatment
Professionalism

4 After giving bad news, arrange definitive follow-up opportunities to Patient-centred Approach Follow-up
assess impact and understanding. Communication

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 Part III: Priority Topics and Key Features

Behavioural Problems
Key Feature Skill Phase

1 In all patients, when working up a behavioural problem,

a) Ensure a thorough assessment of medical and mental Clinical reasoning Hypothesis generation
Patient-centred Approach History
health conditions (e.g., schizophrenia in adolescents and young
adults) and psychosocial factors before offering a diagnosis or
definitive advice (i.e., do not dismiss the problem as being “a phase,”
or “hormones,” or “just adolescence”)
b) Use a validated assessment tool if available Selectivity History
Clinical reasoning Investigation

c) Use multiple sources of information (e.g., workplace, Professionalism History

family, school) with consent
d) Explore the patient’s own perspective, not just that of the Patient-centred Approach History
caregiver
2 In assessing behavioural problems in adolescents specifically look for Clinical reasoning History
substance use, peer issues, abuse, and other stressors. Patient-centred Approach

3 While assessing behavioural problems in a patient,

a) Evaluate the impact of the behaviour Clinical reasoning History
Patient-centred Approach

b) Explore any underlying emotional distress with the patient Communication History
Patient-centred Approach Treatment

c) Destigmatize embarrassing behaviours Communication Treatment

Patient-centred Approach

4 When making a diagnosis of a behavioural problem in a patient, Clinical reasoning Hypothesis generation
a) Avoid premature labelling of a behaviour as a disorder Diagnosis

b) Follow up with support and regular visits until the Clinical reasoning Follow-up
situation is clearer and any therapeutic requirements are more
evident
5 When managing behavioural problems:
a) Assess and address immediate risk for the patient and Patient-centred Approach Treatment
others
b) Do not limit treatment to medication; address other Patient-centred Approach Treatment
dimensions (e.g., do not just use amphetamines to treat ADD, but
add social skills teaching, time management, etc.) and match to
available community resources
6 When there is a challenging relationship with a patient with Patient-centred Approach Follow-up
behavioural problems maintain a continuous, therapeutic, and non- Professionalism
judgmental relationship with the patient and family.

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 Part III: Priority Topics and Key Features

Breast Lump
Key Feature Skill Phase

1 Given a well woman with concerns about breast disease, during a

clinical encounter (annual or not):
Clinical Reasoning Selectivity History
a) Identify high-risk patients by assessing modifiable and non-
Diagnosis
modifiable risk factors
b) Advise regarding screening (mammography, breast self- Clinical Reasoning Treatment
examination) and its limitations. Patient-centred Approach

c) Advise concerning the woman’s role in preventing or Clinical Reasoning Treatment

detecting breast disease (breast self-examination, lifestyle changes). Patient-centred Approach

2 Given a woman presenting with a breast lump (i.e., clinical

features):
Selectivity Diagnosis
a) Use the history, features of the lump, and the patient’s age to
Clinical Reasoning Treatment
determine (interpret) if aggressive work-up or watchful waiting is
indicated.
b) Ensure adequate support throughout investigation of the Patient-centred Approach Treatment
breast lump by availability of a contact resource. Professionalism Follow-up

c) Use diagnostic tools (e.g., needle aspiration, imaging, core Clinical Reasoning Investigation
biopsy , referral) in an appropriate manner (i.e., avoid over- or Treatment
under-investigation, misuse) for managing the breast lump.
3 In a woman who presents with a malignant breast lump and knows
the diagnosis:
Clinical Reasoning Diagnosis
a) Recognize and manage immediate and long-term
Treatment
complications of breast cancer.
b) Consider and diagnose metastatic disease in the follow-up Clinical Reasoning Selectivity Hypothesis generation
care of a breast cancer patient by appropriate history and History
investigation.
c) Appropriately direct (provide a link to) the patient to Patient-centred Approach Follow-up
community resources able to provide adequate support Clinical Reasoning Treatment
(psychosocial support).

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 Part III: Priority Topics and Key Features

Cancer
Key Feature Skill Phase

1 In all patients, be opportunistic in giving cancer prevention advice Patient-centred Approach Treatment
(e.g., stop smoking, reduce unprotected sexual intercourse, prevent Communication
human papillomavirus infection), even when it is not the primary
reason for the encounter.
2 In all patients, provide the indicated evidence-based screening Clinical Reasoning Selectivity Diagnosis
(according to age group, risk factors, etc.) to detect cancer at an
early stage (e.g., with Pap tests, mammography, colonoscopy, digital
rectal examinations, prostate-specific antigen testing).
3 In patients diagnosed with cancer, offer ongoing follow-up and Patient-centred Approach Follow-up
support and remain involved in the treatment plan, in collaboration Professionalism Treatment
with the specialist cancer treatment system. (Don’t lose track of
your patient during cancer care.)
4 In a patient diagnosed with cancer, actively inquire, with Patient-centred Approach History
compassion and empathy, about the personal and social Communication
consequences of the illness (e.g., family issues, loss of job), and the
patient’s ability to cope with these consequences.
5 In a patient treated for cancer, actively inquire about side effects or Clinical Reasoning History
expected complications of treatment (e.g., diarrhea, feet Follow-up
paresthesias), as the patient may not volunteer this information.
6 In patients with a distant history of cancer who present with new Clinical Reasoning Hypothesis generation
symptoms (e.g., shortness of breath, neurologic symptoms), include
recurrence or metastatic disease in the differential diagnosis.
7 In a patient diagnosed with cancer, be realistic and honest when Communication Treatment
discussing prognosis. (Say when you don’t know.) Professionalism Follow-up

Note: For pain control, see the key features on chronic disease and palliative care. See also the key feature on
depression.

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 Part III: Priority Topics and Key Features

Chest Pain
Key Feature Skill Phase

1 Given a patient with undefined chest pain, take an adequate history Clinical Reasoning History
to make a specific diagnosis (e.g., determine risk factors, whether
the pain is pleuritic or sharp, pressure, etc.).
2 Given a clinical scenario suggestive of life-threatening conditions Selectivity Diagnosis
(e.g., pulmonary embolism, tamponade, dissection, pneumothorax), Treatment
begin timely treatment (before the diagnosis is confirmed, while
doing an appropriate work-up).
3 In a patient with unexplained chest pain, rule out ischemic heart Clinical Reasoning Selectivity Hypothesis generation
disease.* Investigation

4 Given an appropriate history of chest pain suggestive of herpes

zoster infection, hiatal hernia, reflux, esophageal spasm, infections,
or peptic ulcer disease:
Clinical Reasoning Diagnosis
a) Propose the diagnosis.
b) Do an appropriate work-up/follow-up to confirm the Clinical Reasoning Investigation
suspected diagnosis.
5 Given a suspected diagnosis of pulmonary embolism: Clinical Reasoning Hypothesis generation
a) Do not rule out the diagnosis solely on the basis of a test Diagnosis
with low sensitivity and specificity.
b) Begin appropriate treatment immediately. Selectivity Treatment

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 Part III: Priority Topics and Key Features

Chronic Disease
Key Feature Skill Phase

1 In a patient with a diagnosed chronic disease who presents with Clinical Reasoning Diagnosis
acute symptoms, diagnose:
• acute complications of the chornic disease (e.g., diabetic
ketoacidosis).
• acute exacerbations of the disease (e.g., asthma
exacerbation, acute arthritis).
• a new, unrelated condition.
2 Regularly reassess adherence (compliance) to the treatment plan Clinical Reasoning History
(including medications). Follow-up

3 In patients with chronic disease:

a) Actively inquire about pain. Clinical Reasoning History

b) Treat appropriately by: Clinical Reasoning Treatment

Hypothesis generation
• titrating medication to the patient's pain.
• taking into account other treatments and conditions (e.g.,
watching for interactions).
• considering non-pharmacologic treatment and adjuvant
therapies.
4 In patients with chronic disease, actively inquire about: Patient-centred Approach History
• the psychological impact of diagnosis and treatment. Clinical Reasoning

• functional impairment.
• underlying depression or risk of suicide.
• underlying substance abuse.
5 Given a non-compliant patient, explore the reasons why, with a Patient-centred Approach History
view to improving future adherence to the treatment plan.

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 Part III: Priority Topics and Key Features

Chronic Obstructive Pulmonary Disease

Key Feature Skill Phase

1 In all patients presenting with symptoms of prolonged or recurrent Clinical Reasoning Hypothesis generation
cough, dyspnea, or decreased exercise tolerance, especially those Diagnosis
who also have a significant smoking history, suspect the diagnosis of
chronic obstructive pulmonary disease (COPD).
2 When the diagnosis of COPD is suspected, seek confirmation with Clinical Reasoning Investigation
pulmonary function studies (e.g., FEV1).
3 In patients with COPD, use pulmonary function tests periodically Clinical Reasoning Investigation
to document disease progression. Follow-up

4 Encourage smoking cessation in all patients diagnosed with Clinical Reasoning Treatment
COPD.* Patient-centred Approach

5 Offer appropriate vaccinations to patients diagnosed with COPD Clinical Reasoning Treatment
(e.g., influenza/pneumococcal vaccination).
6 In an apparently stable patient with COPD, offer appropriate Clinical Reasoning Treatment
inhaled medication for treatment (e.g.,
anticholinergics/bronchodilators if condition is reversible, steroid
trial).
7 Refer appropriate patients with COPD to other health Clinical Reasoning Referral
professionals (e.g., a respiratory technician or pulmonary
rehabilitation personnel) to enhance quality of life.
8 When treating patients with acute exacerbations of COPD, rule out Clinical Reasoning Hypothesis generation
co-morbidities (e.g., myocardial infarction, congestive heart failure, Diagnosis
systemic infections, anemia).
9 In patients with end-stage COPD, especially those who are Patient-centred Approach Treatment
currently stable, discuss, document, and periodically re-evaluate Clinical Reasoning Follow-up
wishes about aggressive treatment interventions.

See also: Smoking Cessation

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 Part III: Priority Topics and Key Features

Chronic Pain
Key Feature Skill Phase
1 In a patient with chronic pain:
a) Establish the etiology Clinical reasoning Diagnosis
Selectivity
b) Reassess and periodically review the etiology (e.g., previously Clinical reasoning Diagnosis
undisclosed abuse, evolution of the underlying cause) Selectivity Follow-up
c) Periodically look for potential comorbidities or complications, Clinical reasoning Hypothesis
particularly mental illness and addictions Follow-up
2 In a patient with chronic pain who complains of significantly increased Clinical reasoning Hypothesis
pain, search for an alternative etiology (e.g., malignancy, addiction, Diagnosis
diversion) as you cannot assume that the original cause of the pain is the
reason for the exacerbation.
3 In a patient in whom you did not make the initial diagnosis of chronic
pain:
a) Establish an effective relationship Clinical reasoning Treatment
b) Verify the diagnosis Clinical reasoning Diagnosis
c) Clarify goals of treatment and plans for management Patient-centred Approach Treatment
4 In managing a patient with chronic pain:
a) Use shared decision-making Clinical reasoning Treatment
Patient-centered approach
b) Engage other professionals in this care when appropriate Clinical reasoning Treatment
Professionalism Referral
5 In a patient with chronic pain:
a) Comprehensively document the assessment, plan, goals, and Communication Follow-up
prescription details
b) Make the treatment plan appropriately accessible (e.g., to the Communication Follow-up
patient, team members, emergency department, on-call doctors, Professionalism
pharmacy)
6 When prescribing medications with abuse potential in a patient with Professionalism Diagnosis
chronic pain where you have no established relationship or insufficient Selectivity Treatment
records, be prudent in your prescribing (e.g., limit doses, document
reasons, check for double doctoring). Do not simply provide or refuse to
prescribe.
7 Use a written treatment contract with realistic consequences (e.g., limiting Communication Treatment
prescribed quantities/carries) when prescribing medications with abuse Professionalism Follow-up
potential to a patient with chronic pain.
8 When a patient with chronic pain has breached a contract:
a) Manage your own emotions Professionalism Treatment
b) Address the possible impact on your staff and team Professionalism Treatment
c) Apply or judiciously amend the contract (e.g., not putting a Clinical reasoning Treatment
patient into immediate withdrawal) Professionalism
9 In a patient with chronic pain and addiction who presents with a Clinical reasoning Hypothesis
destabilization of behaviour, carefully identify the etiology and Patient-centred Approach Treatment
contributing factors to adapt your management plan.

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 Part III: Priority Topics and Key Features

Contraception
Key Feature Skill Phase

1 With all patients, especially adolescents, young men, postpartum Patient-centred Approach Treatment
women, and perimenopausal women, advise about adequate Communication
contraception when opportunities arise.
2 In patients using specific contraceptives, advise of specific factors Clinical Reasoning Treatment
that may reduce efficacy (e.g., delayed initiation of method, illness, Patient-centred Approach
medications, specific lubricants).
3 In aiding decision-making to ensure adequate contraception:
a) Look for and identify risks (relative and absolute
Clinical Reasoning History
contraindications).
b) Assess (look for) sexually transmitted disease exposure. Clinical Reasoning History
Patient-centred Approach

c) Identify barriers to specific methods (e.g., cost, cultural Patient-centred Approach History
concerns). Communication

d) Advise of efficacy and side effects, especially short-term side Clinical Reasoning Treatment
effects that may result in discontinuation.
4 In patients using hormonal contraceptives, manage side effects Clinical Reasoning Treatment
appropriately (i.e., recommend an appropriate length of trial,
discuss estrogens in medroxyprogesterone acetate [Depo–
Provera]).
5 In all patients, especially those using barrier methods or when Clinical Reasoning Treatment
efficacy of hormonal methods is decreased, advise about post-coital
contraception.
6 In a patient who has had unprotected sex or a failure of the chosen Clinical Reasoning Treatment
contraceptive method, inform about time limits in post-coital
contraception (emergency contraceptive pill, intrauterine device).

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 Part III: Priority Topics and Key Features

Cough
Key Feature Skill Phase

1 In patients presenting with an acute cough:

a) Include serious causes (e.g., pneumothorax, pulmonary Clinical Reasoning Selectivity Hypothesis generation
embolism [PE]) in the differential diagnosis.
b) Diagnose a viral infection clinically, principally by taking an Clinical Reasoning Diagnosis
appropriate history.
c) Do not treat viral infections with antibiotics. (Consider Clinical Reasoning Treatment
antiviral therapy if appropriate.)
2 In pediatric patients with a persistent (or recurrent) cough, generate Clinical Reasoning Hypothesis generation
a broad differential diagnosis (e.g., gastroesophageal reflux disease
[GERD], asthma, rhinitis, presence of a foreign body, pertussis).
3 In patients with a persistent (e.g., for weeks) cough:
a) Consider non-pulmonary causes (e.g., GERD, congestive Clinical Reasoning Selectivity Hypothesis generation
Diagnosis
heart failure, rhinitis), as well as other serious causes (e.g., cancer,
PE) in the differential diagnosis. (Do not assume that the child has
viral bronchitis).
b) Investigate appropriately. Clinical Reasoning Investigation

4 Do not ascribe a persistent cough to an adverse drug effect (e.g., Clinical Reasoning Diagnosis
from an angiotensin-converting enzyme inhibitor) without first
considering other causes.
5 In smokers with persistent cough, assess for chronic bronchitis Clinical Reasoning Hypothesis generation
(chronic obstructive pulmonary disease) and make a positive Diagnosis
diagnosis when it is present. (Do not just diagnose a smoker’s
cough.)

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Counselling
Key Feature Skill Phase

1 When counselling a patient:

a) Set clear therapeutic goals with the patient Clinical reasoning Treatment
Patient-centred Approach

b) Allow adequate time Patient-centred Approach Treatment

Professionalism

c) Evaluate your own skills (e.g., Does the problem exceed the Professionalism Treatment
limits of your abilities? Are you the right person and is this the right
time to unpack the patient’s concerns?)
d) Recognize when you are approaching or exceeding Professionalism Treatment
boundaries (e.g., transference, counter-transference)
e) Recognize when your beliefs or biases may interfere with Professionalism Treatment
counselling
f) Remain aware of the risks of offering advice versus providing Professionalism Treatment
options
g) Pay close attention to the quality of the therapeutic Patient-centred Approach Treatment
relationship and alliance Communication Follow-up

2 For a patient who is considering or requesting referral for

counselling/psychotherapy, clarify concerns and provide realistic Clinical reasoning Treatment
Patient-centred Approach Referral
information about the process and available resources (e.g.,
expectations, timing, frequency, costs, duration, homework,
starting/ending the relationship if ineffective).

See also: Crisis

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Crisis
Key Feature Skill Phase

1 When a patient presents with acute emotional distress:

a) Take the necessary time to assist the patient, even if Selectivity Hypothesis generation
they present unexpectedly
b) Acknowledge their feelings and help them de-escalate Communication History
Patient-centred Approach Treatment

c) Employ the therapeutic effect of conversation Clinical reasoning Treatment

Communication

2 As part of your management of a patient facing a crisis:

a) Identify your patient’s personal resources for support Clinical reasoning
Patient-centred Approach History
(e.g., family, internal strength, friends) as part of your management
Treatment
of a patient facing a crisis.
b) Offer appropriate community resources (e.g., Selectivity Treatment
counsellor) as part of your ongoing management of a patient with Patient-centred Approach Referral
a crisis
c) Negotiate a follow-up plan with the patient Communication Treatment
Patient-centred Approach Follow-up

d) Be careful not to cross boundaries when treating a Professionalism Treatment

patient in crisis (e.g., lending money, providing appointments Hypothesis
outside regular hours)
3 When a patient presents with emotional distress or declares
themselves in crisis:
Clinical reasoning Diagnosis
a) Carefully assess the risk of harm to themselves or others
History

b) Ask your patient if there are others needing help Clinical reasoning Treatment
associated with the crisis Patient-centred Approach Follow-up

c) Act accordingly Clinical reasoning Diagnosis

Selectivity Treatment

4 Use psychoactive medication rationally to assist patients in crisis. Clinical Reasoning Diagnosis
Selectivity Treatment

5 Inquire about unhealthy coping methods (e.g., drugs, alcohol, Clinical Reasoning History
eating, gambling, violence, sloth, promiscuity) in your patients Professionalism
facing crisis.
6 Prepare your practice environment for possible crises or disasters Professionalism Hypothesis generation
and include colleagues and staff in the planning for both medical Treatment
and non-medical crises.

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7 When dealing with an unanticipated medical crisis (e.g.,

seizure, shoulder dystocia):
Professionalism History
a) Be calm and methodical
Clinical reasoning Treatment

b) Assess the environment for needed and available Selectivity Treatment

resources (people, material)
c) Ask for the help you need Professionalism Treatment
Communication Referral

d) Take timely action as appropriate in the context of the Clinical reasoning Treatment
situation (e.g., resuscitation in the waiting room of the clinic Selectivity
versus in the emergency department)
8 In all patients, to identify possible previous crises and avoid re-
traumatization during medical encounters: Clinical reasoning Hypothesis generation
Patient-centred Approach Diagnosis
a) Be attentive to triggers for re-traumatization

b) Recognize different manifestations of emotional distress Clinical reasoning Diagnosis

Patient-centred Approach

c) Address as appropriate Clinical reasoning Diagnosis

Patient-centred Approach Treatment

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 Part III: Priority Topics and Key Features

Croup
Key Feature Skill Phase

1 In patients with croup,

a) Identify the need for respiratory assistance (e.g., assess Selectivity Hypothesis generation
Clinical Reasoning Diagnosis
ABCs, fatigue, somnolence, paradoxical breathing, in drawing)
b) Provide that assistance when indicated. Clinical Reasoning Selectivity Treatment

2 Before attributing stridor to croup, consider other possible causes Clinical Reasoning Selectivity Hypothesis generation
(e.g., anaphylaxis, foreign body (airway or esophagus), Diagnosis
retropharyngeal abcess, epiglottitis).
3 In any patient presenting with respiratory symptoms, look Clinical Reasoning History
specifically for the signs and symptoms that differentiate upper Physical
from lower respiratory disease (e.g., stridor vs. wheeze vs. whoop).
4 In a child presenting with a clear history and physical examination Clinical Reasoning Selectivity Diagnosis
compatible with mild to moderate croup, make the clinical Investigation
diagnosis without further testing (e.g., do not routinely X-ray).
5 In patients with a diagnosis of croup, use steroids (do not under Clinical Reasoning Treatment
treat mild-to-moderate cases of croup).
6 In a patient presenting with croup, address parental concerns (e.g., Clinical Reasoning Treatment
not minimizing the symptoms and their impact on the parents), Communication Follow-up
acknowledging fluctuating course of the disease, providing a plan
anticipating recurrence of the symptoms.

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 Part III: Priority Topics and Key Features

Deep Venous Thrombosis

Key Feature Skill Phase

1 In patients complaining of leg pain and/or swelling, evaluate the Clinical Reasoning Selectivity Hypothesis generation
likelihood of deep venous thrombosis (DVT) as investigation and Diagnosis
treatment should differ according to the risk.
2 In patients with high probability for thrombotic disease (e.g., Clinical Reasoning Selectivity Treatment
extensive leg clot, suspected pulmonary embolism) start
anticoagulant therapy if tests will be delayed.
3 Identify patients likely to benefit from DVT prophylaxis. Selectivity Hypothesis generation
Clinical Reasoning Diagnosis

4 Utilize investigations for DVT allowing for their limitations (e.g., Clinical Reasoning Selectivity Investigation
Ultrasound and D-dimer). Diagnosis

5 In patients with established DVT use oral anticoagulation Clinical Reasoning Treatment
appropriately, (e.g., start promptly, watch for drug interactions, Follow-up
monitor lab values and adjust dose when appropriate, stop warfarin
when appropriate,provide patient teaching).
6 Consider the possibility of an underlying coagulopathy in patients Clinical Reasoning Hypothesis generation
with DVT, especially when unexpected.
7 Use compression stockings in appropriate patients, to prevent and Clinical Reasoning Treatment
treat post-phlebitic syndrome.

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Dehydration
Key Feature Skill Phase

1 When assessing the acutely ill patient, look for signs and symptoms Clinical Reasoning Hypothesis generation
of dehydration. (e.g., look for dehydration in the patient with a
debilitating pneumonia).
2 In the dehydrated patient, assess the degree of dehydration using Clinical Reasoning Physical
reliable indicators (e.g., vital signs) as some patients' hydration Investigation
status may be more difficult to assess (e.g., elderly, very young,
pregnant).
3 In a dehydrated patient,
a) Determine the appropriate volume of fluid for replacement Clinical Reasoning Treatment
Diagnosis
of deficiency and ongoing needs,
b) Use the appropriate route (oral if the patient is able; IV Clinical Reasoning Treatment
when necessary).
4 When treating severe dehydration, use objective measures (e.g., lab Clinical Reasoning Investigation
values) to direct ongoing management. Treatment

5 In a dehydrated patient,
a) Identify the precipitating illness or cause, especially looking Clinical Reasoning Hypothesis generation
for non-gastro-intestinal, including drug-related, causes,
b) Treat the precipitating illness concurrently. Clinical Reasoning Treatment

6 Treat the dehydrated pregnant patient aggressively, as there are Clinical Reasoning Selectivity Hypothesis generation
additional risks of dehydration in pregnancy. Treatment

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Dementia
Key Feature Skill Phase

1 In patients with early, non-specific signs of cognitive impairment:

a) Suspect dementia as a diagnosis.
Hypothesis generation
Clinical Reasoning Diagnosis

b) Use validated tests of cognitive function and careful Clinical Reasoning Diagnosis
functional inquiry, as well as a careful history (including collateral
history from family and caregivers if available) and physical
examination, to make an early positive diagnosis.
2 In patients with obvious cognitive impairment,
a) Select proper laboratory investigations and neuroimaging Clinical reasoning Investigation
techniques to complement the history and physical findings and to
distinguish between dementia, delirium, and depression
b) Consider possible contributing causes, including mental Clinical reasoning Hypothesis generation
health, alcohol or substance use problems, or delirium
3 In patients with dementia, distinguish Alzheimer’s disease from Clinical Reasoning Diagnosis
other dementias, as treatment and prognosis differ.
4 In patients with dementia who exhibit worsening function, look for Clinical Reasoning Hypothesis generation
other diagnoses (i.e., don’t assume the dementia is worsening). Diagnosis
These diagnoses may include depression, infection, concurrent
medical illness, substance use, etc.
5 When disclosing the diagnosis of dementia,
a) Do so compassionately Patient-centred Approach Diagnosis
Communication Treatment

b) Respect the patient’s right to autonomy, confidentiality, and Professionalism Treatment

safety
6 In patients with dementia, assess competency to involve them in Clinical Reasoning Diagnosis
decision making, as appropriate to the situation Treatment

7 In following patients diagnosed with dementia:

a) Assess function and cognitive impairment on an ongoing Clinical Reasoning Follow-up
Physical
basis.
b) Assist with and plan for appropriate interventions (e.g., deal Clinical Reasoning Treatment
with medication issues, behavioural disturbance management, safety Patient-centred Approach
issues, caregiver issues, comprehensive care plans, advanced care
planning, driving safety, placement) in the context of disease
progression
c) Manage comorbidities, including mental health problems Patient-centred Approach Treatment
based on the goals of care Clinical reasoning

d) Review pharmacotherapy (e.g. side effects, drug interaction, Selectivity Treatment

polypharmacy)
8 Assess the needs of and supports for caregivers of patients with Patient-centred Approach History
dementia.
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 Part III: Priority Topics and Key Features

9 Report patients with dementia to the appropriate authorities if you Professionalism Treatment
suspect they should not be driving. Clinical Reasoning

10 In patients with early-onset dementia, consider genetic testing Clinical Reasoning Hypothesis generation
Patient-centred Approach History

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 Part III: Priority Topics and Key Features

Depression
Key Feature Skill Phase

1 In a patient with a diagnosis of depression:

a) Assess the patient for the risk of suicide Clinical reasoning History
Communication Diagnosis

b) Decide on appropriate management (i.e., hospitalization or Clinical Reasoning Treatment

close follow-up, which will depend, for example, on severity
of symptoms, psychotic features, and suicide risk)
2 Identify patients who may be at a higher risk for depression (e.g., Clinical reasoning History
certain socio-economic groups, those who suffer from substance
abuse, postpartum women, people with chronic pain) and assess
appropriately.
3 In patients who have medically unexplained symptoms consider and Clinical reasoning Hypothesis generation
assess for depression. Patient-centred Approach History

4 After a diagnosis of depression is made look for and diagnose other Clinical reasoning Hypothesis generation
comorbid psychiatric conditions (e.g., anxiety, bipolar disorder, Diagnosis
personality disorder).
5 In a patient diagnosed with depression:
a) Manage appropriately (e.g., medications, psychotherapy,
Clinical reasoning Treatment
supported self-management)
Patient-centred Approach

b) Monitor their response to therapy and modify appropriately Clinical reasoning Treatment
(e.g., augmentation, dose changes, medication changes) Follow-up

c) Reassess the patient’s safety Clinical reasoning Follow-up

d) Set goals, including a return-to-work plan Patient-centred Approach Treatment

e) Refer as necessary (including community resources) Clinical reasoning Referral

Patient-centred Approach

6 In a patient presenting with symptoms consistent with depression Clinical reasoning Hypothesis generation
consider and rule out serious organic pathology using a targeted History
history, physical examination, and investigations (especially in
elderly or difficult patients).
7 In patients presenting with depression inquire about abuse: Clinical reasoning History
Selectivity
• Sexual, physical, and emotional abuse (past and current,
witnessed or inflicted)
• Addictions (e.g., substance use/abuse, gambling)
8 In a patient with symptoms of depression differentiate major Clinical reasoning History
depression from adjustment disorder, dysthymia, and a grief Diagnosis
reaction.
9 Following failure of an appropriate treatment in a patient with Clinical reasoning Hypothesis generation
depression consider other diagnoses (e.g., bipolar disorder,
schizoaffective disorder, organic disease).
10 In very young and elderly patients presenting with changes in Clinical reasoning Hypothesis generation

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 Part III: Priority Topics and Key Features

behaviour consider the diagnosis of depression (as they may not

present with classic features).
11 When treating a patient with antidepressants use them in a selective Clinical reasoning History
and careful manner, adapted to the presentation and the needs of Selectivity Treatment
the individual patient, by:
• Selecting the most appropriate antidepressant and dose for
the patient based on patient factors and on
pharmacological factors (e.g., possible drug interactions)
• Monitoring medication effectiveness, including adherence
and the patient’s possible self-medication using other
substances (e.g., herbal and naturopathic remedies, alcohol,
cannabis)
• Considering augmentation strategies when appropriate
• Monitoring side effects carefully when initiating treatment,
especially in young and elderly patients
• Discontinuing medication gradually, monitoring for
relapse, recognizing risk, and following response
12 When developing a return-to-work plan for a patient who is being
treated for depression:
Patient-centred Approach Treatment
a) Assess the impact of residual symptoms on work
Selectivity
hardiness, performance, and safety
b)Communicate with the patient and the workplace to Patient-centred Approach Treatment
ensure the plan is realistic and provides clear guidance Communication

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 Part III: Priority Topics and Key Features

Diabetes
Key Feature Skill Phase

1 Given a symptomatic or asymptomatic patient at high risk for Clinical Reasoning Selectivity Investigation
diabetes (e.g., patients with gestational diabetes, obese, certain Hypothesis generation
ethnic groups, and those with a strong family history), screen at
appropriate intervals with the right tests to confirm the diagnosis.
2 Given a patient diagnosed with diabetes, either new-onset or Clinical Reasoning Treatment
established, treat and modify treatment according to disease status Follow-up
(e.g., use oral hypoglycemic agents, insulin, diet, and/or lifestyle
changes).
3 Given a patient with established diabetes, advise about signs and Clinical Reasoning Treatment
treatment of hypoglycemia/hyperglycemia during an acute illness or Patient-centred Approach
stress (i.e., gastroenteritis, physiologic stress, decreased intake.
4 In a patient with poorly controlled diabetes, use effective Communication Patient- Treatment
educational techniques to advise about the importance of optimal centred Approach
glycemic control through compliance, lifestyle modification, and
appropriate follow-up and treatment.
5 In patients with established diabetes:
a) Look for complications (e.g., proteinuria). Clinical Reasoning Hypothesis generation
Diagnosis

b) Refer them as necessary to deal with these complications Clinical Reasoning Treatment
Follow-up

6 In the acutely ill diabetic patient, diagnose the underlying cause of Clinical Reasoning Selectivity Diagnosis
the illness and investigate for diabetic ketoacidosis and Treatment
hyperglycemia.
7 Given a patient with diabetic ketoacidosis, manage the problem Clinical Reasoning Selectivity Treatment
appropriately and advise about preventing future episodes. Follow-up

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 Part III: Priority Topics and Key Features

Diarrhea
Key Feature Skill Phase

1 In all patients with diarrhea,

a) Determine hydration status, Clinical Reasoning Diagnosis

b) Treat dehydration appropriately. Clinical Reasoning Treatment

2 In patients with acute diarrhea, use history to establish the possible Clinical Reasoning Hypothesis generation
etiology (e.g., infectious contacts, travel, recent antibiotic or other History
medication use, common eating place for multiple ill patients).
3 In patients with acute diarrhea who have had recent hospitalization Clinical Reasoning Hypothesis generation
or recent antibiotic use, look for clostridium difficile.
4 In patients with acute diarrhea, counsel about the timing of return Clinical Reasoning Treatment
to work/school (re: the likelihood of infectivity).
5 Pursue investigation, in a timely manner, of elderly with Clinical Reasoning Selectivity Hypothesis generation
unexplained diarrhea, as they are more likely to have pathology. Investigation

6 In a young person with chronic or recurrent diarrhea, with no red Clinical Reasoning Selectivity Diagnosis
flag symptoms or signs, use established clinical criteria to make a
positive diagnosis of irritable bowel syndrome (do not
overinvestigate).
7 In patients with chronic or recurrent diarrhea, look for both gastro- Clinical Reasoning History
intestinal and non-gastro-intestinal symptoms and signs suggestive Physical
of specific diseases (e.g., inflammatory bowel disease, malabsorption
syndromes, and compromised immune system).

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Difficult Patient
Key Feature Skill Phase

1 When physician-patient interaction is deemed difficult, diagnose Clinical Reasoning Diagnosis

personality disorder when it is present in patients.
2 When confronted with difficult patient interactions, seek out and Patient-centred Approach History
update, when necessary, information about the patient’s life Diagnosis
circumstances, current context, and functional status.
3 In a patient with chronic illness, expect difficult interactions from Patient-centred Approach Treatment
time to time. Be especially compassionate and sensitive at those Professionalism Follow-up
times.
4 With difficult patients remain vigilant for new symptoms and Selectivity Hypothesis generation
physical findings to be sure they receive adequate attention (e.g., Diagnosis
psychiatric patients, patients with chronic pain).
5 When confronted with difficult patient interactions, identify your Professionalism Treatment
own attitudes and your contribution to the situation. Diagnosis

6 When dealing with difficult patients, set clear boundaries. Professionalism Treatment

7 Take steps to end the physician-patient relationship when it is in Professionalism Patient- Treatment
the patient’s best interests. centred Approach

8 With a difficult patient, safely establish common ground to Patient-centred Approach Treatment
determine the patient’s needs (eg. threatening or demanding Professionalism
patients).

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Disability
Key Feature Skill Phase

1 Determine whether a specific decline in functioning (e.g., social, Patient-centred Approach Diagnosis
physical, emotional) is a disability for that specific patient. Clinical Reasoning

2 Screen elderly patients for disability risks (e.g., falls, cognitive Clinical Reasoning History
impairment, immobilization, decreased vision) on an ongoing basis. Hypothesis generation

3 In patients with chronic physical problems (e.g., arthritis, multiple Clinical Reasoning Diagnosis
sclerosis) or mental problems (e.g., depression), assess for and Patient-centred Approach Hypothesis generation
diagnose disability when it is present.
4 In a disabled patient, assess all spheres of function (emotional, Patient-centred Approach History
physical, and social, the last of which includes finances,
employment, and family).
5 For disabled patients, offer a multi-faceted approach (e.g., orthotics, Patient-centred Approach Treatment
lifestyle modification, time off work, community support) to Professionalism
minimize the impact of the disability and prevent further functional
deterioration.
6 In patients at risk for disability (e.g., those who do manual labour, Clinical Reasoning Treatment
the elderly, those with mental illness), recommend primary Patient-centred Approach
prevention strategies (e.g., exercises, braces, counselling, work
modification).
7 Do not limit treatment of disabling conditions to a short-term Clinical Reasoning Treatment
disability leave (i.e., time off is only part of the plan). Patient-centred Approach

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Dizziness
Key Feature Skill Phase

1 In patients complaining of dizziness, rule out serious cardiovascular, Clinical Reasoning Hypothesis generation
cerebrovascular, and other neurologic disease (e.g., arrhythmia, Diagnosis
myocardial infarction [MI], stroke, multiple sclerosis).
2 In patients complaining of dizziness, take a careful history to Clinical Reasoning History
distinguish vertigo, presyncope, and syncope.
3 In patients complaining of dizziness, measure postural vital signs. Clinical Reasoning Physical
Procedures Skills

4 Examine patients with dizziness closely for neurologic signs. Clinical Reasoning Physical
Procedures Skills Hypothesis generation

5 In hypotensive dizzy patients, exclude serious conditions (e.g., MI, Clinical Reasoning Hypothesis generation
abdominal aortic aneurysm, sepsis, gastrointestinal bleeding) as the Diagnosis
cause.
6 In patients with chronic dizziness, who present with a change in Clinical Reasoning Hypothesis generation
baseline symptoms, reassess to rule out serious causes. Diagnosis

7 In a dizzy patient, review medications (including prescription and Clinical Reasoning Hypothesis generation
over-the-counter medications) for possible reversible causes of the Diagnosis
dizziness.
8 Investigate further those patients complaining of dizziness who Selectivity Investigation
have:
• signs or symptoms of central vertigo.
• a history of trauma.
• signs, symptoms, or other reasons (e.g., anticoagulation) to
suspect a possible serious underlying cause.

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Domestic Violence
Key Feature Skill Phase

1 In a patient with new, obvious risks for domestic violence, take Patient-centred Approach History
advantage of opportunities in pertinent encounters to screen for Clinical Reasoning
domestic violence (e.g., periodic annual exam, visits for
anxiety/depression, ER visits).
2 In a patient in a suspected or confirmed situation of domestic
violence: Selectivity History
Clinical Reasoning
a) Assess the level of risk and the safety of children (i.e., the
need for youth protection).
b) Advise about the escalating nature of domestic violence. Clinical Reasoning Treatment
Patient-centred Approach

3 In a situation of suspected or confirmed domestic violence, develop, Clinical Reasoning Treatment

in collaboration with the patient, an appropriate emergency plan to Patient-centred Approach
ensure the safety of the patient and other household members.
4 In a patient living with domestic violence, counsel about the cycle of Patient-centred Approach Treatment
domestic violence and feelings associated with it (e.g., helplessness, Communication
guilt), and its impact on children.

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Dyspepsia
Key Feature Skill Phase

1 In a patient presenting with dyspepsia, include cardiovascular Clinical Reasoning Hypothesis generation
disease in the differential diagnosis.
2 Attempt to differentiate, by history and physical examination, Clinical Reasoning History
between conditions presenting with dyspepsia (e.g., Physical
gastroesophageal reflux disease, gastritis, ulcer, cancer), as plans for
investigation and management may be very different.
3 In a patient presenting with dyspepsia, ask about and examine the Clinical Reasoning History
patient for worrisome signs/symptoms (e.g., gastrointestinal Physical
bleeding, weight loss, dysphagia).

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Dysuria
Key Feature Skill Phase

1 In a patient presenting with dysuria, use history and dipstick Clinical Reasoning Selectivity Diagnosis
urinalysis to determine if the patient has an uncomplicated urinary
tract infection.
2 When a diagnosis of uncomplicated urinary tract infection is made, Clinical Reasoning Selectivity Treatment
treat promptly without waiting for a culture result.
3 Consider non-urinary tract infection related etiologies of dysuria Clinical Reasoning Hypothesis generation
(e.g., prostatitis, vaginitis, sexually transmitted disease, chemical
irritation) and look for them when appropriate.
4 When assessing patients with dysuria, identify those at higher risk Clinical Reasoning Selectivity Hypothesis generation
of complicated urinary tract infection (e.g., pregnancy, children,
diabetes, urolithiasis).
5 In patients with recurrent dysuria, look for a specific underlying Clinical Reasoning Hypothesis generation
cause (e.g., post-coital urinary tract infection, atrophic vaginitis,
retention).

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Earache
Key Feature Skill Phase

1 Make the diagnosis of otitis media (OM) only after good Clinical Reasoning Diagnosis
visualization of the eardrum (i.e., wax must be removed), and when Procedures Skills Physical
sufficient changes are present in the eardrum, such as bulging or
distorted light reflex (i.e., not all red eardrums indicate OM).
2 Include pain referred from other sources in the differential Clinical Reasoning Hypothesis generation
diagnosis of an earache (eg. Tooth abscess, trigeminal Neuralgia,
TMJ dysfunction, pharyngitis, etc.).
3 Consider serious causes in the differential diagnosis of an earache Clinical Reasoning Hypothesis generation
(eg. tumors, temporal arteritis, mastoiditis).
4 In the treatment of otitis media, explore the possibility of not giving Selectivity Treatment
antibiotics, thereby limiting their use (e.g., through proper patient Communication
selection and patient education because most otitis Media is of viral
origin), and by ensuring good follow-up (e.g., reassessment in 48
hours).
5 Make rational drug choices when selecting antibiotic therapy for the Selectivity Treatment
treatment of otitis media. (Use first-line agents unless given a Professionalism
specific indication not to.)
6 In patients with earache (especially those with otitis media), Clinical Reasoning Treatment
recommend appropriate pain control (oral analgesics).
7 In a child with a fever and a red eardrum, look for other possible Clinical Reasoning Hypothesis generation
causes of the fever (i.e., do not assume that the red ear is causing the
fever).*
8 Test children with recurrent ear infections for hearing loss. Clinical Reasoning Investigation

See also: Fever

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Eating Disorders

Key Feature Skill Phase

1 During clinical encounters with children, adolescents, and young Clinical reasoning History
adults include an assessment of the risk of eating disorders, Patient-centred Approach Hypothesis generation
irrespective of the patient’s gender, as this may be the only
opportunity.
2 When caring for a patient with ongoing psychological distress or Clinical reasoning History
unexplained physical symptoms ask about body image and self- Patient-centred Approach Hypothesis generation
harm behaviours, including disordered eating.
3 In a patient for whom concerns about eating behaviours have been Clinical reasoning History
identified take an appropriate history, including: Patient-centred Approach

• Eating patterns, relationship with food, body image,

distress
• Underlying mental health, alcohol, and substance use
problems, including previous psychological trauma
• Use of prescribed and over-the-counter medications,
tobacco, caffeine, laxatives, and supplements
4 In a patient with disordered eating behaviour(s):
a) Assess for physiological and metabolic complications Clinical reasoning Physical
Patient-centred Approach Investigation
b)Determine if there is a need for hospitalization or Clinical reasoning Treatment
immediate intervention Patient-centred Approach
5 When an eating disorder has been diagnosed:
a) Discuss the impact and potential consequences, Professionalism Treatment
Patient-centred Approach
regardless of the patient’s acceptance of the diagnosis
b) Engage the parents/caregivers/partners in treatment Professionalism Treatment
when appropriate and with consent Patient-centred Approach

c) Collaborate with the patient and, when appropriate, Communication Treatment

family to develop a treatment plan, including an inter- and intra- Patient-centred Approach Referral
professional referral when necessary
d) Use simple cognitive behavioural intervention first Clinical reasoning Treatment
(i.e., do not automatically assume tertiary care is needed) Selectivity

e) Periodically reassess behaviours and their impact on Clinical reasoning History

mood, anxiety, cognitive function, and relationships Patient-centred Approach Follow-up
6 When assessing a patient presenting with a problem that has Clinical reasoning Hypothesis generation
defied diagnosis (e.g., arrhythmias without cardiac disease, an Patient-centred Approach
electrolyte imbalance without drug use or renal impairment,
amenorrhea without pregnancy) include “complication of an
eating disorder” in the differential diagnosis.

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 Part III: Priority Topics and Key Features

Elderly
Key Feature Skill Phase

1 In the elderly patient taking multiple medications, avoid Clinical Reasoning Treatment
polypharmacy by: Follow-up

• monitoring side effects.

• periodically reviewing medication (e.g., is the medication still
indicated, is the dosage appropriate).
• monitoring for interactions.
2 In the elderly patient, actively inquire about non-prescription Clinical Reasoning History
medication use (e.g., herbal medicines, cough drops, over-the-
counter drugs, vitamins).
3 In the elderly patient, screen for modifiable risk factors (e.g., visual Clinical Reasoning History
disturbance, impaired hearing) to promote safety and prolong Hypothesis generation
independence.
4 In the elderly patient, assess functional status to: Clinical Reasoning Treatment
Patient-centred Approach History
• anticipate and discuss the eventual need for changes in the
living environment.
• ensure that social support is adequate.
5 In older patients with diseases prone to atypical presentation, do Selectivity Hypothesis generation
not exclude these diseases without a thorough assessment (e.g., Clinical Reasoning Diagnosis
pneumonia, appendicitis, depression).

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Epistaxis
Key Feature Skill Phase

1 Through history and/or physical examination, assess the Clinical Reasoning Hypothesis generation
hemodynamic stability of patients with epistaxis. Diagnosis

2 While attending to active nose bleeds, recognize and manage Patient-centred Approach Treatment
excessive anxiety in the patient and accompanying family. Clinical Reasoning Diagnosis

3 In a patient with an active or recent nosebleed, obtain a focused Clinical Reasoning History
history to identify possible etiologies (e.g., recent trauma, recent Hypothesis generation
upper respiratory infection, medications).
4 In a patient with an active or recent nosebleed,
a) Look for and identify anterior bleeding sites, Clinical Reasoning Physical

b) Stop the bleeding with appropriate methods. Clinical Reasoning Treatment

Procedures Skills

5 In a patient with ongoing or recurrent bleeding in spite of Clinical Reasoning Hypothesis generation
treatment, consider a posterior bleeding site.
6 In a patient with a nosebleed, obtain lab work only for specific Clinical Reasoning Selectivity Investigation
indications (e.g., unstable patient, suspicion of a bleeding diathesis, Hypothesis generation
use of anticoagulation)
7 In a patient with a nosebleed, provide thorough aftercare Clinical Reasoning Treatment
instructions (e.g., how to stop a subsequent nose bleed, when to Follow-up
return, humidification, etc.)

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Family Issues
Key Feature Skill Phase

1 Routinely ask about family issues to understand their impact on the Patient-centred Approach History
patient’s illness and the impact of the illness on the family.
2 Ask about family issues Patient-centred Approach Hypothesis generation
Clinical Reasoning History
• periodically
• at important life-cycle points (e.g., when children move out,
after the birth of a baby)
• when faced with problems not resolving in spite of
appropriate therapeutic interventions (e.g. medication
compliance, fibromyalgia, hypertension)

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 Part III: Priority Topics and Key Features

Fatigue
Key Feature Skill Phase

1 In all patients complaining of fatigue, include depression in the Clinical Reasoning Hypothesis generation
differential diagnosis.
2 Ask about other constitutional symptoms as part of a systematic Clinical Reasoning History
approach to rule out underlying medical causes in all patients
complaining of fatigue.
3 Exclude adverse effects of medication as the cause in all patients Clinical Reasoning Hypothesis generation
complaining of fatigue. Diagnosis

4 Avoid early, routine investigations in patients with fatigue unless Selectivity Investigation
specific indications for such investigations are present.
5 Given patients with fatigue in whom other underlying disorders Patient-centred Approach Treatment
have been ruled out, assist them to place, in a therapeutic sense, the Communication
role of their life circumstances in their fatigue.
6 In patients whose fatigue has become chronic, manage supportively, Patient-centred Approach Hypothesis generation
while remaining vigilant for new diseases and illnesses. Clinical Reasoning Treatment

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 Part III: Priority Topics and Key Features

Fever
Key Feature Skill Phase

1 In febrile infants 0-3 months old:

a) Recognize the risk of occult bacteremia. Clinical Reasoning Hypothesis generation
Diagnosis

b) Investigate thoroughly (e.g., blood cultures, urine, lumbar Clinical Reasoning Investigation
puncture +/- chest X-ray).
2 In a febrile patient with a viral infection, do NOT prescribe Clinical Reasoning Treatment
antibiotics.
3 In a febrile patient requiring antibiotic therapy, prescribe the Clinical Reasoning Treatment
appropriate antibiotic(s) according to likely causative organism(s)
and local resistance patterns.
4 Investigate patients with fever of unknown origin appropriately Clinical Reasoning Investigation
(e.g., with blood cultures, echocardiography, bone scans).
5 In febrile patients, consider life-threatening infectious causes (e.g., Selectivity Hypothesis generation
endocarditis, meningitis). Diagnosis

6 Aggressively and immediately treat patients who have fever Selectivity Treatment
resulting from serious causes before confirming the diagnosis,
whether these are infectious (e.g., febrile neutropenia, septic shock,
meningitis) or non-infectious (e.g., heat stroke, drug reaction,
malignant neuroleptic syndrome).
7 In the febrile patient, consider causes of hyperthermia other than Clinical Reasoning Hypothesis generation
infection (e.g., heat stroke, drug reaction, malignant neuroleptic Diagnosis
syndrome).
8 In an elderly patient, be aware that no good correlation exists Clinical Reasoning Hypothesis generation
between the presence or absence of fever and the presence or
absence of serious pathology.

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 Part III: Priority Topics and Key Features

Fractures
Key Feature Skill Phase

1 In a patient with multiple injuries, stabilize the patient (e.g., airway, Clinical Reasoning Treatment
breathing, and circulation, and life-threatening injuries) before
dealing with any fractures.
2 When examining patients with a fracture, assess neurovascular Clinical Reasoning Physical
status and examine the joint above and below the injury.
3 In patients with suspected fractures that are prone to have normal Clinical Reasoning Selectivity Treatment
X-ray findings (e.g., scaphoid fractures in wrist injuries, elbow
fracture, growth plate fracture in children, stress fractures), manage
according to your clinical suspicion, even if X-ray
4 In assessing elderly patients with an acute change in mobility (i.e., Clinical Reasoning Investigation
those who can no longer walk) and equivocal X-ray findings (e.g.,
no obvious fracture), investigate appropriately (e.g., with bone
scans, computed tomography) before excluding a fracture.
5 Identify and manage limb injuries that require urgent Selectivity Treatment
immobilization and/or reduction in a timely manner. Diagnosis

6 In assessing patients with suspected fractures, provide analgesia that Clinical Reasoning Treatment
is timely (i.e., before X-rays) and adequate (e.g., narcotic) analgesia.
7 In patients presenting with a fracture, look for and diagnose high- Clinical Reasoning Hypothesis generation
risk complications (e.g., an open fracture, unstable cervical spine, Diagnosis
compartment syndrome).
8 Use clinical decision rules (e.g., Ottawa ankle rules, C-spine rules, Clinical Reasoning Selectivity Investigation
and knee rules) to guide the use of X-ray examinations.

Note: These key features do not include technical and or psychomotor skills such as casting, reduction of
dislocations, etc. See Procedural Skills.

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 Part III: Priority Topics and Key Features

Gastro-intestinal Bleed
Key Feature Skill Phase

1 In a patient with blood in the stools who is hemodynamically stable, Clinical Reasoning Diagnosis
use history to differentiate upper vs. lower gastro-intestinal (GI) History
bleed as the investigation differs.
2 In a patient with suspected blood in the stool, explore other possible Clinical Reasoning Hypothesis generation
causes (e.g., beet ingestion, iron, Pepto-Bismol) before doing History
extensive investigation.
3 Look for patients at higher risk for GI bleed (e.g., previous GI Clinical Reasoning Hypothesis generation
bleed, intensive care unit admission, nonsteroidal anti-inflammatory History
drugs, alcohol) so as to modify treatment to reduce risk of GI bleed
(e.g cytoprotection).
4 In a patient with obvious GI bleeding, identify patients who may Clinical Reasoning Selectivity Hypothesis generation
require timely treatment even though they are not yet in shock. Diagnosis

5 In a stable patient with lower GI bleeding, look for serious causes Clinical Reasoning Selectivity Hypothesis generation
(e.g., malignancy, inflammatory bowel disease, ulcer, varices) even
when there is an apparent obvious cause for the bleeding (e.g., do
not attribute a rectal bleed to hemorrhoids or to oral
anticoagulation).
6 In a patient with an upper GI bleed, Clinical Reasoning Hypothesis generation
a) Include variceal bleeding in your differential,
b) Use history and physical examination to assess the likelihood Clinical Reasoning History
of a variceal bleed as its management differs. Physical

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 Part III: Priority Topics and Key Features

Gender Specific Issues

Key Feature Skill Phase

1 In the assessment of clinical problems that might present differently Clinical Reasoning Hypothesis generation
in men and women, maintain an inclusive differential diagnosis that
allows for these differences (e.g., women with coronary artery
disease, depression in males).
2 As part of caring for women with health concerns, assess the Clinical Reasoning Hypothesis generation
possible contribution of domestic violence. History

3 When men and women present with stress-related health concerns, Patient-centred Approach Hypothesis generation
assess the possible contribution of role-balancing issues (e.g., work- Clinical Reasoning History
life balance or between partners).
4 Establish office policies and practices to ensure patient comfort and Professionalism Physical
choice, especially with sensitive examinations (e.g., positioning for
Pap, chaperones for genital/rectal exams).
5 Interpret and apply research evidence for your patients in light of Clinical Reasoning Hypothesis generation
gender bias present in clinical studies (e.g., ASA use in women). Professionalism

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 Part III: Priority Topics and Key Features

Grief
Key Feature Skill Phase
1 In patients who have experienced a loss prepare them for Clinical reasoning Treatment
the types of reactions (e.g., emotional, physical, varying Patient-centred Approach
length) they may have.
2 In all grieving patients, especially those with a prolonged or
complex grief reaction:
a) Inquire about depression, suicidal ideation, self- Clinical reasoning History
medication, and alcohol and substance use Hypothesis generation
b) Consider the requirement for additional Clinical reasoning Treatment
treatments or referral
3 Recognize that grief reactions may vary based on the Patient-centred Approach Hypothesis generation
individual’s context and experiences; life cycle and
developmental stages; and cultural and family contexts.
4 In patients with presentations suggestive of grief reactions Clinical reasoning History
without obvious triggers look for triggers that may be unique Patient-centred Approach Hypothesis generation
to each patient (e.g., death of a pet, loss of a job, reactions to
anniversary).
5 In patients with unexplained or unresponsive physical or Clinical reasoning History
mental health concerns; alcohol or substance use; or Hypothesis generation
functional or behavioural change ask about loss and/or grief
as possible contributing factors.

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 Part III: Priority Topics and Key Features

Headache
Key Feature Skill Phase

1 Given a patient with a new-onset headache, differentiate benign Selectivity History

from serious pathology through history and physical examination. Physical

2 Given a patient with worrisome headache suggestive of serious Selectivity Investigation

pathology (e.g., meningitis, tumour, temporal arteritis, Clinical Reasoning
subarachnoid bleed):
a) Do the appropriate work-up (e.g., biopsy, computed
tomography [CT], lumbar puncture [LP], erythrocyte
sedimentation rate).
b) Make the diagnosis. Selectivity Diagnosis
Clinical Reasoning

c) Begin timely appropriate treatment (i.e., treat before a Selectivity Treatment

diagnosis of temporal arteritis or meningitis is confirmed).
d) Do not assume that relief of symptoms with treatment Clinical Reasoning Diagnosis
excludes serious pathology.
3 Given a patient with a history of chronic and/or relapsing headache Clinical Reasoning Treatment
(e.g., tension, migraine, cluster, narcotic-induced, medication-
induced), treat appropriately, and avoid narcotic, barbiturate
dependence.
4 In a patient with a history of suspected subarachnoid bleed and a Selectivity Hypothesis generation
negative CT scan, do a lumbar puncture. Clinical Reasoning Investigation

5 In a patient suffering from acute migraine headache:

a) Treat the episode. Clinical Reasoning Treatment

b) Assess the ongoing treatment plan. (referral when necessary, Clinical Reasoning Treatment
take a stepwise approach). Patient-centred Approach Referral

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 Part III: Priority Topics and Key Features

Heart Failure
Key Feature Skill Phase

1 In patients with newly diagnosed heart failure determine the Clinical reasoning Hypothesis
underlying cause, as treatment will differ. Selectivity Diagnosis

2 In an older patient presenting with fatigue include heart failure in Clinical reasoning Hypothesis
your differential diagnosis. Selectivity

3 In a patient with symptoms suggestive of heart failure and a Clinical reasoning Hypothesis
normal ejection fraction do not exclude this diagnosis. Selectivity Diagnosis
4 In patients with heart failure periodically assess functional Clinical reasoning History
impairment using validated tools (e.g., New York Heart Follow-up
Association class, activities of daily living).
5 To guide your management of a patient with an exacerbation of Clinical reasoning Hypothesis
heart failure:
a) Identify possible triggers (e.g., infection, arrhythmia,
adherence, diet, ischemia)
b) Consider comorbid conditions (e.g., renal failure) Clinical reasoning Hypothesis
Selectivity
6 When treating heart failure: Clinical reasoning Diagnosis
a) Identify the type of heart failure (e.g., systolic, Selectivity
diastolic) because the treatment is different
b) Appropriately prescribe medications to reduce mortality as Clinical reasoning Treatment
well as treat the symptoms of congestive failure (e.g., diuretics, Selectivity Follow-up
beta-blockers, ACE inhibitors, digoxin)
7 For patients with heart failure ensure you offer patient education Clinical reasoning Treatment
and self-monitoring, such as routine self-weighing, healthy diet,
medication adherence, smoking cessation, and exercise, to Patient-centred Approach Follow-up
minimize exacerbations.
8 In a patient with heart failure recognize non-sustained response to Clinical reasoning Diagnosis
treatment as an indicator of worsening prognosis. Selectivity Follow-up

9 In a patient with heart failure and a progressively deteriorating

clinical course:
a) Provide a realistic prognosis to patients and families Clinical reasoning Treatment
Communication
b) Introduce palliative care principles when appropriate for Clinical reasoning Treatment
the patient Patient-centred Approach

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 Part III: Priority Topics and Key Features

Hepatitis
Key Feature Skill Phase

1 In a patient presenting with hepatitis symptoms and/or abnormal Clinical Reasoning History
liver function tests, take a focused history to assist in establishing Hypothesis generation
the etiology (e.g., new drugs, alcohol, blood or body fluid exposure,
viral hepatitis).
2 In a patient with abnormal liver enzyme tests interpret the results to Clinical Reasoning Diagnosis
distinguish between obstructive and hepatocellular causes for
hepatitis as the subsequent investigation differs.
3 In a patient where an obstructive pattern has been identified,
a) Promptly arrange for imaging, Clinical Reasoning Selectivity Investigation

b) Refer for more definitive management in a timely manner. Clinical Reasoning Selectivity Treatment
Referral

4 In patients positive for Hepatitis B and/or C,

a) Assess their infectiousness, Clinical Reasoning Hypothesis generation
Investigation

b) Determine human immunodeficiency virus status. Clinical Reasoning Hypothesis generation

Investigation

5 In patients who are Hepatitis C antibody positive determine those Clinical Reasoning Hypothesis generation
patients who are chronically infected with Hepatitis C, because they Investigation
are at greater risk for cirrhosis and hepatocellular cancer.
6 In patients who are chronically infected with Hepatitis C, refer for Clinical Reasoning Treatment
further assessment and possible treatment. Referral

7 In patients who are at risk for Hepatitis B and/or Hepatitis C

exposure,
Patient-centred Approach Treatment
a) Counsel about harm reduction strategies, risk of other blood
Communication
borne diseases,
b) Vaccinate accordingly. Clinical Reasoning Treatment

8 Offer post-exposure prophylaxis to patients who are exposed or Clinical Reasoning Treatment
possibly exposed to Hepatitis A or B. Hypothesis generation

9 Periodically look for complications (e.g., cirrhosis, hepatocellular Clinical Reasoning Hypothesis generation
cancer) in patients with chronic viral hepatitis, especially hepatitis C Follow-up
infection.

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 Part III: Priority Topics and Key Features

Hyperlipidemia
Key Feature Skill Phase

1 Screen appropriate patients for hyperlipidemia. Clinical Reasoning Hypothesis generation

History

2 In all patients whose cardiovascular risk is being evaluated, include Clinical Reasoning Investigation
the assessment of lipid status.
3 When hyperlipidemia is present, take an appropriate history, and Clinical Reasoning Hypothesis generation
examine and test the patient for modifiable causes (e.g., alcohol History
abuse, thyroid disease).
4 Ensure that patients diagnosed with hyperlipidemia receive Clinical Reasoning Treatment
appropriate lifestyle and dietary advice. Periodically reassess Patient-centred Approach Follow-up
compliance with this advice (especially in patients at overall low or
moderate CV risk).
5 In treating hyperlipidemic patients, establish target lipid levels Clinical Reasoning Diagnosis
based on overall CV risk.
6 In patients receiving medication for hyperlipidemia, periodically Clinical Reasoning Treatment
assess compliance with and side effects of treatment. Patient-centred Approach Follow-up

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 Part III: Priority Topics and Key Features

Hypertension
Key Feature Skill Phase

1 Screen for hypertension. Clinical Reasoning Hypothesis generation

Physical

2 Use correct technique and equipment to measure blood pressure. Procedures Skills Physical

3 Make the diagnosis of hypertension only after multiple BP readings Clinical Reasoning Diagnosis
(i.e., at different times and during different visits).
4 In patients with an established diagnosis of hypertension, assess and Clinical Reasoning History
re-evaluate periodically the overall cardiovascular risk and end-
organ complications:
a) Take an appropriate history.
b) Do the appropriate physical examination. Clinical Reasoning Physical

c) Arrange appropriate laboratory investigations. Clinical Reasoning Investigation

5 In appropriate patients with hypertension (e.g., young patients

requiring multiple medications, patients with an abdominal bruit,
patients with hypokalemia in the absence of diuretics): Selectivity Hypothesis generation
Clinical Reasoning
a) Suspect secondary hypertension.
b) Investigate appropriately. Clinical Reasoning Selectivity Investigation
Treatment

6 Suggest individualized lifestyle modifications to patients with Clinical Reasoning Treatment

hypertension. (e.g., weight loss, exercise, limit alcohol consumption, Patient-centred Approach
dietary changes).
7 In a patient diagnosed with hypertension, treat the hypertension Clinical Reasoning Treatment
with appropriate pharmacologic therapy (e.g., consider the patient’s
age, concomitant disorders, other cardiovascular risk factors).
8 Given a patient with the signs and symptoms of hypertensive Selectivity Diagnosis
urgency or crisis, make the diagnosis and treat promptly. Treatment

9 In all patients diagnosed with hypertension, assess response to Clinical Reasoning Follow-up
treatment, medication compliance, and side effects at follow-up
visits.

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 Part III: Priority Topics and Key Features

Immigrants
Key Feature Skill Phase

1 As part of the periodic health assessment of newly arrived

immigrants:
Clinical Reasoning History
a) Assess vaccination status (as it may not be up to date).
b) Provide the necessary vaccinations to update their status. Clinical Reasoning Treatment

2 As part of the ongoing care of immigrants, modify your approach Patient-centred Approach Treatment
(when possible) as required by their cultural context (e.g., history Communication History
given only by husband, may refuse examination by a male physician,
language barriers).
3 When dealing with a language barrier, make an effort to obtain the Communication History
history with the help of a medical interpreter and recognize the
limitations of all interpreters (e.g., different agendas, lack of medical
knowledge, something to hide).
4 As part of the ongoing care of all immigrants (particularly those
who appear not to be coping):
Clinical Reasoning History
a) Screen for depression (i.e., because they are at higher risk
and frequently isolated).
b) Inquire about a past history of abuse or torture. Clinical Reasoning History

c) Assess patients for availability of resources for support (e.g., Clinical Reasoning History
family, community organizations). Patient-centred Approach

5 In immigrants presenting with a new or ongoing medical condition, Clinical Reasoning Selectivity Hypothesis generation
consider in the differential diagnosis infectious diseases acquired
before immigration (e.g., malaria, parasitic disease, tuberculosis).
6 As part of the ongoing care of all immigrants, inquire about the use Clinical Reasoning History
of alternative healers, practices, and/or medications (e.g., ‘‘natural’’
or herbal medicines, spiritual healers, medications from different
countries, moxibustion).

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 Part III: Priority Topics and Key Features

Immunization
Key Feature Skill Phase

1 Do not delay immunizations unnecessarily (e.g., vaccinate a child Clinical Reasoning Treatment
even if he or she has a runny nose).
2 With parents who are hesitant to vaccinate their children, explore Patient-centred Approach Treatment
the reasons, and counsel them about the risks of deciding against Communication History
routine immunization of their children.
3 Identify patients who will specifically benefit from immunization Clinical Reasoning Treatment
(e.g., not just the elderly and children, but also the Hypothesis generation
immunosuppressed, travellers, those with sickle cell anemia, and
those at special risk for pneumonia and hepatitis A and B), and
ensure it is offered.
4 Clearly document immunizations given to your patients. Clinical Reasoning Treatment
Professionalism

5 In patients presenting with a suspected infectious disease, assess Clinical Reasoning History
immunization status, as the differential diagnosis and consequent Hypothesis generation
treatment in unvaccinated patients is different.
6 In patients presenting with a suspected infectious disease, do not Clinical Reasoning Selectivity Hypothesis generation
assume that a history of vaccination has provided protection against
disease (e.g., pertussis, rubella, diseases acquired while travelling).

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 Part III: Priority Topics and Key Features

In Children
Key Feature Skill Phase

1 When evaluating children, generate a differential diagnosis that Clinical Reasoning Hypothesis generation
accounts for common medical problems, which may present
differently in children (e.g., urinary tract infections, pneumonia,
appendicitis, depression).
2 As children, especially adolescents, generally present infrequently Clinical Reasoning History
for medical care, take advantage of visits to ask about: Patient-centred Approach Treatment

• unverbalized problems (e.g., school performance)

• social well-being (e.g., relationships, home, friends)
• modifiable risk factors (e.g., exercise, diet)
• risk behaviours (e.g., use of bike helmets and seatbelts).
3 At every opportunity, directly ask questions about risk behaviours Clinical Reasoning History
(e.g., drug use, sex, smoking, driving) to promote harm reduction. Communication Treatment

4 In adolescents, ensure the confidentiality of the visit, and, when Communication Treatment
appropriate, encourage open discussion with their caregivers about Patient-centred Approach
specific problems (e.g., pregnancy, depression and suicide, bullying,
drug abuse).
5 In assessing and treating children, use age-appropriate language. Communication Treatment
Patient-centred Approach History

6 In assessing and treating children, obtain and share information Communication History
with them directly (i.e., don’t just talk to the parents). Patient-centred Approach Treatment

7 When investigation is appropriate, do not limit it because it may be Clinical Reasoning Selectivity Treatment
unpleasant for those involved (the child, parents, or health care Investigation
providers).

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 Part III: Priority Topics and Key Features

Infections
Key Feature Skill Phase

1 In patients with a suspected infection,

a) Determine the correct tools (e.g., swabs, culture/transport
Clinical Reasoning Investigation
medium), techniques, and protocols for cultures,
b) Culture when appropriate (e.g., throat swabs/sore throat Clinical Reasoning Selectivity Investigation
guidelines).
2 When considering treatment of an infection with an antibiotic, do
so
Clinical Reasoning Selectivity Treatment
a) Judiciously (e.g., delayed treatment in otitis media with
comorbid illness in acute bronchitis),
b) Rationally (e.g., cost, guidelines, comorbidity, local resistance Clinical Reasoning Selectivity Treatment
patterns).
3 Treat infections empirically when appropriate (e.g., in life Clinical Reasoning Selectivity Treatment
threatening sepsis without culture report or confirmed diagnosis,
candida vaginitis post-antibiotic use).
4 Look for infection as a possible cause in a patient with an ill-defined Clinical Reasoning Hypothesis generation
problem (e.g., confusion in the elderly, failure to thrive, unexplained
pain [necrotizing fasciitis, abdominal pain in children with
pneumonia]).
5 When a patient returns after an original diagnosis of a simple Clinical Reasoning Hypothesis generation
infection and is deteriorating or not responding to treatment, think
about and look for more complex infection. (i.e., When a patient
returns complaining they are not getting better, don’t assume the
infection is just slow to resolve).
6 When treating infections with antibiotics use other therapies when Clinical Reasoning Treatment
appropriate (e.g., aggressive fluid resuscitation in septic shock,
incision and drainage abscess, pain relief).

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 Part III: Priority Topics and Key Features

Infertility
Key Feature Skill Phase

1 When a patient consults you with concerns about difficulties

becoming pregnant:
a) Take an appropriate history (e.g., ask how long they have
Clinical Reasoning History
been trying, assess menstrual history, determine coital frequency
and timing) before providing reassurance or investigating further.
b) Ensure follow-up at an appropriate time (e.g., after one to Clinical Reasoning Treatment
two years of trying; in general, do not investigate infertility too
early).
2 In patients with fertility concerns, provide advice that accurately Clinical Reasoning Treatment
describes the likelihood of fertility.
3 With older couples who have fertility concerns, refer earlier for Clinical Reasoning Selectivity Hypothesis generation
investigation and treatment, as their likelihood of infertility is Referral
higher.
4 When choosing to investigate primary or secondary infertility, Clinical Reasoning Hypothesis generation
ensure that both partners are assessed.
5 In couples who are likely infertile, discuss adoption when the time is Patient-centred Approach Treatment
right. (Remember that adoption often takes a long time.) Clinical Reasoning

6 In evaluating female patients with fertility concerns and menstrual Clinical Reasoning Hypothesis generation
abnormalities, look for specific signs and symptoms of certain History
conditions (e.g., polycystic ovarian syndrome, hyperprolactinemia,
thyroid disease) to direct further investigations (e.g., prolactin,
thyroid-stimulating hormone, and luteal phase progesterone
testing).

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 Part III: Priority Topics and Key Features

Insomnia
Key Feature Skill Phase
1 In patients presenting with sleep complaints take a careful history to Clinical reasoning History
distinguish insomnia from specific psychiatric diagnoses or other Hypothesis generation
sleep-related diagnoses (e.g., sleep apnea, periodic limb movements,
restless legs syndrome, sleepwalking, sleep talking).
2 When assessing patients with sleep complaints:
a) Obtain a collateral history from the bed partner or Clinical reasoning History
parents, if possible and appropriate
b) Assess the contribution of drugs (prescription, over-the- Clinical reasoning History
counter, recreational), caffeine, and alcohol Hypothesis generation

3 In all patients with insomnia:

a) Provide appropriate advice about sleep hygiene (e.g.,
limiting caffeine, naps, and screen time, following regular sleep Clinical reasoning Treatment
schedule, limiting bedroom activities to sleep and sex) Patient-centred Approach
b) Offer other non-pharmacological options, such as Clinical reasoning Treatment
cognitive behavioural therapy
4 When initiating sleep medications:
a) Educate the patient about risks and discuss these Clinical reasoning Treatment
medications’ time-limited effects Communication
b) Use hypnotic medications judiciously (e.g., prescribe Clinical reasoning Treatment
only when disordered sleep has a severe impact on function, and Selectivity
only with a clear indication)
c) Negotiate a reduction and cessation plan with the patient Patient-centred Approach Treatment
Communication
5 When a patient with a long-term history of using sleep medication Patient-centred Approach Hypothesis generation
presents for renewal of their prescription reassess, educate, and Professionalism Treatment

discuss tapering and alternative therapies.

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 Part III: Priority Topics and Key Features

Ischemic Heart Disease

Key Feature Skill Phase

1 Given a specific clinical scenario in the office or emergency setting, Clinical Reasoning Selectivity Hypothesis generation
diagnose presentations of ischemic heart disease (IHD) that are: Diagnosis

• Classic
• atypical (e.g., in women, those with diabetes, the young,
those at no risk).
2 In a patient with modifiable risk factors for ischemic heart disease Clinical Reasoning Treatment
(e.g., smoking, diabetes control, obesity), develop a plan in
collaboration with the patient to reduce her or his risk of developing
the disease.
3 In a patient presenting with symptoms suggestive of ischemic heart Selectivity Diagnosis
disease but in whom the diagnosis may not be obvious, do not Clinical Reasoning Investigation
eliminate the diagnosis solely because of tests with limited
specificity and sensitivity (e.g., electrocardiography, exercise stress
testing, normal enzyme results).
4 In a patient with stable ischemic heart disease manage changes in Clinical Reasoning Treatment
symptoms with self-initiated adjustment of medication (e.g.,
nitroglycerin) and appropriate physician contact (e.g., office visits,
phone calls, emergency department visits), depending on the nature
an severity of symptoms.
5 In the regular follow-up care of patients with established ischemic Clinical Reasoning History
heart disease, specifically verify the following to detect Patient-centred Approach Diagnosis
complications and suboptimal control:
• symptom control.
• medication adherence.
• impact on daily activities.
• lifestyle modification
• clinical screening (i.e., symptoms and signs of
complications)
6 In a person with diagnosed acute coronary syndrome (e.g., Selectivity Treatment
cardiogenic shock, arrhythmia, pulmonary edema, acute myocardial
infarction, unstable angina), manage the condition in an appropriate
and timely manner.

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 Part III: Priority Topics and Key Features

Joint Disorder
Key Feature Skill Phase

1 In a patient presenting with joint pain, distinguish benign from

serious pathology (e.g., sarcoma, septic joint):
Selectivity Hypothesis generation
a) By taking pertinent history
Clinical Reasoning History

b) By investigating in a timely and appropriate manner (e.g., Clinical Reasoning Selectivity Investigation
aspirate, blood work, an X-ray examination). Diagnosis

2 In a patient presenting with non-specific musculoskeletal pain, Clinical Reasoning Diagnosis

make a specific rheumatologic diagnosis when one is evident
through history, physical examination, and investigations. (e.g.,
gout, fibromyalgia, monoarthropathy vs. polyarthropathy).
3 In a patient presenting with a monoarthropathy, rule out infectious Selectivity Diagnosis
causes. (e.g., sexually transmitted diseases). Clinical Reasoning Hypothesis generation

4 In patients presenting with musculoskeletal pain, include referred Clinical Reasoning Hypothesis generation
and visceral sources of pain in the differential diagnosis. (e.g.,
angina, slipped capital epiphysis presenting as knee pain,
neuropathic pain).
5 Clinically diagnose ligamentous injuries. Do NOT do an X-ray Clinical Reasoning Physical
examination. Procedures Skills Diagnosis

6 In a patient presenting with joint pain, include systemic conditions Clinical Reasoning Hypothesis generation
in the differential diagnosis (e.g., Wegener’s granulomatosis, lupus,
ulcerative colitis).
7 In patients with a diagnosed rheumatologic condition: Clinical Reasoning History
a) Actively inquire about pre-existing co-morbid conditions
that may modify the treatment plan.
b) Choose the appropriate treatment plan (e.g., no nonsteroidal Clinical Reasoning Treatment
anti-inflammatory drugs in patients with renal failure or peptic
ulcer disease).
8 In assessing patients with a diagnosed rheumatologic condition, Clinical Reasoning Hypothesis generation
search for disease-related complications (e.g., iritis).
9 In patients experiencing musculoskeletal pain:
a) Actively inquire about the impact of the pain on daily life.
Patient-centred Approach History

b) Treat with appropriate doses of analgesics. Clinical Reasoning Treatment

c) Arrange for community resources and aids (e.g., splints, Clinical Reasoning Treatment
cane), if necessary. Referral

10 In patients with rheumatoid arthritis, start treatment with disease- Clinical Reasoning Treatment
modifying agents within an appropriate time interval.

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 Part III: Priority Topics and Key Features

Lacerations
Key Feature Skill Phase

1 When managing a laceration, identify those that are more Clinical Reasoning Selectivity Diagnosis
complicated and may require special skills for repair (e.g., a second- Physical
versus third-degree perineal tear, lip or eyelid lacerations involving
margins, arterial lacerations).
2 When managing a laceration, look for complications (e.g., flexor Clinical Reasoning Diagnosis
tendon lacerations, open fractures, bites to hands or face, Physical
neurovascular injury, foreign bodies) requiring more than simple
suturing.
3 Given a deep or contaminated laceration, thoroughly clean with Clinical Reasoning Treatment
copious irrigation and debride when appropriate, before closing.
4 Identify wounds at high risk of infection (e.g., puncture wounds, Clinical Reasoning Selectivity Hypothesis generation
some bites, some contaminated wounds), and do not close them. Treatment

5 When repairing lacerations in children, ensure appropriate Clinical Reasoning Treatment

analgesia (e.g., topical anesthesia) and/or sedation (e.g., procedural
sedation) to avoid physical restraints.
6 When repairing a laceration, allow for and take adequate time to Clinical Reasoning Treatment
use techniques that will achieve good cosmetic results (e.g., layer
closure, revision if necessary, use of regional rather than local
anesthesia).
7 In treating a patient with a laceration: Clinical Reasoning History
a) Ask about immunization status for tetanus.
b) Immunize the patient appropriately. Clinical Reasoning Treatment

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 Part III: Priority Topics and Key Features

Learning (Patients/Self)
Patients

Key Feature Skill Phase

1 As part of the ongoing care of children, ask parents about their Clinical Reasoning History
children’s functioning in school to identify learning difficulties.
2 In children with school problems, take a thorough history to assist Clinical Reasoning History
in making a specific diagnosis of the problem (e.g., mental health Hypothesis generation
problem, learning disability, hearing).
3 When caring for a child with a learning disability, regularly assess Patient-centred Approach Hypothesis generation
the impact of the learning disability on the child and the family. Communication Follow-up

4 When caring for a child with a learning disability, ensure the patient Patient-centred Approach Treatment
and family have access to available community resources to assist Clinical Reasoning Referral
them.
5 To maximize the patient’s understanding and management of their
condition,
Patient-centred Approach Diagnosis
a) Determine their willingness to receive information,
Communication History

b) Match the complexity and amount of information provided Communication Patient- Treatment
with the patient’s ability to understand. centred Approach

Self Learning

Key Feature Skill Phase

6 Continuously assess your learning needs. Professionalism NA

7 Effectively address your learning needs. Professionalism NA

Selectivity

8 Incorporate your new knowledge into your practice. Professionalism NA

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 Part III: Priority Topics and Key Features

Lifestyle
Key Feature Skill Phase

1 In the ongoing care of patients, ask about behaviours that, if Patient-centred Approach History
changed, can improve health (e.g., diet, exercise, alcohol use, Communication
substance use, safer sex, injury prevention (e.g., seatbelts and
helmets).
2 Before making recommendations about lifestyle modification, Patient-centred Approach Treatment
explore a patient’s readiness to change, as it may alter advice. History

3 Explore a person’s context (e.g., poverty) before making Patient-centred Approach Treatment
recommendations about lifestyle modification (e.g., healthy eating History
choices, exercise suggestions) so as to avoid making
recommendations incompatible with the patient’s context.
4 In the ongoing care of patients, periodically review their behaviours, Clinical Reasoning Hypothesis generation
recognizing that these may change. Follow-up

5 In the ongoing care of a patient, regularly reinforce advice about Clinical Reasoning Treatment
lifestyle modification, whether or not the patient has instituted a Follow-up
change in behaviour.

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 Part III: Priority Topics and Key Features

Loss of Consciousness
Key Feature Skill Phase

1 In an unconscious patient, assess ABC’s and resuscitate as needed. Clinical Reasoning Selectivity Diagnosis
Treatment

2 As part of the assessment of a patient who has lost consciousness, Clinical Reasoning Hypothesis generation
obtain focused history from the patient or witnesses that would History
include duration, trauma, preexisting conditions, drugs, toxins,
medications and seizure activity.
3 Examine unconscious patients for localizing and diagnostic signs Clinical Reasoning Hypothesis generation
(e.g., ketone smell, liver flap, focal neurologic signs). Physical

4 In patients with a loss of consciousness and a history of head Clinical Reasoning Hypothesis generation
trauma, rule out intracranial bleeding. Investigation

5 In patients with a loss of consciousness who are anticoagulated, rule Clinical Reasoning Hypothesis generation
out intracranial bleeding. Investigation

6 Assess and treat unconscious patients urgently for reversible Clinical Reasoning Selectivity Hypothesis generation
conditions (e.g., shock, hypoxia, hypoglycemia, hyperglycemia, and Treatment
narcotic overdose).
7 When following up patients who have lost consciousness, assess and Clinical Reasoning Hypothesis generation
advise regarding return to work, sporting, driving and recreational Communication Treatment
activities to minimize the possibility of injury to self or others in the
event of a recurrence.
8 In patients who have had a loss of consciousness without a clear Clinical Reasoning Hypothesis generation
diagnosis, pursue investigations (e.g., rule out transient arythmia, Investigation
seizure).
9 When following up patients who have lost consciousness and where Clinical Reasoning Treatment Hypothesis
there is potential for recurrent episodes, discuss specific preventive generation
and protective measures (e.g., position changes with orthostatic
pressure changes).
10 In patients with loss of consciousness following head trauma, treat Clinical Reasoning Treatment
and follow up according to current concussion guidelines. Professionalism Follow-up

11 Advise authorities about appropriate patients with loss of Clinical Reasoning Treatment
consciousness (e.g., regarding driving status). Professionalism

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 Part III: Priority Topics and Key Features

Loss of Weight
Key Feature Skill Phase

1 Pursue an underlying cause in a patient with unexplained weight Clinical Reasoning Hypothesis generation
loss through history, physical examination (including weight) and
appropriate investigations.
2 Maintain an ongoing record of patients’ weights so as to accurately Professionalism Physical
determine when true weight loss has occurred.
3 In patients with persistent weight loss of undiagnosed cause, follow- Clinical Reasoning Follow-up
up and reevaluate in a timely manner in order to decide whether
anything needs to be done.

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 Part III: Priority Topics and Key Features

Low-back Pain
Key Feature Skill Phase

1 In a patient with undefined acute low-back pain (LBP):

a) Rule out serious causes (e.g., cauda equina syndrome, Selectivity Hypothesis generation
Diagnosis
pyelonephritis, ruptured abdominal aortic aneurysm, cancer)
through appropriate history and physical examination.
b) Make a positive diagnosis of musculoskeletal pain (not a Clinical Reasoning Diagnosis
diagnosis of exclusion) through an appropriate history and physical
examination.
2 In a patient with confirmed mechanical low back pain:
a) Do not over-investigate in the acute phase. Clinical Reasoning Selectivity Investigation
Treatment

b) Advise the patient:

Clinical Reasoning Treatment
• that symptoms can evolve, and ensure adequate follow-up
care
• that the prognosis is positive (i.e., the overwhelming
majority of cases will get better)
3 In a patient with mechanical low back pain, whether it is acute or Clinical Reasoning Treatment
chronic, give appropriate analgesia and titrate it to the patient’s
pain.
4 Advise the patient with mechanical low back pain to return if new Clinical Reasoning Follow-up
or progressive neurologic symptoms develop. Treatment

5 In all patients with mechanical low back pain, discuss exercises and Clinical Reasoning Treatment
posture strategies to prevent recurrences. Patient-centred Approach

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 Part III: Priority Topics and Key Features

Meningitis
Key Feature Skill Phase

1 In the patient with a non-specific febrile illness, look for meningitis, Clinical Reasoning Selectivity Hypothesis generation
especially in patients at higher risk (e.g., immuno-compromised
individuals, alcoholism, recent neurosurgery, head injury, recent
abdominal surgery, neonates, aboriginal groups, students living in
residence).
2 When meningitis is suspected ensure a timely lumbar puncture. Selectivity Investigation

3 In the differentiation between viral and bacterial meningitis, adjust Clinical Reasoning Diagnosis
the interpretation of the data in light of recent antibiotic use.
4 For suspected bacterial meningitis, initiate urgent empiric IV Selectivity Treatment
antibiotic therapy (i.e., even before investigations are complete). Clinical Reasoning

5 Contact public health to ensure appropriate prophylaxis for family, Clinical Reasoning Treatment
friends and other contacts of each person with meningitis. Professionalism

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 Part III: Priority Topics and Key Features

Menopause
Key Feature Skill Phase

1 In any woman of menopausal age, screen for symptoms of Clinical Reasoning History
menopause and (e.g., hot flashes, changes in libido, vaginal dryness, Patient-centred Approach Hypothesis generation
incontinence, and psychological changes).
2 In a patient with typical symptoms suggestive of menopause, make Clinical Reasoning Diagnosis
the diagnosis without ordering any tests. (This diagnosis is clinical
and tests are not required.)
3 In a patient with atypical symptoms of menopause (e.g., weight loss, Selectivity Hypothesis generation
blood in stools), rule out serious pathology through the history and History
selective use of tests, before diagnosing menopause.
4 In a patient who presents with symptoms of menopause but whose Clinical Reasoning Diagnosis
test results may not support the diagnosis, do not eliminate the
possibility of menopause solely because of these results.
5 When a patient has contraindications to hormone-replacement Clinical Reasoning Treatment
therapy (HRT), or chooses not to take HRT: Explore other Patient-centred Approach
therapeutic options and recommend some appropriate choices
6 In menopausal or perimenopausal women:
a) Specifically inquire about the use of natural or herbal Clinical Reasoning Selectivity History
products.
b) Advise about potential effects and dangers (i.e., benefits and Clinical Reasoning Treatment
problems) of natural or herbal products and interactions.
7 In a menopausal or perimenopausal women, provide counselling Clinical Reasoning Treatment
about preventive health measures (e.g., osteoporosis testing,
mammography).
8 Establish by history a patient’s hormone-replacement therapy Clinical Reasoning Selectivity History
risk/benefit status.

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 Part III: Priority Topics and Key Features

Mental Competency
Key Feature Skill Phase

1 In a patient with a diagnosis that may increase the likelihood of

cognitive and/or functional impairment (e.g., dementia, stroke,
severe mental illness, head injury):
a) Assess the patient’s level of competence in the context of Clinical reasoning History
the decision(s) that the patient needs to make, recognizing that Selectivity Diagnosis
higher-risk decisions require higher cognitive capacity

b) Explain the purpose of the assessment and attempt to Communication History

gain permission before you begin the assessment Professionalism Investigation

c) Include other professionals when appropriate Clinical reasoning Treatment

Professionalism Referral

2 In an otherwise well patient with subtle changes in function (e.g.,

family concerns, medication errors, repetitive questions, decline in
personal hygiene):
Clinical reasoning Physical
a) Perform an appropriate assessment of cognitive and Communication Investigation
functional abilities
b) Refer for further assessment when necessary Clinical reasoning Referral
Selectivity

3 When a patient is making high-stakes care decisions (e.g., Clinical reasoning Hypothesis generation
surgery/no surgery, resuscitation status) think about the need to Treatment
assess their decision-making ability.
4 When capacity assessment is required, actively assess the patient’s Clinical reasoning Diagnosis
ability to understand, appreciate, reason, and express a choice. Investigation

5 When impaired decision-making ability is identified, attempt to Clinical reasoning History

establish severity, reversibility, and duration in order to plan Diagnosis
treatment and regular reassessment.
6 When a patient refuses to participate in capacity assessment:
a) Document their refusal Communication Treatment

b) Continue to engage in the provision of safe care that is Professionalism Treatment

acceptable to the patient
c) Revisit the assessment when indicated Clinical reasoning Hypothesis generation
Selectivity Follow-up

d) Pursue the need for a substitute decision maker when Clinical reasoning Follow-up
necessary Selectivity Treatment

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 Part III: Priority Topics and Key Features

7 When involuntary treatment is indicated:

Communication Treatment
a) Initiate the certification process Professionalism

b) Collaborate with colleagues/family regarding the Communication Treatment

Patient-centred Approach
procedures required

c) Document and communicate according to legal Communication Treatment

Professionalism
requirements

d) Help the patient and family understand why this is Communication Treatment
Patient-centred Approach
necessary
e) Clarify your continuing role in the care of the patient Communication Follow-up
Professionalism

8 When involuntary interventions that impact autonomy are required Patient-centred Approach Treatment
(e.g., loss of driver’s licence) include management of the emotional
impact on the patient and possible effects on the physician-patient
relationship as parts of the treatment plan.

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 Part III: Priority Topics and Key Features

Multiple Medical Problems

Key Feature Skill Phase

1 In all patients presenting with multiple medical concerns (e.g., Selectivity History
complaints, problems, diagnoses), take an appropriate history to Clinical Reasoning
determine the primary reason for the consultation.
2 In all patients presenting with multiple medical concerns, prioritize Patient-centred Approach Treatment
problems appropriately to develop an agenda that both you and the
patient can agree upon (i.e., determine common ground).
3 In a patient with multiple medical complaints (and/or visits), Clinical Reasoning Hypothesis generation
consider underlying depression, anxiety, or abuse (e.g., physical,
medication, or drug abuse) as the cause of the symptoms, while
continuing to search for other organic pathology.
4 Given a patient with multiple defined medical conditions, Clinical Reasoning Hypothesis generation
periodically assess for secondary depression, as they are particularly History
at risk for it.
5 Periodically re-address and re-evaluate the management of patients Clinical Reasoning Treatment
with multiple medical problems in order to: Follow-up
• simplify their management (pharmacologic and other)
• limit polypharmacy
• minimize possible drug interactions
• update therapeutic choices (e.g., because of changing
guidelines or the patient’s situation)
6 In patients with multiple medical problems and recurrent visits for Patient-centred Approach Treatment
unchanging symptoms, set limits for consultations when Professionalism Follow-up
appropriate (e.g., limit the duration and frequency of visits).

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 Part III: Priority Topics and Key Features

Neck Pain
Key Feature Skill Phase

1 In patients with non-traumatic neck pain, use a focused history, Clinical Reasoning Selectivity Hypothesis generation
physical examination and appropriate investigations to distinguish Diagnosis
serious, non-musculoskeletal causes (e.g., lymphoma, carotid
dissection), including those referred to the neck (e.g., myocardial
infarction, pseudotumour cerebri) from other non-serious causes.
2 In patients with non-traumatic neck pain, distinguish by history Clinical Reasoning History
and physical examination, those attributable to nerve or spinal cord Physical
compression from those due to other mechanical causes (e.g.,
muscular).
3 Use a multi-modal (e.g., physiotherapy, chiropractic, acupuncture, Clinical Reasoning Treatment
massage) approach to treatment of patients with chronic neck pain
(e.g., degenerative disc disease +/- soft neuro signs).
4 In patients with neck pain following injury, distinguish by history Clinical Reasoning Selectivity Diagnosis
and physical examination, those requiring an X-ray to rule out a Investigation
fracture from those who do not require an X-ray (e.g., current
guideline/C-spine rules).
5 When reviewing neck X-rays of patients with traumatic neck pain, Clinical Reasoning Diagnosis
be sure all vertebrae are visualized adequately. Investigation

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 Part III: Priority Topics and Key Features

Newborn
Key Feature Skill Phase

1 When examining a newborn, systematically look for subtle Clinical Reasoning Hypothesis generation
congenital anomalies (e.g., ear abnormalities, sacral dimple) as they Physical
may be associated with other anomalies and genetic syndromes.
2 In a newborn, where a concern has been raised by a caregiver
(parent, nurse),
Clinical Reasoning Hypothesis generation
a) Think about sepsis, and
b) Look for signs of sepsis, as the presentation can be subtle (i.e. Clinical Reasoning Selectivity Physical
not the same as in adults, non-specific, feeding difficulties, History
respiratory changes)
c) Make a provisional diagnosis of sepsis. Clinical Reasoning Diagnosis

3 Resuscitate newborns according to current guidelines. Clinical Reasoning Treatment

Procedures Skills

4 Maintain neonatal resuscitation skills if appropriate for your Professionalism Treatment

practice.
5 When a parent elects to bottle feed, support their decision in a non- Professionalism Treatment
judgemental manner. Patient-centred Approach

6 In caring for a newborn ensure repeat evaluations for abnormalities Clinical Reasoning Follow-up
that may become apparent over time (e.g., hips, heart, hearing). Physical

7 When discharging a newborn from hospital,

a) Advise parent(s) of warning signs of serious or impending Clinical Reasoning Treatment
Communication Follow-up
illness, and
b) Develop a plan with them to access appropriate care should a Clinical Reasoning Follow-up
concern arise. Patient-centred Approach

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 Part III: Priority Topics and Key Features

Obesity
Key Feature Skill Phase

1 In patients who appear to be obese, make the diagnosis of obesity Clinical Reasoning Diagnosis
using a clear definition (i.e., currently body mass index) and inform
them of the diagnosis.
2 In all obese patients, assess for treatable co-morbidities such as Clinical Reasoning Hypothesis generation
hypertension, diabetes, coronary artery disease, sleep apnea, and
osteoarthritis, as these are more likely to be present.
3 In patients diagnosed with obesity who have confirmed normal Clinical Reasoning Selectivity Investigation
thyroid function, avoid repeated thyroid-stimulating hormone Treatment
testing.
4 In obese patients, inquire about the effect of obesity on the patient’s Patient-centred Approach History
personal and social life to better understand its impact on the
patient.
5 In a patient diagnosed with obesity, establish the patient’s readiness Patient-centred Approach History
to make changes necessary to lose weight, as advice will differ, and Follow-up
reassess this readiness periodically.
6 Advise the obese patient seeking treatment that effective Clinical Reasoning Treatment
management will require appropriate diet, adequate exercise, and
support (independent of any medical or surgical treatment), and
facilitate the patient’s access to these as needed and as possible.
7 As part of preventing childhood obesity, advise parents of healthy Clinical Reasoning Treatment
activity levels for their children.
8 In managing childhood obesity, challenge parents to make Clinical Reasoning Treatment
appropriate family-wide changes in diet and exercise, and to avoid Communication
counterproductive interventions (e.g., berating or singling out the
obese child).

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 Part III: Priority Topics and Key Features

Osteoporosis
Key Feature Skill Phase

1 Assess osteoporosis risk of all adult patients as part of their periodic Clinical Reasoning Hypothesis generation
health examination. Diagnosis

2 Use bone mineral density testing judiciously (e.g., don’t test Selectivity Investigation
everybody, follow a guideline). Professionalism Follow-up

3 Counsel all patients about primary prevention of osteoporosis (i.e., Clinical Reasoning Treatment
dietary calcium, physical activity, smoking cessation), especially Communication
those at higher risk (e.g., young female athletes, patients with eating
disorders).
4 In menopausal or peri-menopausal women, provide advice about Clinical Reasoning Treatment
fracture prevention that includes improving their physical fitness, Communication Hypothesis generation
reducing alcohol, smoking cessation, risks of physical abuse, and
environmental factors that may contribute to falls (e.g., don’t stop at
suggesting calcium and vitamin D).
5 In patients with osteoporosis, avoid prescribing medications that Clinical Reasoning Hypothesis generation
may increase the risk of falls. Treatment

6 Provide advice and counseling about fracture prevention to older Clinical Reasoning Hypothesis generation
men, as they too are at risk for osteoporosis. Treatment

7 Treat patients with established osteoporosis regardless of their Clinical Reasoning Hypothesis generation
gender (e.g., use bisphosphonates in men). Treatment

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 Part III: Priority Topics and Key Features

Pain
Key Feature Skill Phase
1 In a patient presenting with acute pain provide analgesia while Selectivity Treatment
seeking a diagnosis.
2 When assessing a patient with pain take a detailed history to Clinical reasoning History
recognize clinical patterns (diagnostic discerning characteristics) Hypothesis
to inform diagnosis (e.g., neuropathic, vascular, muscular, visceral
pain).
3 In a patient presenting with pain without a clear diagnosis:
a) Include life-threatening conditions in your differential Selectivity Hypothesis
diagnosis Clinical reasoning
b) Investigate appropriately and in a timely manner Selectivity Investigation
Clinical reasoning
4 When there is a concern about drug-seeking behaviour in a
patient with pain:
a) Maintain your therapeutic relationship (e.g., be Patient-centred Approach Treatment
empathic, avoid stereotyping, manage frustration) Professionalism Follow-up
b) Do not attribute the presentation to drug-seeking Clinical reasoning Hypothesis
without first considering an appropriately broad differential Selectivity
diagnosis
5 When treating pain with narcotics:
a) Dose appropriately considering narcotic naïveté and Clinical reasoning Treatment
renal function
b) Consider addiction risk Clinical reasoning Hypothesis
Treatment
c) Consider variable and potentially dangerous metabolic Clinical reasoning Hypothesis
responses (e.g., codeine, especially in pregnant and Treatment
breastfeeding women; sudden removal of a painful stimulus)
6 In a patient whose pain is not resolving or following the Clinical reasoning Hypothesis
anticipated course, regularly re-evaluate (e.g., diagnosis, Follow-up
complications, medication choices, drug diversion).
7 When prescribing medication for pain inform the patient not to Clinical reasoning Treatment
use over-the-counter products that contain the same drug or
drugs from the same class (e.g., acetaminophen, NSAIDs)
8 When treating a patient with pain appropriately use non- Patient-centred Approach Treatment
pharmacologic treatments and self-management strategies to Clinical reasoning
control pain and optimize function.
9 In a patient where acute pain has become chronic:
a) Recognize the transition Clinical reasoning Diagnosis
b) Readdress the treatment plan and your patient’s Patient-centred Approach Treatment
expectations appropriately Communication

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 Part III: Priority Topics and Key Features

Palliative Care
Key Feature Skill Phase

1 In all patients with terminal illnesses (e.g., end-stage congestive Patient-centred Approach Treatment
heart failure or renal disease), use the principles of palliative care to Clinical Reasoning
address symptoms (i.e.., do not limit the use of palliative care to
cancer patients).
2 In patients requiring palliative care, provide support through self, Patient-centred Approach Treatment
other related disciplines, or community agencies, depending on
patient needs (i.e.., use a team approach when necessary).
3 In patients approaching the end of life:
a) Identify the individual issues important to the patient,
Patient-centred Approach History
including physical issues (e.g., dyspnea, pain, constipation, nausea),
Clinical Reasoning
emotional issues, social issues (e.g., guardianship, wills, finances),
and spiritual issues.
b) Attempt to address the issues identified as important to the Patient-centred Approach Treatment
patient. Clinical Reasoning

4 In patients with pain, manage it (e.g., adjust dosages, change Clinical Reasoning Treatment
analgesics) proactively through: Follow-up
• frequent reassessments
• monitoring of drug side effects (e.g., nausea, constipation,
cognitive impairment)
5 In patients diagnosed with a terminal illness, identify and repeatedly Patient-centred Approach History
clarify wishes about end-of-life issues (e.g., wishes for treatment of Clinical Reasoning Hypothesis generation
infections, intubation, dying at home)

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 Part III: Priority Topics and Key Features

Parkinsonism
Key Feature Skill Phase

1 In patients with suspected Parkinson’s disease, accurately Clinical Reasoning Diagnosis

distinguish idiopathic Parkinson’s disease from atypical Parkinson’s
disease (e.g., disease at a young age, drug-related disease), as
treatment differs.
2 In the care of all patients with Parkinson’s disease, involve other Clinical Reasoning Treatment
health care professionals to enhance the patient’s functional status. Professionalism Referral

3 In an elderly patient with a deterioration in functional status, look Clinical Reasoning Hypothesis generation
for and recognize Parkinson’s disease when it is present, as it is a Diagnosis
potentially reversible contribution to the deterioration.
4 In a patient with a tremor, do an appropriate physical examination Clinical Reasoning Physical
(e.g., observation, use of techniques to enhance the tremor) to
distinguish the resting tremor of parkinsonism from other (e.g.,
essential) tremors.
5 As part of the management of patients with Parkinson’s disease, Clinical Reasoning Treatment
identify anticipated side effects of medications, especially those with Professionalism
which you are unfamiliar.
6 As part of the ongoing follow-up care of patients with Parkinson’s Clinical Reasoning Hypothesis generation
disease: Follow-up

• Assess functional status

• Monitor them for medication side effects
• Look for other problems (e.g., depression, dementia, falls,
constipation), as they are more common

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 Part III: Priority Topics and Key Features

Periodic Health Assessment/Screening

Key Feature Skill Phase

1 Do a periodic health assessment in a proactive or opportunistic Clinical Reasoning Treatment

manner (i.e., address health maintenance even when patients
present with unrelated concerns).
2 In any given patient, selectively adapt the periodic health Selectivity Investigation
examination to that patient’s specific circumstances (i.e., adhere to Patient-centred Approach Hypothesis generation
inclusion and exclusion criteria of each manoeuvre/intervention,
such as the criteria for mammography and prostate-specific antigen
[PSA] testing).
3 In a patient requesting a test (e.g., PSA testing, mammography)
that may or may not be recommended:
Clinical Reasoning Treatment
a) Inform the patient about limitations of the screening test
Investigation
(i.e., sensitivity and specificity).
b) Counsel the patient about the implications of proceeding Clinical Reasoning Treatment Investigation
with the test. Patient-centred Approach

4 Keep up to date with new recommendations for the periodic health Professionalism Treatment
examination, and critically evaluate their usefulness and application Diagnosis
to your practice.

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 Part III: Priority Topics and Key Features

Personality Disorder
Key Feature Skill Phase
1 When assessing a patient with personality traits or behaviours that impair
interactions and/or function:
Clinical reasoning History
a) Distinguish between isolated or intermittent manifestations and
Patient-centred Approach
established, habitual patterns of behaviour
b) Rule out pharmacologic or underlying medical causes (e.g., Clinical reasoning Hypothesis generation
substance use, brain tumour) Selectivity
c) Do not label the patient with a personality disorder prematurely Clinical reasoning Diagnosis
or without clear justification (i.e., personality traits are not a disorder)
2 For any patient with a personality disorder or personality traits that impair
interpersonal interaction:
Communication Treatment
a) Adapt your communication style to optimize the development of
Patient-centred Approach
a therapeutic relationship to provide effective care
b) Determine the impact of the patient’s personality disorder on Patient-centred Approach Treatment
their ability to access health care Communication
3 When providing care for a patient with a personality disorder reflect on,
acknowledge, and manage your own emotional responses in order to provide Professionalism Treatment
Patient-centred Approach
empathetic and patient-centred care.
4 When caring for a patient with a personality disorder or with difficult
behaviours or requests:
Communication Treatment
a) Address the behaviour in a direct but non-threatening manner
Professionalism
b) Co-create realistic goals and expectations with the patient Communication Treatment
Patient-centred Approach Follow-up

c) Establish and maintain clear boundaries and limits (e.g., Communication Treatment
appointment length, drug prescribing, accessibility) and communicate these Professionalism Follow-up
to your team
d) Continue the therapeutic relationship with the patient unless Professionalism Treatment
there is risk to you or others Patient-centred Approach Follow-up
5 In a patient already diagnosed with personality disorder look for medical Clinical reasoning Hypothesis generation
and other psychiatric diagnoses when the patient presents for assessment of
new or changed symptoms. (Patients with personality disorders develop
medical and psychiatric conditions, too.)
6 When seeing a patient whom others have previously identified as having a Clinical reasoning Diagnosis
personality disorder evaluate the patient yourself because the diagnosis may Patient-centred Approach
be wrong, and the label has significant repercussions.

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 Part III: Priority Topics and Key Features

Pneumonia
Key Feature Skill Phase

1 In a patient who presents without the classic respiratory signs and Clinical Reasoning Hypothesis generation
symptoms (e.g., deterioration, delirium, abdominal pain), include
pneumonia in the differential diagnosis.
2 In a patient with signs and symptoms of pneumonia, do not rule out Clinical Reasoning Selectivity Diagnosis
the diagnosis on the basis of a normal chest X-ray film (e.g., consider Hypothesis generation
dehydration, neutropenia, human immunodeficiency virus [HIV]
infection).
3 In a patient with a diagnosis of pneumonia, assess the risks for unusual Clinical Reasoning History
pathogens (e.g., a history of tuberculosis, exposure to birds, travel, Hypothesis generation
HIV infection, aspiration).
4 In patients with pre-existing medical problems (e.g., asthma, diabetes,
congestive heart failure) and a new diagnosis of pneumonia:
a) Treat both problems concurrently (e.g., with prednisone plus
Clinical Reasoning Selectivity Treatment
antibiotics).
b) Adjust the treatment plan for pneumonia, taking into account Clinical Reasoning Selectivity Treatment
the concomitant medical problems (e.g., be aware of any drug Hypothesis generation
interactions, such as that between warfarin [Coumadin] and
antibiotics).
5 Identify patients, through history-taking, physical examination, and Selectivity History
testing, who are at high risk for a complicated course of pneumonia Diagnosis
and would benefit from hospitalization, even though clinically they
may appear stable.
6 In the patient with pneumonia and early signs of respiratory distress, Clinical Reasoning Selectivity Treatment
assess, and reassess periodically, the need for respiratory support
(bilevel positive airway pressure, continuous positive airway pressure,
intubation) (i.e., look for the need before decompensation occurs).
7 For a patient with a confirmed diagnosis of pneumonia, make rational Clinical Reasoning Treatment
antibiotic choices (e.g., outpatient + healthy = first-line antibiotics; Professionalism
avoid the routine use of “big guns”).

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 Part III: Priority Topics and Key Features

8 In a patient who is receiving treatment for pneumonia and is not

responding:
Clinical Reasoning Hypothesis generation
a) Revise the diagnosis (e.g., identify other or contributing causes,
Diagnosis
such as cancer, chronic obstructive pulmonary disease, or
bronchospasm), consider atypical pathogens (e.g., Pneumocystis
carinii,TB, and diagnose complications (e.g., empyema,
pneumothorax).
b) Modify the therapy appropriately (e.g., change antibiotics). Clinical Reasoning Treatment
Diagnosis

9 Identify patients (e.g., the elderly, nursing home residents, Clinical Reasoning Selectivity Treatment
debilitated patients) who would benefit from immunization or
other treatments (e.g., flu vaccine, Pneumovax, ribavarine) to reduce
the incidence of pneumonia.
10 In patients with a diagnosis of pneumonia, ensure appropriate Clinical Reasoning Follow-up
follow-up care (e.g., patient education, repeat chest X-ray
examination, instructions to return if the condition worsens).
11 In patients with a confirmed diagnosis of pneumonia, arrange Clinical Reasoning Follow-up
contact tracing when appropriate (e.g., in those with TB, nursing Referral
home residents, those with legionnaires’ disease).

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 Part III: Priority Topics and Key Features

Poisoning
Key Feature Skill Phase

1 As part of well-child care, discuss preventing and treating poisoning Communication Treatment
with parents (e.g., “child-proofing”, poison control number). Clinical Reasoning

2 In intentional poisonings (overdose) think about multi-toxin Clinical Reasoning Hypothesis generation
ingestion.
3 When assessing a patient with a potentially toxic ingestion, take a Clinical Reasoning History
careful history about the timing and nature of the ingestion.
4 When assessing a patient with a potential poisoning, do a focused Clinical Reasoning Physical
physical examination to look for the signs of toxidromes.
5 When assessing a patient exposed (contact or ingestion) to a Clinical Reasoning Hypothesis generation
substance, clarify the consequences of the exposure (e.g., don’t Treatment
assume it is non-toxic, call poison control).
6 When managing a toxic ingestion, utilize poison control protocols Clinical Reasoning Treatment
that are current. Professionalism

7 When managing a patient with a poisoning,

a) Assess ABC's, Clinical Reasoning Hypothesis generation
Diagnosis

b) Manage ABC's, Clinical Reasoning Treatment

c) Regularly reassess the patient’s ABC’s (i.e., do not focus on Clinical Reasoning Hypothesis generation
antidotes and decontamination while ignoring the effect of the Treatment
poisoning on the patient).

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 Part III: Priority Topics and Key Features

Pregnancy
Key Feature Skill Phase

1 In a patient who is considering pregnancy:

a) Identify risk factors for complications. Clinical Reasoning Hypothesis generation
Patient-centred Approach Diagnosis

b) Recommend appropriate changes (e.g., folic acid intake, Clinical Reasoning Treatment
smoking cessation, medication changes). Patient-centred Approach

2 In a female or male patient who is sexually active, who is Communication Treatment

considering sexual activity, or who has the potential to conceive or Patient-centred Approach
engender a pregnancy, use available encounters to educate about
fertility.
3 In a patient with suspected or confirmed pregnancy, establish the Clinical Reasoning History
desirability of the pregnancy. Patient-centred Approach Treatment

4 In a patient presenting with a confirmed pregnancy for the first

encounter:
Clinical Reasoning Hypothesis generation
a) Assess maternal risk factors (medical and social).
Patient-centred Approach History

b) Establish accurate dates. Clinical Reasoning Diagnosis

c) Advise the patient about ongoing care. Clinical Reasoning Treatment

5 In pregnant patients:
a) Identify those at high risk (e.g., teens, domestic violence Clinical Reasoning Selectivity Hypothesis generation
History
victims, single parents, drug abusers, impoverished women).
b) Refer these high-risk patients to appropriate resources Clinical Reasoning Treatment
throughout the antepartum and postpartum periods. Referral

6 In at-risk pregnant patients (e.g., women with human Selectivity Treatment

immunodeficiency virus infection, intravenous drug users, and Clinical Reasoning
diabetic or epileptic women), modify antenatal care appropriately.
7 In a pregnant patient presenting with features of an antenatal
complication (e.g., premature rupture of membranes, hypertension,
bleeding):
Clinical Reasoning Selectivity Hypothesis generation
a) Establish the diagnosis. Diagnosis

b) Manage the complication appropriately. Clinical Reasoning Selectivity Treatment

8 In a patient presenting with dystocia (prolonged dilatation, failure

of descent):
Clinical Reasoning Selectivity Hypothesis generation
a) Diagnose the problem.
Diagnosis

b) Intervene appropriately. Clinical Reasoning Selectivity Treatment

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9 In a patient with clinical evidence of complications in labour (e.g.,

abruption, uterine rupture, shoulder dystocia, non-reassuring fetal
monitoring):
Clinical Reasoning Selectivity Hypothesis generation
a) Diagnose the complication. Diagnosis

b) Manage the complication appropriately. Clinical Reasoning Selectivity Treatment

10 In the patient presenting with clinical evidence of a postpartum

complication (e.g., delayed or immediate bleeding, infection):
a) Diagnose the problem (e.g., unrecognized retained placenta, Clinical Reasoning Selectivity Hypothesis generation
Diagnosis
endometritis, cervical laceration).
b) Manage the problem appropriately. Clinical Reasoning Selectivity Treatment

11 In pregnant or postpartum patients, identify postpartum depression Selectivity Hypothesis generation

by screening for risk factors, monitoring patients at risk, and Clinical Reasoning Diagnosis
distinguishing postpartum depression from the “blues.’’
12 In a breast-feeding woman, screen for and characterize Clinical Reasoning Hypothesis generation
dysfunctional breast-feeding (e.g., poor latch, poor production, poor Patient-centred Approach History
letdown).

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Prostate
Key Feature Skill Phase

1 Appropriately identify patients requiring prostate cancer screening. Selectivity Diagnosis

History

2 In a patient suitable for prostate cancer screening, use and interpret Selectivity Investigation
tests (e.g., prostate-specific antigen testing, digital rectal Patient-centred Approach Diagnosis
examination [DRE], ultrasonography) in an
individualized/sequential manner to identify potential cases.
3 In patients with prostate cancer, actively search out the Patient-centred Approach History
psychological impact of the diagnosis and treatment modality. Communication

4 In patients with prostate cancer, considering a specific treatment

option (e.g., surgery, radiotherapy, chemotherapy, hormonal
treatment, no treatment):
Clinical Reasoning Treatment
a) Advise about the risks and benefits of treatment. Patient-centred Approach

b) Monitor patients for complications following treatment. Clinical Reasoning Hypothesis generation
Follow-up

5 In patients with prostate cancer, actively ask about symptoms of Clinical Reasoning History
local recurrence or distant spread. Hypothesis generation

6 Given a suspicion of benign prostatic hypertrophy, diagnose it using Clinical Reasoning Diagnosis
appropriate history, physical examination, and investigations.
7 In patients presenting with specific or non-specific urinary Clinical Reasoning Hypothesis generation
symptoms: Diagnosis
a) Identify the possibility of prostatitis.
b) Interpret investigations (e.g., urinalysis, urine culture-and- Clinical Reasoning Diagnosis
sensitivity testing, Digital Rectal Exam, swab testing, reverse Investigation
transcription-polymerase chain reaction assay) appropriately.

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Rape/Sexual Assault
Key Feature Skill Phase

1 Provide comprehensive care to all patients who have been sexually Clinical Reasoning Treatment
assaulted, regardless of their decision to proceed with evidence Professionalism
Sexual assault kit if <5 days
collection or not.
2 Apply the same principles of managing sexual assault in the acute Clinical Reasoning Treatment
setting to other ambulatory settings (i.e. medical assessment,
pregnancy prevention, STI screening/treatment/prophylaxis,
counselling).
3 Limit documentation in sexual assault patients to observations and Clinical Reasoning History
other necessary medical information (i.e., avoid recording hearsay Professionalism
information).
4 In addition to other post-exposure prophylactic measures taken, Clinical Reasoning Hypothesis generation
assess the need for human immunodeficiency virus and hepatitis B Diagnosis
prophylaxis in patients who have been sexually assaulted.
5 Offer counselling to all patients affected by sexual assault, whether Clinical Reasoning Treatment
they are victims, family members, friends, or partners; do not
discount the impact of sexual assault on all of these people.
6 Revisit the need for counselling in patients affected by sexual Clinical Reasoning Treatment
assault. Follow-up

7 Enquire about undisclosed sexual assault when seeing patients who Clinical Reasoning Hypothesis generation
have symptoms such as depression, anxiety, and somatization. History

hiv within 72 hours

Contraception
Hep B if not immune
Chlamydia/Gonorrhea/Trich
Test for Syphilis - RPR or EIA

If not taking prohylaxis repeat STI, HCG in 2 weeks. For Hep B, Syhilis,
and HIV, repeat at 6 weeks, 12 weeks, 24 weeks

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 Part III: Priority Topics and Key Features

Rash
Key Feature Skill Phase

1 In a patient with a new rash: Clinical reasoning History

a) Take a focused history and do an appropriate skin Selectivity Physical
examination
b) If the diagnosis remains unclear obtain a more detailed Clinical reasoning History
history and examination, including the entire mucocutaneous Selectivity Physical
system and other body systems as indicated
2 When assessing a patient with a rash look for and recognize Clinical reasoning Diagnosis
common patterns to aid diagnosis.
3 Use appropriate terminology with respect to lesion type, shape, Communication Physical
arrangement, and distribution to facilitate communication and Follow-up
documentation
4 In an unwell patient presenting with a rash: Clinical reasoning Hypothesis
a) Identify potential life-threatening systemic conditions (e.g., Selectivity Diagnosis
meningococcal septicemia, necrotizing fasciitis, toxic shock,
Stevens-Johnson syndrome)
b) Initiate treatment and/or urgent/emergent referral Selectivity Treatment
Referral

5 In a patient with a persisting undiagnosed rash: Clinical reasoning Hypothesis

a) Consider a systemic disorder (e.g., systemic lupus
erythematosus, diabetes, celiac)
b) Investigate appropriately (e.g., scraping, culture, biopsy, lab Clinical reasoning Investigation
work) Procedure skills

c) Pursue further investigations and/or refer as indicated Clinical reasoning Hypothesis

regardless of negative results Follow-up

6 In all patients with a persistent or recurrent rash explore the Patient-centred Approach History
functional and emotional aspects of that disorder, recognizing that Follow-up
what looks like a minor condition may have a profound impact.
7 7 In a patient with a persistent or recurrent rash explore issues of: Clinical reasoning Hypothesis
Patient-centred Approach
• Exposure to skin irritants or allergens
• Adherence to the treatment plan
• Use of confounding medications and treatments (e.g.,
topical anesthetics, topical steroids, home remedies)

8 In a patient with an infectious rash: Clinical reasoning Treatment

a) Manage contagion risk Selectivity

b) Ensure that public health bodies are informed when Clinical reasoning Follow-up
indicated Professionalism

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 Part III: Priority Topics and Key Features

Red Eye
Key Feature Skill Phase

1 In addressing eye complaints, always assess visual acuity using Clinical Reasoning History
history, physical examination, or the Snellen chart, as appropriate. Physical

2 In a patient with a red eye, distinguish between serious causes (e.g.,

keratitis, glaucoma, perforation, temporal arteritis) and non-serious
causes (i.e., do not assume all red eyes are caused by conjunctivitis):
a) Take an appropriate history (e.g., photophobia, changes in
vision, history of trauma). Clinical Reasoning History

b) Do a focused physical examination (e.g., pupil size, and Clinical Reasoning Physical
visual acuity, slit lamp, fluorescein).
c) Do appropriate investigations (e.g., erythrocyte Clinical Reasoning Investigation
sedimentation rate measurement, tonometry).
d) Refer the patient appropriately (if unsure of the diagnosis or Clinical Reasoning Referral
if further work-up is needed).
3 In patients presenting with an ocular foreign body sensation, Clinical Reasoning Hypothesis generation
correctly diagnose an intraocular foreign body by clarifying the Diagnosis
mechanism of injury (e.g., high speed, metal on metal, no glasses)
and investigating (e.g., with computed tomography, X-ray
examination) when necessary.
4 In patients presenting with an ocular foreign body sensation, evert Clinical Reasoning Hypothesis generation
the eyelids to rule out the presence of a conjunctival foreign body. Procedures Skills Physical

5 In neonates with conjunctivitis (not just blocked lacrimal glands or Clinical Reasoning Hypothesis generation
‘‘gunky’’ eyes), look for a systemic cause and treat it appropriately Treatment
(i.e., with antibiotics).
6 In patients with conjunctivitis, distinguish by history and physical Clinical Reasoning Diagnosis
examination between allergic and infectious causes (viral or History
bacterial).
7 In patients who have bacterial conjunctivitis and use contact lenses, Clinical Reasoning Treatment
provide treatment with antibiotics that cover for Pseudomonas.
8 Use steroid treatment only when indicated (e.g., to treat iritis; avoid Clinical Reasoning Treatment
with keratitis and conjunctivitis).
9 In patients with iritis, consider and look for underlying systemic Clinical Reasoning Hypothesis generation
causes (e.g., Crohn’s disease, lupus, ankylosing spondylitis).

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 Part III: Priority Topics and Key Features

Renal Failure
Key Feature Skill Phase
1 In patients with chronic renal failure ensure they are aware of their Communication Treatment
diagnosis and its implications. Patient-centred Approach
2 In any patient mitigate the risks of precipitating renal failure when Clinical reasoning Hypothesis
investigation and treatment combinations are likely to be harmful (e.g., Treatment
metformin and contrast dye, bowel preparation).
3 When prescribing drugs to a patient in renal failure:
a) Determine drug safety (e.g., interactions, dose adjustments, Clinical r3easoning Treatment
metabolic considerations)
b) Adjust doses when appropriate (e.g., ACE inhibitors, Clinical reasoning Treatment
angiotensin II receptor blockers, metformin, allopurinol, antibiotics, low
molecular weight heparin, direct oral anticoagulants)
c) Monitor the impact of the drug on the renal function more Clinical reasoning Follow-up
frequently Selectivity
4 Advise patients with existing moderate or severe renal failure to pay Clinical reasoning Treatment
close attention to hydration (e.g., when travelling, elderly patients in hot
weather, when ill) to avoid exacerbating their condition.
5 Advise patients with existing renal failure to avoid certain over-the- Clinical reasoning Treatment
counter treatments (e.g., NSAIDS, herbals, supplements) as they may
worsen their condition.
6 In patients with moderate or severe renal failure provide anticipatory Clinical reasoning Treatment
guidance that if they become ill and cannot maintain fluid intake they Selectivity
should:
• Stop certain medications promptly (e.g., ACE inhibitors,
diuretics)
• Seek prompt reassessment
7 In a patient with an exacerbation of their renal failure (acute on chronic
renal failure):
Clinical reasoning Treatment
a) Correct factors (e.g., hydration, pneumonia, congestive heart
failure, urinary retention)
b) Stop drugs that might be aggravating the situation (e.g., ACE Clinical reasoning Treatment
inhibitors, metformin) Selectivity
c) Determine the appropriateness of restarting medications, once Clinical reasoning Treatment
renal function has stabilized Selectivity
8 Monitor patients with renal failure periodically, as some patients will Clinical reasoning Follow-up
worsen over time.
9 For patients with renal failure determine, based on patient factors and Clinical reasoning Treatment
local resources, if and when consultation is required (e.g., progressive Selectivity Follow-up
renal failure, bone disease, refractory anemia, mild renal failure in a
young person).
10 Ensure those involved in consultant care of patients with renal failure are Communication Follow-up
aware of other important health considerations that may affect decision Referral
making around treatment (e.g., patient preferences, frailty, malignancy,
consideration of dialysis in patients with cognitive impairment).

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 Part III: Priority Topics and Key Features

Schizophrenia
Key Feature Skill Phase
1 In adolescents and young adults presenting with problem behaviours:
a) Consider schizophrenia in the differential diagnosis
Clinical reasoning Hypothesis generation
Diagnosis
b) Reassess the diagnosis as the situation evolves Clinical reasoning Hypothesis generation
Diagnosis
2 In apparently stable patients with schizophrenia (e.g., those who are Clinical reasoning History
not floridly psychotic) assess periodically in a structured fashion
(ideally seeking collateral information from family members and other
caregivers):
• Positive and negative symptoms
• Performance of activities of daily living and their level of
social functioning
• Ideation of harm to themslves or others, including the risk for
violence
• Medication compliance and side effects
• Substance use
• Capacity to accept or refuse treatement
3 When caring for patients with psychosis clearly communicate limits of Professionalism Treatment
confidentiality to the patient and the family Communication
4 In all patients presenting with psychotic symptoms inquire about Clinical reasoning History
substance use and abuse.
5 In patients with schizophrenia ensure early treatment and follow-up, Clinical reasoning Treatment
including referral and collaborative care, because this may improve Communication Referral
prognosis.
6 In decompensating patients with schizophrenia determine if substance Clinical reasoning Hypothesis generation
use is a contributor, whether there are medication compliance and Diagnosis
side-effect problems, and if psychosocial supports have changed.
7 In a decompensating patient with schizophrenia,
a) Determine whether they meet the criteria for involuntary Clinical Reasoning Diagnosis
treatment Professionalism Treatment
b) Help the patient understand why this is necessary Communication Referral
c) Clarify your continuing role in care Patient Centred Follow-up
Communication
8 Diagnose and manage serious complications/side effects of Clinical reasoning Treatment
antipsychotic medications (e.g., neuroleptic malignant syndrome, Diagnosis
tardive dyskinesia, cardiometabolic risks).
9 Include psychosocial supports (e.g., social determinants of health, Patient-centred Approach Treatment
family support, disability issues, vocational rehabilitation) as part of Selectivity Referral
the treatment plan for patients with schizophrenia.

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 Part III: Priority Topics and Key Features

Seizures
Key Feature Skill Phase

1 In a patient having a seizure:

a) Ensure proper airway control (e.g., oropharyngeal airway or Clinical Reasoning Treatment
nasal trumpet, lateral decubitus to prevent aspiration).
b) Use drugs (e.g., benzodiazepines, phenytoin) promptly to Clinical Reasoning Treatment
stop the seizure, even before the etiology is confirmed.
c) Rule out reversible metabolic causes in a timely fashion (e.g., Clinical Reasoning Selectivity Diagnosis
hypoglycemia, hypoxia, heat stroke, electrolytes abnormalities). Hypothesis generation

2 In a patient presenting with an ill-defined episode (e.g., fits, spells, Clinical Reasoning History
turns), take a history to distinguish a seizure from other events.
3 In a patient presenting with a seizure, take an appropriate history to Clinical Reasoning History
direct the investigation (e.g., do not overinvestigate; a stable known
disorder may require only a drug-level measurement, while new or
changing seizures may require an extensive work-up).
4 In all patients presenting with a seizure, examine carefully for focal Clinical Reasoning Physical
neurologic findings.
5 In a patient with a previously known seizure disorder, who presents
with a seizure or a change in the pattern of seizures:
Clinical Reasoning History
a) Assess by history the factors that may affect the primary
seizure disorder (e.g., medication compliance, alcohol use, lifestyle,
recent changes in medications [not just antiepileptic medications],
other illnesses).
b) Include other causes of seizure in the differential diagnosis. Clinical Reasoning Hypothesis generation
(Not all seizures are caused by epilepsy.)
6 In the ongoing care of a patient with a stable seizure disorder:
a) Regularly inquire about compliance (with medication and Clinical Reasoning Treatment
Patient-centred Approach History
lifestyle measures). side effects of anticonvulsant medication, and
the impact of the disorder and its treatment on the patient’s life
(e.g., on driving, when seizures occur at work or with friends).
b) Monitor for complications of the anticonvulsant medication Clinical Reasoning Hypothesis generation
(e.g., hematologic complications, osteoporosis).
c) Modify management of other health issues taking into Clinical Reasoning Treatment
account the anticonvulsant medication (e.g., in prescribing
antibiotics, pregnancy).

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 Part III: Priority Topics and Key Features

Sex
Key Feature Skill Phase
1 Ask about sexual health and function, in a sensitive manner, when Clinical reasoning History
appropriate, e.g.:
• In conditions with higher risk for sexual dysfunction (e.g.,
post-MI, diabetes, use of certain medications)
• Throughout life cycle transitions (e.g., adolescence,
pregnancy, menopause, andropause)
• Not assuming sexual inactivity within specific populations
(e.g., people with disabilities, seniors, singles)
2 Educate patients about sexual health, consent, and safety, especially Clinical reasoning Treatment
patients at risk (e.g., for stigmatization, exploitation), using plain Communication
language appropriate to the age, developmental stage, and culture
of the patient.
3 With a patient (especially adolescents or those in vulnerable Communication Treatment
situations) presenting with a concern about sex or sexuality Professionalism
explicitly discuss confidentiality.
4 In a patient presenting with sexual dysfunction, perform a Clinical reasoning History
thorough assessment (including specific systems; mental health; Hypothesis generation
alcohol and substance use; relationship factors and impacts;
medication; and sexual history, including positive and negative
experiences) to make an accurate diagnosis.
5 When caring for a patient with gender or sexuality-related
concerns:
a) Take opportunities to destigmatize gender and
Communication History
sexuality-related concerns (e.g., using the person’s preferred
Patient-centred Approach Treatment
pronoun, using terms such as partner instead of boyfriend)
b) Identify and recognize your own biases, manage them, Professionalism History
and ensure the patient receives appropriate care Treatment

c) Differentiate between sexual orientation, gender Clinical reasoning History

identity, and sexual function Selectivity
d) Refer the patient to appropriate specialty care when Clinical reasoning Referral
indicated
e) Inform the patient about available community resources Communication Treatment
6 When performing a physical examination that triggers an
unexpected response: Professionalism Physical
Communication Treatment
a) Acknowledge the response
b) Stop the examination Professionalism Physical
c) Discuss the response in a sensitive manner, respecting Communication Treatment
the dignity of the patient Professionalism
d) Decide on next steps together with the patient Patient-centred Approach Treatment
Communication

CMPA (age of consent): 18 years for exploitative (prostitution, pornography or relationship of

trust, authority or dependency), 16 years for non-exploitative, 14 years up to 5 years older, 12
years up to 2 years older

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 Part III: Priority Topics and Key Features

Sexually Transmitted Infections

Key Feature Skill Phase

1 In a patient who is sexually active or considering sexual activity, take Patient-centred Approach Treatment
advantage of opportunities to advise her or him about prevention, Clinical Reasoning
screening, and complications of sexually transmitted diseases
(STIs).
2 In a patient with symptoms that are atypical or non-specific for
STIs (e.g., dysuria, recurrent vaginal infections):
Selectivity Hypothesis generation
a) Consider STIs in the differential diagnosis.
Clinical Reasoning

b) Investigate appropriately. Clinical Reasoning Selectivity Investigation

3 In high-risk patients who are asymptomatic for STIs, screen and Clinical Reasoning Treatment
advise them about preventive measures. Patient-centred Approach Investigation

4 In high-risk patients who are symptomatic for STIs, provide Clinical Reasoning Selectivity Treatment
treatment before confirmation by laboratory results.
5 In a patient requesting STI testing:
a) Identify the reason(s) for requesting testing. Clinical Reasoning Hypothesis generation
Patient-centred Approach Treatment

b) Assess the patient’s risk. Clinical Reasoning History

Patient-centred Approach Diagnosis

c) Provide counselling appropriate to the risk (i.e., human Clinical Reasoning Diagnosis
immunodeficiency virus [HIV] infection risk, non-HIV risk). Patient-centred Approach Treatment

6 In a patient with a confirmed STI, initiate: Clinical Reasoning Treatment

Follow-up
• treatment of partner(s).
• contact tracing through a public health or community
agency.
7 Use appropriate techniques for collecting specimens. Procedures Skills Clinical Investigation
Reasoning Physical

8 Given a clinical scenario that is strongly suspicious for an STI and a Selectivity Diagnosis
negative test result, do not exclude the diagnosis of an STI (i.e., Clinical Reasoning Investigation
because of sensitivity and specificity problems or other test
limitations).

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 Part III: Priority Topics and Key Features

Shortness of Breath
Key Feature Skill Phase
1 In a patient with a new presentation of shortness of breath take a Clinical reasoning Hypothesis
sufficient history to avoid inappropriately or prematurely limiting History
the diagnosis to respiratory and cardiac causes (i.e., consider
causes such as hematologic, environmental, psychogenic,
deconditioning, gastrointestinal).
2 Regardless of where you assess the patient who presents with Selectivity Hypothesis
shortness of breath (e.g., office, home visit) consider life-
threatening conditions (e.g., pulmonary embolus, foreign body
aspiration in a child, anaphylaxis, myocardial infarction).
3 When a patient with a diagnosed cause of dyspnea presents with
worsening symptoms or treatment failure:
a) Ask about other factors that might have exacerbated Clinical reasoning Hypothesis
their symptoms (e.g., new pets, environmental factors, History
medication technique/adherence, dietary changes)
b) Re-evaluate your primary diagnosis (i.e., the original Clinical reasoning Hypothesis
diagnosis may have been incorrect)
c) Consider co-existing diagnoses (e.g., a patient with Clinical reasoning Hypothesis
asthma who has pneumonia)
4 In an anxious patient with shortness of breath don’t assume Clinical reasoning Hypothesis
anxiety is the cause of their symptoms. Selectivity

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 Part III: Priority Topics and Key Features

Skin Disorder
Key Feature Skill Phase

1 In dealing with a persistent skin problem that is not responding to

treatment as expected:
Clinical Reasoning Hypothesis generation
a) Reconsider the diagnosis (e.g., “eczema” may really be a
Diagnosis
fungal infection).
b) Investigate or modify treatment (e.g., for acne). Clinical Reasoning Treatment
Investigation

2 In a patient presenting with a skin lesion, distinguish benign from Selectivity Physical
serious pathology (e.g., melanoma, pemphigus, cutaneous T-cell Clinical Reasoning Investigation
lymphoma) by physical examination and appropriate investigations
(e.g., biopsy or excision).
3 In a patient presenting with a cutaneous manifestation of a systemic Clinical Reasoning Hypothesis generation
disease or condition (e.g., Wegener’s granulomatosis, lupus, a drug Diagnosis
reaction), consider the diagnosis of systemic disease and confirm it
through history, physical examination, and appropriate
investigations.
4 When prompted by a patient with a concern about a localized skin Clinical Reasoning Physical
lesion or when screening for mucocutaneous lesions, inspect all
areas of the skin (e.g., nails, scalp, oral cavity, perineum, soles of the
feet, back of the neck).
5 Diagnose and promptly treat suspected life-threatening Selectivity Diagnosis
dermatologic emergencies (e.g., Stevens-Johnson syndrome, invasive Hypothesis generation
cellulitis, chemical or non-chemical burns).
6 In high-risk patients (diabetics, bed or chair bound, peripheral
vascular disease):
Clinical Reasoning Selectivity Physical
a) Examine the skin even when no specific skin complaint is
present.
b) Treat apparently minor skin lesions aggressively. Clinical Reasoning Selectivity Treatment

7 In a patient being treated for a new or persistent skin condition Patient-centred Approach Treatment
(e.g., acne, psoriasis), determine the impact on the patient’s personal History
and social life.

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 Part III: Priority Topics and Key Features

Smoking Cessation
Key Feature Skill Phase

1 In all patients, regularly evaluate and document smoking status, Clinical Reasoning Hypothesis generation
recognizing that people may stop or start at any time. Follow-up

2 In smokers:
a) Discuss the benefits of quitting or reducing smoking. Clinical Reasoning Treatment
Patient-centred Approach

b) Regularly assess interest in quitting or reducing smoking. Clinical Reasoning History

Follow-up

3 In smokers motivated to quit, advise the use of a multi-strategy Clinical Reasoning Treatment
approach to smoking cessation. Communication Follow-up

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 Part III: Priority Topics and Key Features

Somatization
Key Feature Skill Phase

1 In patients with recurrent unexplained or confusing symptoms:

Hypothesis generation
a) Do not attribute symptoms to somatization unless an Clinical reasoning Diagnosis
adequate workup rules out any medical or psychiatric condition Patient-centred
(e.g., depression) Approach

b) Reassess the symptoms periodically as they may evolve into Clinical reasoning Follow-up
diagnosable medical conditions/mental health diagnoses or remain Selectivity
unexplained
2 When a patient presents with symptoms that may be somatoform
(e.g., caused by emotional distress) clearly distinguish between the Clinical reasoning
Diagnosis
stressed individual with somatoform traits and somatic symptom Selectivity
disorder by using established diagnostic criteria.
3 In patients with a previously diagnosed somatic symptom disorder Clinical reasoning Hypothesis generation
do not assume that somatization is the cause of new or ongoing Patient-centred Approach
symptoms.
4 In patients who somatize acknowledge the illness experience and Patient-centred Diagnosis
strive to find common ground with them concerning their diagnosis Approach Treatment
and management, including investigations. Communication

5 When a patient presents frequently with medically inconsistent or Clinical reasoning Investigation
confusing symptoms that are not worrisome: Selectivity

a) Order investigations judiciously

b) Educate the patient about the connection between physical Patient-centred Approach Treatment
symptoms and psychological distress Communication

6 In a patient with existing mental health conditions do not dismiss Clinical reasoning Treatment
new physical symptoms as somatization without appropriate Selectivity Follow-up

assessment.
7 When caring for a patient with somatization identify and manage Professionalism Treatment
your own emotional responses. Patient-centred Approach Follow-up

8 When somatic symptom disorder has been established as the most Patient-centred Approach Treatment
likely diagnosis recommend and discuss evidence-informed Clinical reasoning Referral

psychotherapy and refer when appropriate, ensuring appropriate

ongoing care and follow-up.
9 In patients who have somatic symptoms inquire about the use of Professionalism History
and suggest therapies that may provide symptomatic relief and/or Patient-centred Approach Treatment

help them cope with their symptoms.

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 Part III: Priority Topics and Key Features

Stress
Key Feature Skill Phase

1 In a patient presenting with a symptom that could be attributed to Clinical Reasoning Hypothesis generation
stress (e.g., headache, fatigue, pain) consider and ask about stress as Communication History
a cause or contributing factor.
2 In a patient in whom stress is identified, assess the impact of the Patient-centred Approach History
stress on their function (i.e., coping vs. not coping, stress vs. Diagnosis
distress).
3 In patients not coping with stress, look for and diagnose, if present, Clinical Reasoning Hypothesis generation
mental illness (e.g., depression, anxiety disorder). Diagnosis

4 In patients not coping with the stress in their lives,

a) Clarify and acknowledge the factors contributing to the Patient-centred Approach History
stress, Clinical Reasoning

b) Explore their resources and possible solutions for improving Patient-centred Approach History
the situation. Treatment

5 In patients experiencing stress, look for inappropriate coping Clinical Reasoning Hypothesis generation
mechanisms (e.g., drugs, alcohol, eating, violence). Communication History

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 Part III: Priority Topics and Key Features

Stroke
Key Feature Skill Phase

1 In patients presenting with symptoms and/or signs suggestive of Clinical Reasoning Hypothesis generation
stroke, include other diagnoses in the differential diagnosis (e.g.,
transient ischemic attack [TIA], brain tumour, hypoglycemia,
subdural hematoma, subarachnoid bleed).
2 In a patient presenting with a stroke, differentiate, if possible, Clinical Reasoning Diagnosis
hemorrhagic from embolic/thrombotic stroke (e.g., through the
history, physical examination, and ancillary testing, such as scanning
and electrocardiography), as treatment differs.
3 Assess patients presenting with neurologic deficits in a timely Selectivity Treatment
fashion, to determine their eligibility for thrombolysis.
4 In a patient diagnosed with stroke, involve other professionals as Clinical Reasoning Treatment
needed (e.g., a physical therapist, an occupational therapist, social Patient-centred Approach Referral
service personnel, a physiatrist, a neurologist) to ensure the best
outcome for the patient.
5 When caring for a stroke patient with severe/serious deficits, Patient-centred Approach Treatment
involve the patient and her or his family in decisions about Communication
intervention (e.g., resuscitation, use of a feeding tube, treatment of
pneumonia).
6 In patients who have suffered stroke, diagnose “silent” cognitive Clinical Reasoning Diagnosis
deficits (not associated with sensory or motor symptoms or signs,
such as inattention and impulsivity) when they are present.
7 Provide realistic prognostic advice about their disabilities to stroke Patient-centred Approach Treatment
patients and their families.
8 In stroke patients with disabilities, evaluate the resources and Clinical Reasoning Treatment
supports needed to improve function (e.g., a cane, a walker, home Patient-centred Approach
care).
9 In the continuing care of stroke patients with deficits (e.g., Clinical Reasoning Treatment
dysphagia, being bedridden), include the prevention of certain Hypothesis generation
complications (e.g., aspiration pneumonia, decubitus ulcer) in the
treatment plan, as they are more common.
10 In patients at risk of stroke, treat modifiable risk factors (e.g., atrial Clinical Reasoning Treatment
fibrillation, diabetes, hyperlipidemia, and hypertension).
11 In all patients with a history of TIA or completed stroke, and in Clinical Reasoning Treatment
asymptomatic patients at high risk for stroke, offer antithrombotic
treatment (e.g., acetylsalicylic acid, clopidogrel) to appropriate
patients to lower stroke risk.

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 Part III: Priority Topics and Key Features

Substance use and addiction

Key Feature Skill Phase
1 In all patients, and especially in high-risk groups (e.g., those with Patient-centred Approach History
mental health issues, chronic disability), opportunistically ask Selectivity Hypothesis generation
about substance use (tobacco, alcohol, other substances).
2 For a patient using alcohol or substances (including those who use
them only occasionally):
Patient-centred Approach Treatment
a) Discuss the possible impact of their use on themselves and
Professionalism
others (e.g., risk to children, sexual indiscretion)
b) Discuss harm-reduction strategies in detail (e.g., needle Clinical reasoning Treatment
exchange, not drinking and driving, immunizations) Patient-centred Approach
3 For any patient presenting with a functional decline, confusion, or Clinical reasoning Hypothesis generation
delirium, assess for alcohol/substance use and withdrawal, even Diagnosis
when other causes may seem more apparent.
4 Discuss substance use with adolescents and their caregivers when Clinical reasoning Hypothesis generation
warning signs are present (e.g., school failure, behaviour change). Patient-centred Approach Treatment

5 Consider and look for substance use as a possible factor in Clinical reasoning Hypothesis generation
problems not responding to appropriate intervention (e.g., alcohol Patient-centred Approach Treatment
use in patients with hypertriglyceridemia, inhalational drug use in
asthmatic patients).
6 For a patient with a medical problem being treated with opioids,
stimulants, sedatives, or hypnotics:
Clinical reasoning History
a) Episodically reassess their clinical problem to affirm the
Selectivity Follow-up
ongoing need for the medication
b) Discuss tapering and cessation planning when appropriate Clinical reasoning Treatment
Patient-centred Approach Follow-up
c) Discuss safety and security of medication (e.g. storing, risk Patient-centred Approach Treatment
to children, diversion, misuse)
7 For a patient requesting or requiring a new prescription for
opioids, stimulants, or tranquillizers:
a) Assess alcohol and substance use Clinical reasoning History
Hypothesis generation
b) Explain clearly the benefits and risks, and do not prescribe Clinical reasoning Treatment
before the risks of misuse have been assessed and mitigated Professionalism
8 In patients who use substances or those with a substance use Clinical reasoning Diagnosis
disorder, regularly determine their readiness to change their Patient-centred Approach Follow-up
patterns of use.

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 Part III: Priority Topics and Key Features

9 For a patient with an alcohol or substance use disorder, assess their Patient-centred Approach Treatment
level of motivation and engage them in the development of an Clinical reasoning
individualized plan for withdrawal and ongoing treatment that
involves:
• Appropriate use of pharmacotherapy (e.g., methadone,
acamprosate)
• Use of community resources and other health
professionals
• Appropriate follow-up with you
10 In patients with a substance use disorder take advantage of Clinical reasoning History
opportunities to screen for comorbidities (e.g., poverty, crime, Patient-centred Approach Physical
sexually transmitted infections, mental health issues) and long-
term complications (e.g., cirrhosis).
11 Offer support to patients and family members affected by Patient-centred Approach Treatment
substance use disorder. (The user may not be your patient.)

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 Part III: Priority Topics and Key Features

Suicide
Key Feature Skill Phase

1 Actively inquire about suicidal and homicidal ideation (e.g., ideas, Clinical reasoning History
thoughts, a specific plan), particularly when caring for patients with Selectivity
chronic illness, mental illness, or substance use problems; recent loss
or emotional distress; impulsivity; or repeated suicidal ideation or
attempts.
2 Given a suicidal patient, assess the degree of risk (e.g., thoughts, Clinical reasoning Diagnosis
specific plans, access to means, impulsivity) to determine an
appropriate intervention and follow-up plan.
3 In patients who present with self-injury (e.g., cutting):
a) Assess the risk of suicide, but do not assume that this is Clinical reasoning History
a suicidal gesture (not all people who cut are suicidal, but some are)
b) Explore the underlying emotional distress Patient-centred Approach History

c) Discuss alternative adaptive coping strategies Clinical reasoning Treatment

Patient-centred Approach

4 In patients at low risk of suicide whom you are managing in the

community:
a) Provide specific instructions for follow-up
Communication Follow-up

b) Develop an appropriate contingency plan with the Patient-centred Approach Treatment

patient should their suicidal ideation progress/worsen Follow-up

5 When assessing and managing a patient at risk of harm to Clinical reasoning Diagnosis
themselves or others that has been reported by proxy, balance the Professionalism Treatment
patient’s and the informant’s rights to confidentiality with the risk
of harm to the patient, the informant, or others.
6 In suicidal patients presenting at the emergency department with a Clinical reasoning Hypothesis generation
suspected drug overdose always screen for acetylsalicylic acid and Investigation
acetaminophen overdoses as these are common, dangerous, and
frequently overlooked.
7 In trauma patients consider attempted suicide as the precipitating Clinical reasoning History
cause. Hypothesis generation

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 Part III: Priority Topics and Key Features

Thyroid
Key Feature Skill Phase

1 Limit testing for thyroid disease to appropriate patients, namely Clinical Reasoning Selectivity Investigation
those with a significant pre-test probability of abnormal results,
such as:
• those with classic signs or symptoms of thyroid disease
• those whose symptoms or signs are not classic, but who are
at a higher risk for disease (e.g., the elderly, postpartum
women, those with a history of atrial fibrillation, those with
other endocrine disorders)
2 In patients with established thyroid disease, do not check thyroid- Clinical Reasoning Selectivity Investigation
stimulating hormone levels too often, but rather test at the
appropriate times, such as:
• after changing medical doses
• when following patients with mild disease before initiating
treatment
• periodically in stable patients receiving treatment
3 When examining the thyroid gland, use proper technique (i.e., from Procedures Skills Physical
behind the patient, ask the patient to swallow), especially to find
nodules (which may require further investigation).
Note: The investigation of thyroid nodules is not covered here.

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 Part III: Priority Topics and Key Features

Trauma
Key Feature Skill Phase

1 Assess and stabilize trauma patients with an organized approach, Clinical Reasoning Treatment
anticipating complications in a timely fashion, using the primary Physical
and secondary surveys.
2 Suspect, identify, and immediately begin treating life-threatening Selectivity Treatment
complications (e.g., tension pneumothorax, tamponade). Diagnosis

3 When faced with several trauma patients, triage according to Selectivity Treatment
resources and treatment priorities.
4 In trauma patients, secure the airway appropriately (e.g., assume Clinical Reasoning Selectivity Treatment
cervical spine injury, use conscious sedation, recognize a difficult Hypothesis generation
airway, plan for back-up methods/cricothyrotomy).
5 In a patient with signs and symptoms of shock:
a) Recognize the shock. Clinical Reasoning Selectivity Hypothesis generation
Diagnosis

b) Define the severity and type (neurogenic, hypovolemic, Clinical Reasoning Selectivity Physical
septic). Diagnosis

c) Treat the shock. Clinical Reasoning Selectivity Treatment

6 In trauma patients, rule out hypothermia on arrival and Clinical Reasoning Hypothesis generation
subsequently (as it may develop during treatment). Physical

7 Suspect certain medical problems (e.g., seizure, drug intoxication, Clinical Reasoning Hypothesis generation
hypoglycemia, attempted suicide) as the precipitant of the trauma.
8 Do not move potentially unstable patients from treatment areas for Clinical Reasoning Treatment Investigation
investigations (e.g., computed tomography, X-ray examination).
9 Determine when patient transfer is necessary (e.g., central nervous Selectivity Treatment
system bleeds, when no specialty support is available). Clinical Reasoning Referral

10 Transfer patients in an appropriate manner (i.e., stabilize them Clinical Reasoning Treatment
before transfer and choose the method, such as ambulance or Referral
flight).
11 Find opportunities to offer advice to prevent or minimize trauma Clinical Reasoning Treatment
(e.g., do not drive drunk, use seatbelts and helmets).
12 In children with traumatic injury, rule out abuse. (Carefully assess Clinical Reasoning Selectivity Diagnosis
the reported mechanism of injury to ensure it corresponds with the Hypothesis generation
actual injury.)

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 Part III: Priority Topics and Key Features

Travel Medicine
Key Feature Skill Phase

1 Make sure travelers get up to date, timely, itinerary-specific advice Clinical Reasoning History
from a reliable source (e.g., travel clinic, travel website). Hypothesis generation

2 When seeing patients planning travel, discuss the common, non- Clinical Reasoning History
infectious perils of travel (e.g., accidents, safer sex, alcohol, safe Hypothesis generation
travel for women).
3 In patients presenting with symptoms of infection without an Patient-centred Approach Hypothesis generation
obvious cause, especially those with a fever, enquire about recent Communication Follow-up
travel history to identify potential sources (especially, but not
exclusively, malaria).
4 Provide prevention and treatment advice and prescribe medications Patient-centred Approach Treatment
for common conditions associated with travel (e.g., traveler’s Clinical Reasoning Referral
diarrhea, altitude sickness).
5 Ensure patients understand how to manage their chronic disease Clinical Reasoning Treatment
while traveling (e.g., diabetes, asthma, international normalized
ratios [INRs]).
6 Use patient visits for travel advice as an opportunity to update Clinical Reasoning Selectivity Treatment
routine vaccinations. Hypothesis generation

7 Advise patients to check insurance coverage issues especially in Professionalism Treatment

regard to recent changes in chronic disease and any recent treatment Hypothesis generation
changes.
8 Advise patients traveling with medications to have an adequate Clinical Reasoning Treatment
supply, documentation of need for use, and to transport them Hypothesis generation
securely (e.g., carry-on bag).

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 Part III: Priority Topics and Key Features

Upper Respiratory Tract Infection

Key Feature Skill Phase

1 Given an appropriate history and/or physical examination:

a) Differentiate life-threatening conditions (epiglottitis, Selectivity Diagnosis
retropharyngeal abscess) from benign conditions.
b) Manage the condition appropriately. Clinical Reasoning Treatment

2 Make the diagnosis of bacterial sinusitis by taking an adequate Clinical Reasoning History
history and performing an appropriate physical examination, and Treatment
prescribe appropriate antibiotics for the appropriate duration of
therapy.
3 In a patient presenting with upper respiratory symptoms:
a) Differentiate viral from bacterial infection (through history Clinical Reasoning History
Diagnosis
and physical examination).
b) Diagnose a viral upper respiratory tract infection (URTI) Clinical Reasoning Diagnosis
(through the history and a physical examination).
c) Manage the condition appropriately (e.g., do not give Clinical Reasoning Treatment
antibiotics without a clear indication for their use). Communication

4 Given a history compatible with otitis media, differentiate it from Clinical Reasoning Diagnosis
otitis externa and mastoiditis, according to the characteristic Physical
physical findings.
5 In high-risk patients (e.g., those who have human Clinical Reasoning Hypothesis generation
immunodeficiency virus infection, chronic obstructive pulmonary Follow-up
disease, or cancer) with upper respiratory infections: Lood for
complications more aggressively, and follow up more closely.
6 In a presentation of pharyngitis, look for mononucleosis. Clinical Reasoning Hypothesis generation
Physical

7 In high-risk groups:
a) Take preventive measures (e.g., use flu and pneumococcal Selectivity Patient-centred Treatment
Approach
vaccines).
b) Treat early to decrease individual and population impact Clinical Reasoning Treatment
(e.g., with oseltamivir phosphate [Tamiflu], amantadine). Professionalism

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 Part III: Priority Topics and Key Features

Urinary Tract Infection

Key Feature Skill Phase

1 Take an appropriate history and do the required testing to exclude Clinical Reasoning Hypothesis generation
serious complications of urinary tract infection (UTI) (e.g., sepsis, Investigation
pyelonephritis, impacted infected stones).
2 Appropriately investigate all boys with urinary tract infections, and Clinical Reasoning Investigation
young girls with recurrences(e.g., ultrasound).
3 In diagnosing urinary tract infections, search for and/or recognize Clinical Reasoning Hypothesis generation
high-risk factors on history (e.g., pregnancy; immune compromise, History
neonate, a young male, or an elderly male with prostatic
hypertrophy).
4 In a patient with a diagnosed urinary tract infection, modify the Selectivity Treatment
choice and duration of treatment according to risk factors (e.g.,
pregnancy, immunocompromise, male extremes of age); and treat
before confirmation of culture results in some cases (e.g.,pregnancy,
sepsis, pyelonephritis).
5 Given a non-specific history (e.g., abdominal pain, fever, delirium) Clinical Reasoning Hypothesis generation
in elderly or very young patients, suspect the diagnosis and do an Investigation
appropriate work-up.
6 In a patient with dysuria, exclude other causes (e.g., sexually Clinical Reasoning Hypothesis generation
transmitted diseases, vaginitis, stones, interstitial cystitis, Diagnosis
prostatitis) through an appropriate history, physical examination,
and investigation before diagnosing a urinary tract infection.

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 Part III: Priority Topics and Key Features

Vaginal Bleeding
Key Feature Skill Phase

1 In any woman with vaginal bleeding, rule out pregnancy. Clinical Reasoning Hypothesis generation
Diagnosis

2 In pregnant patients with vaginal bleeding

a) Consider worrisome causes (e.g., ectopic pregnancy, Clinical Reasoning Hypothesis generation
Diagnosis
abruption, abortion), and confirm or exclude the diagnosis through
appropriate interpretation of test results.
b) Do not forget blood typing and screening, and offer rH Clinical Reasoning Treatment
immunoglobulin treatment, if appropriate. Hypothesis generation

c) Diagnose (and treat) hemodynamic instability. Selectivity Diagnosis

Clinical Reasoning Treatment

3 In a non-pregnant patient with vaginal bleeding:

a) Do an appropriate work-up and testing to diagnose Clinical Reasoning Investigation
Diagnosis
worrisome causes (e.g., cancer), using an age-appropriate approach.
b) Diagnose (and treat) hemodynamic instability. Clinical Reasoning Selectivity Diagnosis
Treatment

c) Manage hemodynamically stable but significant vaginal Clinical Reasoning Treatment

bleeding (e.g., with medical versus surgical treatment).
4 In a post-menopausal woman with vaginal bleeding, investigate any Clinical Reasoning Investigation
new or changed vaginal bleeding in a timely manner (e.g., with
endometrial biopsy testing, ultrasonography, computed
tomography, a Pap test, and with a pelvic examination).

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 Part III: Priority Topics and Key Features

Vaginitis
Key Feature Skill Phase

1 In patients with recurrent symptoms of vaginal discharge and/or Clinical Reasoning Hypothesis generation
perineal itching, have a broad differential diagnosis (e.g., lichen Physical
sclerosus et atrophicus, vulvar cancer, contact dermatitis,
colovaginal fistula), take a detailed history, and perform a careful
physical examination to ensure appropriate investigation or
treatment. (Do not assume that the symptoms indicate just a yeast
infection.)
2 In patients with recurrent vaginal discharge, no worrisome features Clinical Reasoning Diagnosis
on history or physical examination, and negative tests, make a
positive diagnosis of physiologic discharge and communicate it to
the patient to avoid recurrent consultation, inappropriate
trreatment, and investigation in the future.
3 When bacterial vaginosis and candidal infections are identified Clinical Reasoning Selectivity History
through routine vaginal swab or Pap testing, ask about symptoms Treatment
and provide treatment only when it is appropriate.
4 In a child with a vaginal discharge, rule out sexually transmitted Clinical Reasoning Selectivity Hypothesis generation
infections and foreign bodies. (Do not assume that the child has a Diagnosis
yeast infection.)
5 In a child with a candidal infection, look for underlying illness (e.g., Clinical Reasoning Hypothesis generation
immunocompromise, diabetes). Diagnosis

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 Part III: Priority Topics and Key Features

Violent/Aggressive Patient
Key Feature Skill Phase

1 In certain patient populations (e.g., intoxicated patients, psychiatric

patients, patients with a history of violent behaviour):
a) Anticipate possible violent or aggressive behaviour.
Clinical Reasoning Hypothesis generation

b) Recognize warning signs of violent/aggressive behaviour. Clinical Reasoning Diagnosis

c) Have a plan of action before assessing the patient (e.g., stay Clinical Reasoning Treatment
near the door, be accompanied by security or other personnel,
prepare physical and/or chemical restraints if necessary).
2 In all violent or aggressive patients, including those who are Clinical Reasoning Selectivity Hypothesis generation
intoxicated, rule out underlying medical or psychiatric conditions
(e.g., hypoxemia, neurologic disorder, schizophrenia) in a timely
fashion (i.e., don`t wait for them to sober up, and realize that their
calming down with or without sedation does not necessariy mean
they are better).
3 In a violent or aggressive patient, ensure the safety (including Clinical Reasoning Treatment
appropriate restraints) of the patient and staff before assessing the Professionalism
patient.
4 In managing your practice environment (e.g., office, emergency Professionalism Treatment
department), draw up a plan to deal with patients who are verbally
or physically aggressive, and ensure your staff is aware of this plan
and able to apply it.

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 Part III: Priority Topics and Key Features

Well-baby Care
Key Feature Skill Phase

1 Measure and chart growth parameters, including head Clinical Reasoning Physical
circumference, at each assessment; examine appropriate systems at Procedures Skills
appropriate ages, with the use of an evidence-based pediatric flow
sheet such as the Rourke Baby Record.
2 Modify the routine immunization schedule in those patients who Clinical Reasoning Selectivity Treatment
require it (e.g., those who are immunocompromised, those who
have allergies).
3 Anticipate and advise on breast-feeding issues (e.g., weaning, Clinical Reasoning Hypothesis generation
returning to work, sleep patterns) beyond the newborn period to Patient-centred Approach Treatment
promote breast-feeding for as long as it is desired.
4 At each assessment, provide parents with anticipatory advice on Clinical Reasoning Treatment
pertinent issues (e.g., feeding patterns, development, immunization,
parenting tips, antipyretic dosing, safety issues).
5 Ask about family adjustment to the child (e.g., sibling interaction, Patient-centred Approach History
changing roles of both parents, involvement of extended family).
6 With parents reluctant to vaccinate their children, address the Patient-centred Approach Treatment
following issues so that they can make an informed decision: Clinical Reasoning History
• their understanding of vaccinations.
• the consequences of not vaccinating (e.g., congenital
rubella, death).
• the safety of unvaccinated children (e.g., no Third World
travel).
7 When recent innovations (e.g., new vaccines) and recommendations Professionalism Treatment
(e.g., infant feeding, circumcision) have conflicting, or lack defined, Patient-centred Approach
guidelines, discuss this information with parents in an unbiased way
to help them arrive at an informed decision.
8 Even when children are growing and developing appropriately, Clinical Reasoning History
evaluate their nutritional intake (e.g., type, quality, and quantity of Treatment
foods) to prevent future problems (e.g., anemia, tooth decay),
especially in at-risk populations (e.g., the socioeconomicaly
disadvantaged, those with voluntarily restricted diets, those with
cultural variations)

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Appendices

Priority Topics and Key Features for Rural and Remote Family Medicine

Priority Topics and Key Features for Intrapartum and Perinatal Care

Priority Topics and Key Features for Mental Health (other than those that overlap
with the existing priority topics for family medicine)

2010 List of Core Procedures in Family Medicine

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Priority Topics and Key Features for Rural and Remote Family Medicine20

Priority Topics

1. Trauma
2. Patient transfer
3. Septicemia
4. Pediatric emergencies
5. Acute cardiac presentations
6. Psychiatric emergencies
7. Diabetic emergencies
8. Active airway management
9. Urgent respiratory presentation
10. Fracture and dislocation management
11. Intrapartum care
12. Altered level of consciousness
13. Procedural sedation
14. Chronic pain
15. Indigenous health
16. Clinical courage
17. Adapting to rural life
18. Cultural safety and sensitivity

20 Suggested citation: Blau E, Cambell G, Chase C, Dhillon P, Miller K, Geller B, et al. Priority Topics and Key Features for the
Assessment of Competence in Rural and Remote Family Medicine. Mississauga, ON: College of Family Physicians of Canada;
2018

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 Priority Topics and Key Features for Rural and Remote Family Medicine

Trauma
Key Feature Skill Phase

1 When a patient presents with trauma: Clinical Reasoning Diagnosis

a) Assess and stabilize life-threatening conditions using a Selectivity Treatment
standardized approach before addressing non-life-threatening
distracting injuries.
b) Reassess thoroughly while considering mechanisms of injury, Clinical Reasoning Diagnosis
possible underlying causes (e.g., intoxication, seizure, physical Selectivity Follow-up
abuse), and patient as a whole.
c) Have a high index of suspicion for significant injuries, and Clinical Reasoning Hypothesis generation
differentiate between multi-organ and single-system trauma Selectivity Diagnosis

2 When a need for transfer is suspected, initiate transfer process early. Selectivity Treatment
(see also Patient transfer) Communication Referral

3 In a complex trauma situation (e.g., multi-patient), assume the Professionalism Treatment

leadership role by:
• Communicating clearly
• Multitasking and triaging appropriately
• Assigning roles to your team members
• Mobilizing your community’s resources (e.g., off-service
doctors, firefighters, police, clergy) early
4 When treating patients with trauma,
a) Reassess regularly for change in patient condition Clinical Reasoning Hypothesis generation
Follow-up

b) Maintain communication with the team, as well as the Communication Treatment

family, and inform them of any changes Follow-up

See also: Trauma and Loss of Consciousness

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 Priority Topics and Key Features for Rural and Remote Family Medicine

Patient transfer
Key Feature Skill Phase

1 With any patient potentially requiring transfer, consider the

following factors: Clinical Reasoning Hypothesis generation
Selectivity Treatment
t Patient stability
t Own and resources’ limitations
t Weather conditions and geographic factors
t Prolonged transfer delays
t Socio-cultural aspects, and patient’s and family wishes
2 For all patients, assess and recognize those needing immediate
transfer and do not delay the transfer for paperwork or further Clinical Reasoning Treatment
Selectivity Referral
investigation unless it will change immediate management.
3 When a transfer has been decided:
a) Stabilize the patient and continue to reassess the Clinical Reasoning Treatment
Selectivity Follow-up
conditions for transfer (e.g., weather) and patient’s status
b) Initiate communication with the receiving team, clearly and Clinical Reasoning Treatment
assertively articulating needs and reasons for transfer Communication Referral

c) Assess for the best method(s) of transportation based on the Selectivity Hypothesis generation
patient’s condition, and weather and geographic factors Referral

d) Anticipate possible transfer complications (e.g., barometric Clinical Reasoning Hypothesis generation
trauma, pressure sores) and prepare the patient accordingly (e.g., Procedure Treatment
ensure IV lines and airway are secured, ensure adequate warming)
e) Identify the need for accompanying health professionals and Professionalism Hypothesis generation
consider the implications on the remaining health team and Selectivity Treatment
community
f) Ensure ongoing communication with the family, the receiving Communication Referral
hospital, and the team Follow-up

g) Ensure adequate documentation Communication Referral

Follow-up

4 1. During the transfer: Clinical Reasoning Treatment

a) Ensure regular reassessment of the patient’s status, Follow-up
including body temperature and pressure points
b) Maintain communication with the receiving hospital Communication Referral
Follow-up

a) Remain engaged and intervene as necessary until the safe Communication Referral
handover to the receiving physician Professionalism Follow-up

See also: Trauma

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 Priority Topics and Key Features for Rural and Remote Family Medicine

Septicemia
Key Feature Skill Phase

1 For a patient presenting with an infection: Clinical Reasoning Hypothesis generation

a) Recognize early symptoms and signs of sepsis, based on Diagnosis
currently accepted guidelines
b) Be alert to presentations that can be subtle and atypical Clinical Reasoning Hypothesis generation
(e.g., in newborns, children, the elderly) Selectivity

c) Consider patients at risk (e.g., patients on biologic agents, Clinical Reasoning Hypothesis generation
patients with addiction) Diagnosis

2 For a patient presenting with signs and symptoms of sepsis: Clinical Reasoning Treatment
a) Manage with antibiotics immediately; do not delay treatment Selectivity
if there is difficulty in obtaining investigations (e.g., collecting
culture, imaging)
b) Be aware of the local antibiotic resistance patterns and Clinical Reasoning Hypothesis generation
institute therapy as indicated Selectivity Treatment

c) Consider antiviral and/or antifungal therapy Clinical Reasoning Diagnosis

Treatment

3 Monitor septic patients closely and manage without delay as these

patients decompensate quickly: Selectivity Treatment
Follow-up
• Recognize septic shock
• Recognize the need for vasopressors
• Proactively consider patient transfer, based on local
treatment norms and capacity
4 When treating a septic patient, contact Public Health where Communication Treatment
applicable to ensure contacts are treated appropriately. Professionalism Follow-up

See also: Infection

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 Priority Topics and Key Features for Rural and Remote Family Medicine

Pediatric emergencies
Key Feature Skill Phase

1 When a child presents in distress:

a) Anticipate rapid deterioration regardless of the setting, and Clinical Reasoning History
Selectivity Hypothesis generation
identify life-threatening situations; do not underestimate the
seriousness of symptoms if the child presents at the office and not
the emergency department
b) Do not delay treatment and/or transfer when appropriate Clinical Reasoning Hypothesis generation
Selectivity Treatment

c) Mobilize appropriate resources Clinical Reasoning Treatment

Communication

2 When assessing a child in distress:

a) Check vital signs and measure height, weight, and glucose Clinical Reasoning Physical
Procedures Skills

b) Perform a comprehensive physical examination, recognizing Clinical Reasoning Physical

that the history might be incomplete and considering that certain Procedures Skills
illnesses may present differently in children
c) Consider child abuse as an etiology and take appropriate Clinical Reasoning Hypothesis generation
action
3 When developing a management plan for a child in distress: Procedures Skills Hypothesis generation
Treatment
a) Prepare available pediatric equipment and supplies (e.g.,
intraosseous access, Broselow-pediatric emergency tape)
b) Base dosage on estimated weight, not age Clinical Reasoning Treatment
Procedures Skills

4 When managing a child in distress: Clinical Reasoning Hypothesis generation

a) Be prepared for rapid decompensation Selectivity Treatment

b) Monitor constantly following a systematic approach, and be Clinical Reasoning Treatment

prepared to resuscitate Selectivity Follow-up

5 After managing a pediatric emergency and especially after a negative Patient-centred Approach Follow-up
outcome: Professionalism
a) Recognize the emotional impact on family, staff, the
community, and yourself,
b) Debrief and address consequences appropriately Communication Follow-up
Professionalism

See also: Advanced Cardiac Life Support and Trauma

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 Priority Topics and Key Features for Rural and Remote Family Medicine

Acute cardiac presentations

Key Feature Skill Phase

1 For a patient with an acute cardiac presentation:

a) Recognize the potentially unstable patient and the need for Clinical Reasoning Diagnosis
Treatment
immediate intervention, consultation, and/ or transfer
b) Maintain a high index of suspicion and recognize variable Clinical Reasoning Hypothesis generation
presentations according to gender, age, and lifestyle
2 For a patient presenting with symptoms indicative of a myocardial
infarction:
Clinical Reasoning Diagnosis
a) Order and interpret the ECG and available laboratory results
Selectivity Investigation
in a timely fashion
b) Initiate treatment based on patient presentation and ECG Clinical Reasoning Diagnosis
findings, in an environment where cardiac serology is not available Treatment

c) Identify patients requiring thrombolysis, considering absolute Clinical Reasoning Diagnosis

and relative contraindications, and manage any complications that Treatment
arise
d) Assess the need for telephone consultation versus immediate Clinical Reasoning Treatment
or delayed transfer Selectivity Referral

See also: Ischemic Heart Disease and Chest Pain

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 Priority Topics and Key Features for Rural and Remote Family Medicine

Psychiatric emergencies
Key Feature Skill Phase

1 When developing a differential diagnosis for a patient presenting in

a psychiatric crisis, consider cultural differences and potential Clinical Reasoning Hypothesis generation
Diagnosis
underlying causes.
2 For a patient with a diagnosed psychiatric crisis, identify safe Clinical Reasoning Treatment
disposition, taking into account:
• Cultural and geographic setting
• Local resources
• Caregiver fatigue
3 When considering admitting or transferring a patient in psychiatric
crisis:
a) Follow the provincial or territorial Mental Health Act, and be Clinical Reasoning Treatment
aware of the limitations of your local facility to admit and care for Professionalism
psychiatric emergencies
b) Ensure safety for the patient, family, and staff Professionalism Treatment

c) Advocate strongly for the patient’s admission to the Communication Treatment

appropriate level of care Professionalism Referral

4 When transferring a patient in psychiatric crisis, consider their need Clinical Reasoning Hypothesis generation
for sedation. Treatment

5 If faced with a co-worker, friend, or family member in a psychiatric Professionalism Treatment

crisis, recognize the possibility of your own discomfort, consult Referral
early, and hand over care as soon as possible.

See also: Schizophrenia, Depression and Suicide

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 Priority Topics and Key Features for Rural and Remote Family Medicine

Diabetic emergencies
Key Feature Skill Phase

1 For a patient presenting with symptoms indicative of a blood sugar

related emergency:
a) Consider and identify hypo- and hyperglycemia even with
Clinical Reasoning Hypothesis generation
atypical presentations (e.g., young patients with other symptoms, Selectivity Diagnosis
patients on newer classes of diabetic medications)
b) Assess for underlying causes (e.g., infection, acute coronary Clinical Reasoning History
syndrome) Diagnosis

c) Evaluate the need for transfer Clinical Reasoning Treatment

Selectivity Referral

2 For a patient presenting with a hyperglycemic emergency;

a) Differentiate diabetic ketoacidosis (DKA) from Clinical Reasoning Treatment
hyperosmolar hyperglycemic state (HHS)
b) Assess the severity of the metabolic derangement Clinical Reasoning Investigation
Diagnosis

3 For a patient with diagnosed DKA or HHS, follow a systematic

Clinical Reasoning Treatment
approach to management, including using:
• Point of care tools
• Laboratory resources
• Local, tertiary, and online resources
• Currently accepted guidelines
4 Following an acute diabetic emergency, educate the patient and the Clinical Reasoning Treatment
family about the prevention (including use of local resources) and Communication Follow-up
early recognition of future, similar episodes.

See also: Diabetes

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 Priority Topics and Key Features for Rural and Remote Family Medicine

Active airway management

Key Feature Skill Phase

1 When considering active airway management, use a systematic

approach to assessment and identify: Clinical Reasoning Hypothesis generation
Treatment
Urgency of the situation
Indications and contraindications to the interventions
being considered
Available resources (human, equipment, and medications)
Possibility of prolonged ventilation support requirements
2 Before securing the airway:
a) Prepare all necessary equipment Procedures Skills Hypothesis generation
Treatment

b) Always anticipate a difficult airway and be prepared to use Clinical Reasoning Hypothesis generation
alternative strategies (e.g., laryngeal mask, surgical airways) Treatment

3 After securing the airway: Clinical Reasoning Physical

a) Clinically confirm airway placement
b) Continue to reassess and be prepared for rapid changes in Selectivity Follow-up
the patient’s status
c) Ensure eye care, naso-gastric drainage, and urinary catheter Procedures Skills Treatment

d) Consider capnography and chest X-ray to confirm Clinical Reasoning Investigation

placement
4 When transferring an intubated patient: Clinical Reasoning Physical
a) Confirm the correct placement of endotracheal tube at each Follow-up
patient transfer point
b) Consider specialized transfer requirements (e.g., saline in the Clinical Reasoning Treatment
cuff, pressure point padding)

See also: Advanced Cardiac Life Support and Trauma

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 Priority Topics and Key Features for Rural and Remote Family Medicine

Urgent respiratory presentations

Key Feature Skill Phase

1 When a patient presents in respiratory distress:

a) Manage the distress immediately Selectivity Treatment

b) Develop a differential diagnosis relying on clinical skills, Clinical Reasoning Hypothesis generation
augmenting with imaging when available Diagnosis

c) Differentiate between upper and lower airway etiologies Clinical Reasoning Diagnosis

2 When managing a patient in respiratory distress: Clinical Reasoning Hypothesis generation

Selectivity Diagnosis
a) Consider early active airway management (e.g., inhalation
injury, pulmonary contusion), based on the patient’s condition and
the available resources
b) Re-evaluate regularly as symptoms evolve and as more Clinical Reasoning Follow-up
information becomes available, bearing in mind that
decompensation can occur quickly
c) Consider transfer before the patient’s needs exceed local Clinical Reasoning Referral
capabilities Professionalism

3 For a patient with upper airway compromise, act promptly to relieve Procedures Skills Treatment
the obstruction (e.g., peritonsillar abscess, epistaxis, foreign object, Selectivity
epiglottitis).

See also: Active airway management, Upper Respiratory Tract Infection, Pneumonia and Chest Pain

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 Priority Topics and Key Features for Rural and Remote Family Medicine

Fracture and dislocation management

Key Feature Skill Phase

1 For a patient presenting with a fracture or dislocation, assess for

vascular compromise and neurologic deficit and document. Clinical Reasoning Physical
Communication Diagnosis

2 For a patient with vascular compromise, promptly reduce the Procedures Skills Treatment
Selectivity
fracture and/or dislocation without waiting for imaging.

3 For a patient presenting with a suspected fracture: Clinical Reasoning Treatment

a) Splint and immobilize as appropriate and consider analgesia Procedures Skills

b) Order appropriate imaging (e.g., specific view, joint above and Clinical Reasoning Investigation
below), based on the urgency of the situation and the available Selectivity
resources
c) Maintain a high index of suspicion for an undisplaced Clinical Reasoning Hypothesis generation
fracture even if the initial X-ray is negative Investigation

4 For patients with significant fractures, anticipate complications (e.g.,

thrombo-embolism, compartment syndrome, occult hemorrhage) Clinical Reasoning Hypothesis generation
Selectivity Treatment
and manage accordingly.
5 Consider appropriate consultation for certain cases, such as: Clinical Reasoning Referral
Selectivity
An intra-articular fracture
A fracture involving the growth plate
An open fracture
6 When managing a patient with a fracture or dislocation,
communicate clearly with the patient and the family (especially Communication Treatment
when the patient is a child) regarding the procedure, possible
complications, and recovery timelines.
7 When preparing a patient with a fracture for transfer: Clinical Reasoning Treatment
Procedures Skills
a) Adequately immobilize the fracture and regularly reassess
neurovascular status, including at transfer points
b) Provide adequate analgesia Clinical Reasoning Treatment

c) Minimize the risk of pressure sores Clinical Reasoning Treatment

See also: Procedural sedation, Fractures

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 Priority Topics and Key Features for Rural and Remote Family Medicine

Intrapartum care
Key Feature Skill Phase

1 During prenatal care, communicate early the benefits and risks of Clinical Reasoning Treatment
delivering locally versus at a distance. Patient-centred Approach

2 When deciding on the location for delivery before or during labour,

Patient-centred Approach Treatment
review important existing and evolving factors, such as:
Selectivity
• Cultural preferences regarding birthing
• Local resources
• Weather
• Patient’s condition
3 For any woman in late pregnancy or in labour, have a high index of Clinical Reasoning Hypothesis generation
suspicion for non-cephalic presentations and manage appropriately. Treatment

4 When a fetus is in distress: Clinical Reasoning Treatment

a) Perform intrapartum resuscitative interventions
b) Anticipate assisted vaginal delivery or surgical delivery Clinical Reasoning Treatment

5 For a pregnant or postpartum woman, assess for and manage

eclampsia if present. Clinical Reasoning Diagnosis
Treatment

6 After every delivery: Clinical Reasoning Treatment

a) Be prepared to manage postpartum hemorrhage
b) Assess for the presence of lacerations, including a rectal exam Clinical Reasoning Diagnosis
Treatment
when indicated
c) Manage appropriately and identify those lacerations that Clinical Reasoning Treatment
Procedures Skills Referral
require consultation
7 For all stable women and neonates, encourage and support
Clinical Reasoning Treatment
breastfeeding, especially in regions with poor water quality.
Patient-centred Approach

See also: Pregnancy and Priority Topics and Key Features for the Assessment of Competence in Intrapartum
and Perinatal Care

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 Priority Topics and Key Features for Rural and Remote Family Medicine

Altered level of consciousness

Key Feature Skill Phase

1 For a patient presenting with an altered level of consciousness: Clinical Reasoning History
Physical
a) Obtain a comprehensive history and perform a detailed
clinical assessment
b) Quickly identify and manage common reversible causes (e.g., Clinical Reasoning Diagnosis
hypoglycemia, opioid overdose, sepsis, hypothermia) Selectivity Treatment

c) Identify the need for additional tests that may require patient Clinical Reasoning Investigation
transfer to another facility Selectivity Referral

d) Reassess frequently for any change in status Clinical Reasoning Treatment

Selectivity Follow-up

2 When a patient with an altered level of consciousness presents in an

Professionalism Treatment
agitated or aggressive state, optimize the safety of the patient and
the staff.

See also: Loss of Consciousness and Dementia

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 Priority Topics and Key Features for Rural and Remote Family Medicine

Procedural sedation
Key Feature Skill Phase

1 When considering procedural sedation, recognize the difference

between elective and emergent situations and obtain consent Clinical Reasoning Diagnosis
Selectivity Treatment
accordingly.
2 When preparing for procedural sedation: Clinical Reasoning Treatment
a) Ensure adequate support and equipment, including a rapid
sequence intubation protocol
b) Select medications and equipment appropriate to the clinical Clinical Reasoning Treatment
Selectivity
presentation, considering personal knowledge and skill
c) Always check the doses according to patient’s weight, Clinical Reasoning Treatment
especially for children

d) Consider airway protection for compromised patients Clinical Reasoning Hypothesis generation
Treatment

3 When performing procedural sedation, anticipate, monitor for, and

respond to potential complications (e.g., laryngospasm, Clinical Reasoning Treatment
hypoventilation, hypotension).
4 For a patient who has undergone procedural sedation, Clinical Reasoning Treatment
a) Ensure an adequate recovery observation period
b) Ensure the patient is accompanied by a responsible person if Clinical Reasoning Treatment
Professionalism
they are being discharged

See also: Fractures and Lacerations

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 Priority Topics and Key Features for Rural and Remote Family Medicine

Chronic pain in rural and remote settings

Key Feature Skill Phase

1 For a patient presenting with chronic pain, recognize that social

determinants of health and previous conditions (e.g., trauma, abuse, Clinical Reasoning History
Hypothesis generation
addiction) may contribute to the pain syndrome.
2 When treating patients with chronic pain, optimize non-opioid
medications and strive to provide non- pharmacological Clinical Reasoning Treatment
Selectivity
management (e.g., trauma-informed counselling, physiotherapy,
splinting/bracing, joint and trigger point injections).
3 When caring for a patient who has been prescribed opioids for
chronic pain, use all resources available in the community Clinical Reasoning Treatment
Patient-centred Approach
(including the local pharmacy) to develop an effective local approach
to prescribing that minimizes addiction potential, enhances
treatment, and promotes safety.
4 When caring for patients with chronic pain in a rural or remote
Patient-centred Approach Treatment
environment with difficult access to other resources, actively
Professionalism
advocate for patients’ access to services.

See also: Pain and Chronic Pain

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 Priority Topics and Key Features for Rural and Remote Family Medicine

Indigenous health

These key features may apply equally to other underserved rural and remote populations.

Key Feature Skill Phase

1 When caring for Indigenous populations: Professionalism Hypothesis generation

a) Recognize personal prejudice, assumptions, and
generalizations
b) Consider local cultural norms of different population groups Patient-centred Approach Hypothesis generation
Treatment

c) Recognize the systemic and individual effects of historical and Patient-centred Approach History
ongoing government policies toward Indigenous populations and Treatment
the impact these have on their health status
d) Take the necessary time to establish trust and find common Patient-centred Approach History
ground Communication Treatment

e) Recognize the connection between poor health and social Clinical Reasoning Hypothesis generation
determinants of health, and actively advocate for patients’ access to Professionalism Treatment
services
2 When assessing Indigenous patients, consider diseases that are Clinical Reasoning Hypothesis generation
prevalent in the local area (e.g., tuberculosis, water-
related/environmental diseases, diseases related to traditional food
sources).
3 When caring for Indigenous populations, consider the impact of Clinical Reasoning Hypothesis generation
dental health, and educate patients and families about dental care. Patient-centred Approach Treatment

4 When caring for Indigenous populations, consider the effect of the Clinical Reasoning Hypothesis generation
geographical location (e.g., amount of daylight, isolation, food Patient-centred Approach
access) on mental and physical health.
5 For Indigenous patients with suicidality, identify safe places and Clinical Reasoning Treatment
Selectivity
involve available supports.
6 When considering transfer for Indigenous patients, recognize the Clinical Reasoning Treatment
Patient-centred Approach
potential trauma related to leaving their community and treat
locally when possible.

See also: Professionalism themes 3,6, and 9, Patient Centred Approach, Suicide and Periodic Health
Assessment/Screening

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 Priority Topics and Key Features for Rural and Remote Family Medicine

Clinical courage
Key Feature Skill Phase

1 When dealing with a clinical situation that might surpass your level
of comfort:
a) Do not minimize the situation (e.g., underestimate the Professionalism Treatment
necessary level of skill, ignore the complexity of the situation to Clinical Reasoning
avoid dealing with it) and do not overreact (e.g., over transferring,
over consulting)
b) Assess comprehensively, considering the resources, Clinical Reasoning Diagnosis
presentation, indications, and contraindications of proposed Selectivity Treatment
interventions
c) Develop a management plan Clinical Reasoning Treatment
Patient-centred Approach

2 When considering an intervention that surpasses your level of Clinical Reasoning Treatment
comfort, be prepared to take a risk by: Professionalism
• Drawing on your parallel education or knowledge
• Anticipating difficulties and consulting when appropriate,
seeking local and external support
• Following a patient-centred approach and maintaining
communication with the patient or advocate, in order to
ensure that you are acting in their best interest
3 After an encounter that was beyond your level of comfort, reflect, Professionalism Follow-up
debrief with colleagues, and identify learning opportunities. Clinical Reasoning

4 When caring for a patient with an uncertain diagnosis in a rural or Clinical Reasoning Follow-up
remote area where resources may be limited, recognize that Patient-centred Approach
repeated assessment over time will help provide reassurance that
appropriate care is being provided.

See also: Professionalism, themes #2,3,6 and 7

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 Priority Topics and Key Features for Rural and Remote Family Medicine

Adapting to rural life

Developing a sensitivity to local culture and social norms provides a foundation for becoming familiar with
your local community. Some individuals may adapt seamlessly, while others may have difficulty making the
transition.

When working in a rural or remote environment:

Key Feature Skill Phase

1 Recognize your own needs and the needs of your family in order to Professionalism
develop a sustainable and satisfying lifestyle.
2 Remain aware of personal visibility in the community and the Professionalism
overlap between personal and professional life.
3 Ensure patients’ privacy, keeping in mind that the community is Professionalism Treatment
connected in ways of which you may not be aware. Patient-centred Approach

4 Be aware that creating and maintaining appropriate boundaries may Professionalism Treatment
be more challenging in rural environments. Patient-centred Approach

5 Actively participate in community life. Professionalism

Communication

6 Consider maintaining academic connections with a medical school as Professionalism

a preceptor.
7 Be prepared to share the administrative responsibilities of health Professionalism
care in your community (e.g., chief of staff, leadership roles,
committee participation).
8 Recognize a strong emotional response and possible post-traumatic Professionalism
Communication
stress in yourself and staff after treating a co-worker, friend, or
family member, or after a traumatic medical or community event,
and address it appropriately.
9 Establish safe supportive relationships with other health care Professionalism
Communication
professionals (including those from other communities) where
difficult medical and social issues may be discussed in an informal
manner (e.g., Balint group, problem-based small group learning,
Society of Rural Physicians of Canada).
10 Have your own family physician Professionalism

See also: Professionalism themes 8, 10 and 11

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 Priority Topics and Key Features for Rural and Remote Family Medicine

Cultural safety and sensitivity

Key Feature Skill Phase

1 When providing health care in a rural or remote community, Professionalism Treatment

Patient-centred Approach
familiarize yourself with local traditions, beliefs, and habits, and
recognize cultural differences in order to anticipate and prevent
potential conflicts.
2 When caring for patients in a rural or remote setting, remain aware Professionalism Treatment
of the already limited choices and resources available to the patients Patient-centred Approach
and that your values may further affect health care services provided
in your community (e.g., opioid prescribing, birth control).
3 When caring for patients in a rural or remote community: Patient-centred Approach Treatment
Communication
a) Identify their priorities, expectations, and preferences (e.g.,
patient transfer, birth, palliative care and dying)

b) Demonstrate respect for important local practices (e.g., sweat Patient-centred Approach Treatment
lodge, smudge ceremony, cupping) Professionalism

c) Consider enlisting the assistance of people who are fluent in Patient-centred Approach Treatment
Professionalism
the patient’s culture (e.g., minister, elder)

4 When working in a community with a predominant ethnic or Patient-centred Approach Treatment

Professionalism
religious group, avoid generalizing and assuming that all community
members share the same beliefs and create a safe place for all
individuals.

See also: Professionalism themes 3, 5, 6 and 10

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Priority Topics and Key Features for Intrapartum and Perinatal Care21

Priority Topics

1 Normal labour and delivery

2 Fetal health surveillance during labour
3 Pain in labour
4 Labour dystocia
5 Vacuum assisted delivery
6 Vacuum assisted delivery—procedure skill
7 Shoulder dystocia
8 Shoulder dystocia—procedure skill
9 Postpartum hemorrhage
10 Perineal lacerations—procedure skill
11 Peripartum fever
12 Antepartum bleeding—after 20 weeks gestation
13 Non-cephalic fetal presentation
14 Pre-labour rupture of membranes
15 Preterm labour
16 Trial of labour after Caesarian
17 Induction of labour
18 Peripartum mental health
19 Gestational hypertension/preeclampsia
20 Gestational diabetes
21 Breastfeeding
22 First week of life
23 Working in teams
24 Limits—practising according to personal and facility limits

21 Suggested citation: Biringer A, Ehman W, Fenton S, Gagnon A, Graves L, Miller K, Northorp S, et al. Priority Topics and Key
Features for the Assessment of Competence in Intrapartum and Perinatal Care. Mississauga, ON: College of Family Physicians of
Canada; 2017

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

Normal labour and delivery

Key Feature Skill Phase

1 When a woman presents in labour,

22 Clinical Reasoning History
a) Assess for risk factors that identify those women for whom
vaginal birth is not appropriate
b) Establish the preferred expectations for the delivery with the Clinical Reasoning Treatment
woman and her supports Patient-centred Approach History

2 When a woman presents in labour, Clinical Reasoning Diagnosis

a) Diagnose the stage and the phase of labour based on history
and abdominal and pelvic exam
b) Decide whether or not to admit based on appropriate Clinical Reasoning Hypothesis generation
medical, social, and personal factors in order to reduce premature Selectivity
admissions
3 Throughout labour:
a) Provide support and pain management, using a patient- Clinical Reasoning Treatment
Patient-centred Approach
centred approach and multiple options (e.g., mobility, different
positions)
b) Monitor maternal and fetal well-being, in order to recognize Clinical Reasoning Treatment
any changes that would alter the management plan
c) Follow progress regularly Clinical Reasoning Treatment

d) Avoid unnecessary or premature interventions (e.g., using Selectivity Treatment

uterotonics when not in active labour)
4 During the second stage of labour: Clinical Reasoning Treatment
a) Initiate pushing at the appropriate time, respecting the
woman’s preferred position and expulsive efforts
b) Conduct a controlled delivery in order to minimize trauma Procedures Skills Treatment

5 Immediately following vaginal birth:

a) Care for the well newborn with skin-to-skin care, assessment,
Clinical Reasoning Treatment
delayed cord clamping, and early initiation of breastfeeding
b) Assess the need for resuscitation of the newborn and manage Clinical Reasoning Hypothesis generation
Treatment
appropriately
c) Assess uterine tone and bleeding, and administer Clinical Reasoning Treatment
prophylactic oxytocin in the third stage

22 We are cognizant and respectful that not all pregnant individuals will identify with traditional gender roles. Our choice of the
word “woman” to refer to the pregnant individual was chosen for consistency and ease throughout the document and is not
intended to exclude those for whom this is not their chosen term.

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

d) Deliver the placenta, avoiding unnecessary traction Procedures Skills Treatment

e) Assess and manage perineal injury Clinical Reasoning Physical Exam

Treatment

6 Following a vaginal delivery: Communication Follow-up

a) Debrief with the team, including the woman and her
supports, and document appropriately
b) Reassess the woman and baby, and review ongoing Clinical Reasoning Follow-up
management plans before leaving the birthing unit

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

Fetal health surveillance during labour

Key Feature Skill Phase

1 Whenever a woman presents in labour, assess the risk factors and Clinical Reasoning Hypothesis generation
Selectivity Treatment
the overall context to select and initiate the appropriate method,
frequency, and timing of fetal surveillance (intermittent auscultation
(IA) versus electronic fetal monitoring (EFM)):
• Assessment of risk factors and context must be current
• In general, use IA for women without risk factors and
EFM when risk factors are present
• Ensure fetal surveillance is maintained as per a standard
protocol
2 When reviewing the findings on fetal surveillance, always correlate Clinical Reasoning Treatment
fetal heart rate with uterine activity. Investigation

3 When conducting fetal health surveillance during labour, classify Clinical Reasoning Diagnosis
and document the fetal surveillance as per standardized Communication
classification (i.e., normal, atypical, or abnormal).
4 When interpreting fetal surveillance,
a) Look for and recognize the abnormalities, especially the Clinical Reasoning Hypothesis generation
subtle ones that require immediate action
b) Act promptly to resolve the situation. Selectivity Treatment

5 When abnormal or atypical fetal surveillance is observed:

a) Interpret within the context of the whole pregnancy and
Clinical Reasoning Diagnosis
labour (e.g., stage and progress of labour, maternal stability,
maternal/fetal risk factors, duration of abnormalities)
b) Assess for etiology and contributing factors Clinical Reasoning Hypothesis generation

c) Institute appropriate intrauterine resuscitation, and when Clinical Reasoning Treatment

abnormal fetal surveillance is not corrected by intrauterine
resuscitation, institute a plan for delivery

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

Pain in labour
Key Feature Skill Phase

1 Prior to labour, discuss pain and pain relief with women, correcting Clinical Reasoning Treatment
misconceptions and providing education.
2 For a woman in labour, use a patient-centred approach to clarify her Patient-centred Approach Treatment
pain experience and her emotional state, as well as her expectations
and preferences for pain management.
3 When managing pain for a woman in labour, optimize the use and Clinical Reasoning Treatment
effectiveness of support and other non-pharmacological measures
(e.g., hydrotherapy, TENS, ambulation).
4 When providing pharmacological pain relief in labour, use an Clinical Reasoning Treatment
appropriate method (e.g., opiates, nitrous oxide, epidural
anesthesia), taking into account the woman’s choices, the stage of
labour, available resources and possible side-effects (e.g., fetal
surveillance changes, newborn respiratory depression, labour
prolongation).
5 For a woman using analgesia in labour, look for and manage side Clinical Reasoning Hypothesis generation
Treatment
effects (e.g., maternal fever, fetal surveillance changes).

6 When pain in labour is unusual or unresponsive to typically Clinical Reasoning Hypothesis generation
effective management, assess to rule out unusual or pathological
causes (e.g., uterine rupture, pulmonary embolus, history of sexual
abuse) that would require other interventions or approaches.

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

Labour dystocia
Key Feature Skill Phase

1 When a woman presents with possible labour, diagnose or rule out Clinical Reasoning Diagnosis
active labour, based on history and on abdominal and pelvic
examination (i.e., avoid premature admission to labour and
delivery).
2 For a woman in labour: Clinical Reasoning Diagnosis
a) Assess and document progress of labour by following cervical Communication
dilation and fetal descent.
b) Make a diagnosis of labour dystocia based on lack of Clinical Reasoning Diagnosis
progress in cervical dilation in the first stage of labour and fetal Selectivity
descent in the second stage, and in the context of maternal and
environmental factors; avoid making the diagnosis too early or too
late
3 When labour dystocia is suspected, or diagnosed: Clinical Reasoning Treatment
a) First consider and use non-pharmacological methods to treat
(e.g., ambulation, continuous support, amniotomy)
b) Systematically look for and identify possible contributing Clinical Reasoning Hypothesis generation
factors (i.e., uterine contractility, fetal size and presentation, pelvic Diagnosis
architecture, maternal pain and psychological state) in order to
optimize management
4 For a woman with labour dystocia that has not responded to Clinical Reasoning Treatment
appropriate non-pharmacological intervention, use an appropriate Follow-up
uterotonic medication, while maintaining careful surveillance of
maternal and fetal well-being.
5 For a woman with labour dystocia, look for and recognize the fetal Clinical Reasoning Hypothesis generation
Diagnosis
and maternal indications for operative delivery.

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

Vacuum assisted delivery

Key Feature Skill Phase

1 For a woman in labour, look for signs that she may need an assisted Clinical Reasoning Hypothesis generation
Treatment
delivery (e.g., labour dystocia, atypical or abnormal fetal
surveillance, maternal fatigue) and, when these signs are present,
start the appropriate preparations, including a backup plan with
additional help as necessary.

2 When assisted delivery is contemplated, assess for contraindications Clinical Reasoning Hypothesis generation
(e.g., any presentation other than cephalic, cervix not fully dilated, Treatment
unengaged head, < 34 weeks) and, when present, make appropriate
alternative plans for delivery.
3 When an assisted delivery is indicated, discuss the options with the Communication Treatment
woman, obtain informed consent, and prepare the team. Patient-centred Approach

4 When performing an assisted delivery, use a standardized approach Clinical Reasoning Treatment
(e.g., the A to J mnemonic from ALARM).
5 When an assisted delivery is not progressing as expected, do not Selectivity Treatment
persist with excessive efforts, but abandon the procedure and
initiate the alternative backup delivery plan.
6 Following an assisted delivery, examine the woman and the Clinical Reasoning Physical Exam
newborn for signs of trauma (e.g., high vaginal laceration, third- Follow-up
degree tear, subgaleal bleeding) or need for further care.
7 At the appropriate time following an assisted delivery, debrief with Communication Follow-up
the woman (and her supports), and with the team. Document
thoroughly.

See also General Key Features of Procedure Skills for Family Medicine for technical aspects.

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

Vacuum assisted delivery—procedure skill

Key Feature Skill Phase

1 When considering a vacuum assisted delivery, confirm full cervical Procedures Skills Treatment
dilatation and assess the station and position of the head to ensure
that the procedure is safe and likely to succeed.

2 Prior to placing the vacuum, optimize the chance of success by Procedures Skills Treatment
ensuring adequate analgesia, emptying the woman’s bladder, and Communication
engaging the woman and her supports in the procedure. Check that
the equipment is working and that a backup plan is in place.
3 When applying the vacuum cup, ensure that the position is correct, Procedures Skills Treatment
there is no entrapment of maternal tissue, and appropriate vacuum
pressure is being applied.
4 When performing a vacuum assisted delivery, apply traction during Procedures Skills Treatment
maternal pushing and pull firmly but not excessively, without
pivoting. Apply traction in the direction of the pelvic curve, initially
downward and finally upward.
5 When applying traction, assess descent on each pull. Reassess the Procedures Skills Hypothesis generation
Treatment
plan if there are indications that the procedure will not succeed:
• No progress after two pulls with a properly positioned cup
and good traction
• Three pop-offs without obvious cause
• Delivery not imminent after four contractions
• Delivery not imminent after 20 minutes of vacuum
application

Note: See also General Key Features of Procedure Skills for Family Medicine for technical aspects.

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

Shoulder dystocia
Key Feature Skill Phase

1 For all deliveries, assess risk factors for shoulder dystocia, develop a Clinical Reasoning Hypothesis generation
Treatment
plan of management according to the risks, and adjust the
preparations according to the evolving risks.

2 For all deliveries, anticipate and remain vigilant for the signs of Selectivity Hypothesis generation
impending shoulder dystocia and, when appropriate, prepare the Communication Treatment
woman and the team for the possibility of shoulder dystocia.
3 During the second stage of labour, recognize shoulder dystocia Clinical Reasoning Diagnosis
promptly when it occurs, communicate its presence clearly to the Communication Treatment
team, including the woman, and, working as a team, use appropriate
manoeuvres to resolve it.
4 After the shoulder dystocia is resolved: Clinical Reasoning Physical Exam
a) Examine the mother and the newborn for signs of trauma Follow-up

b) Debrief with the team, including the woman and her Communication Follow-up
supports

c) Document the manoeuvres used and the timing of events Communication Follow-up
(including head to shoulder time)

Note: See also General Key Features of Procedure Skills for Family Medicine for technical aspects.

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

Shoulder dystocia—procedure skill

Key Feature Skill Phase

1 When a shoulder dystocia occurs, inform the team (including the Procedures Skills Treatment
woman), call for additional assistance, and immediately implement Communication
an accepted algorithm to resolve the dystocia.

2 When managing a shoulder dystocia, avoid actions that may Procedures Skills Treatment
increase the shoulder impaction (e.g., pressure on the fundus,
maternal pushing when the shoulder remains impacted) or that may
injure the baby (e.g., traction on the head, pivoting the head to
rotate the shoulders). Coach the woman to push only when
instructed.
3 When managing a shoulder dystocia, use a systematic approach that Procedures Skills Treatment
includes:
• External manoeuvres: hyperflexion of the hips
(McRoberts), suprapubic pressure on the anterior
shoulder, all fours position
• Internal manoeuvres: shoulder rotations (Rubin, Woods,
delivery of posterior arm
• Episiotomy if required to perform internal manoeuvres
4 When managing a shoulder dystocia, complete one manoeuver Procedures Skills Treatment
before encouraging more maternal pushing. Then, if it does not
work, move rapidly to the next manoeuver before the next pushing
effort.
5 If initial manoeuvres are unsuccessful, repeat them, perfecting the Procedures Skills Treatment
technique, and focusing on the manoeuvres that are most likely to
be successful (e.g., removal of posterior arm, changing maternal
position). Call for additional assistance.

Note: See also General Key Features of Procedure Skills for Family Medicine for technical aspects.

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

Postpartum hemorrhage
Key Feature Skill Phase

1 For all pregnant women, identify risk factors for postpartum Clinical Reasoning Hypothesis generation
Treatment
hemorrhage (PPH; e.g., grand multiparous, prolonged labour,
anticoagulants) and prepare accordingly.

2 Manage the third stage of labour with a prophylactic uterotonic, Clinical Reasoning Treatment
consideration of controlled cord traction, and assessment of uterine
tone after placental delivery.
3 Following all births, closely monitor for ongoing blood loss (both Clinical Reasoning Follow-up
visible and occult) in order to accurately estimate the total blood
loss, and to promptly recognize and diagnose a PPH.
4 When a diagnosis of PPH is made: Clinical Reasoning Diagnosis
a) Identify whether the woman is stable or unstable and adjust Selectivity Treatment
management accordingly
b) Activate the team early to provide extra support Communication Treatment

c) Look for correctible etiologies, in order to treat, specifically Clinical Reasoning Hypothesis generation
• Poor uterine tone (uterotonics) Diagnosis

• Retained products of conception (remove)

• Trauma (repair)
• Distended bladder (urinary catheter)
• Coagulation deficit (correct)
d) Monitor closely to anticipate and recognize the need for Clinical Reasoning Follow-up
further intervention
5 For a PPH that has stabilized, continue to monitor over an Clinical Reasoning Follow-up
extended period until recurrence is unlikely.
6 For a woman who has had a PPH, provide counselling for Clinical Reasoning Follow-up
subsequent pregnancies.

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

Perineal lacerations—procedure skill

Key Feature Skill Phase

1 After every delivery, assess for the presence, location, and degree of Procedures Skills Treatment
Diagnosis
perineal laceration, including a rectal exam when appropriate.
Distinguish between those that need repair and those that do not.

2 When a perineal laceration occurs:

a) Ensure that optimal conditions (e.g., assistance, lighting, Procedures Skills Treatment
retraction, hemostasis, analgesia) are present for assessment and
repair
Identify complicated perineal injury (e.g., third- or fourth-degree Procedures Skills Treatment
tear, high vaginal laceration) and consider the need for assistance or Diagnosis
consultation for the repair
Repair lacerations using techniques that will reduce the risk of Procedures Skills Treatment
complications (e.g., bleeding, infection, incontinence, pain)
3 In the presence of a second-degree perineal laceration, repair using a Procedures Skills Treatment
systematic approach that includes:
• Identifying key anatomic structures—apex of laceration,
hymenal ring, perineal muscles, intact anal sphincter
• Securing the apex and aligning the hymen and the perineal
body, then suturing the vaginal mucosa from apex to
hymen
• Suturing the perineal muscles
• Suturing the skin or planning to let heal by secondary
intention
4 Following the repair of perineal laceration, re-examine for Procedures Skills Treatment
completeness of repair and hemostasis. This may include a rectal
examination.

Note: See also General Key Features of Procedure Skills for Family Medicine for technical aspects.

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

Peripartum fever
Key Feature Skill Phase

1 When a labouring or postpartum woman has a fever, determine Clinical Reasoning Diagnosis
whether the cause is an infection (e.g., chorioamnionitis,
endometritis, pyelonephritis) or not (e.g., epidural, work of labour),
and re-evaluate the diagnosis regularly.
2 When a labouring or postpartum woman has a suspected infection:
a) Anticipate the possible impacts of the infection on the
Clinical Reasoning Hypothesis generation
woman and the fetus/neonate
b) Conduct appropriate investigations, maternal monitoring, Clinical Reasoning Investigation
and fetal surveillance or newborn assessment
c) Initiate treatment without delay Selectivity Treatment

3 When chorioamnionitis is suspected, treat empirically and Selectivity Treatment

aggressively (e.g., IV broad-spectrum antibiotics), even for those
who have received GBS antibiotic prophylaxis, and formulate a plan
for delivery.
4 For all postpartum women:
a) Identify those at higher risk of infection (e.g., long labour, Clinical Reasoning Hypothesis generation
Caesarean section)
b) Recognize early signs of infection Clinical Reasoning Diagnosis

c) Advise regarding symptoms and when to seek care Clinical Reasoning Treatment
Communication

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

Antepartum bleeding—after 20 weeks gestation

Key Feature Skill Phase

1 For a woman presenting with antepartum bleeding, first assess the Clinical Reasoning Diagnosis
stability of both the woman and the fetus, as urgent management
must begin for unstable patients before the exact cause of the
bleeding has been confirmed.
2 If the woman with antepartum bleeding is unstable or if there is
suspected fetal compromise
Selectivity Treatment
a) Resuscitate immediately

b) Mobilize the necessary resources for urgent delivery Communication Treatment

c) Monitor the situation Clinical Reasoning Treatment

d) Identify the cause of the bleeding Clinical Reasoning Diagnosis

3 While managing a woman with antepartum bleeding, assess to Clinical Reasoning Diagnosis
diagnose the cause of the bleeding, using methods that minimize
risks of harm, to recognize potentially life threatening causes:
• Obtain history (e.g., onset, quantity of bleeding, presence
of pain, trauma)
• Determine placental location by ultrasound (previous or
current) prior to vaginal exam (do not perform vaginal
exam unless placenta previa is ruled out)
• Assess the uterus (e.g., activity, tone, tenderness) and fetal
well-being
• Use other diagnostic techniques as indicated (e.g.,
speculum exam)
4 For a woman with antepartum bleeding who is stable with normal Clinical Reasoning Treatment
fetal surveillance, provide ongoing assessment and management Diagnosis
based on the diagnosis and the gestational age (e.g., manage Rh
status, administer corticosteroids for fetal lung maturity). Decide
whether hospitalization or transfer is indicated and the likely mode
of delivery.
5 Following a resolved episode of antepartum bleeding, inform the Clinical Reasoning Follow-up
woman and her supports about the risks of antepartum bleeding in
current and in subsequent pregnancies, and about strategies to
minimize the risk.

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

Non-cephalic fetal presentation

Key Feature Skill Phase

1 For any woman in the third trimester or in labour, determine the Clinical Reasoning Diagnosis
exact fetal presentation using appropriate techniques (e.g.,
Leopold’s manoeuvers, vaginal exam if indicated, ultrasound).

2 When a non-cephalic presentation has been identified pre-labour, Clinical Reasoning Treatment
discuss, with the woman and her supports, alternative plans or Follow-up
possibilities for delivery (e.g., external cephalic version, trial of
labour, planned Caesarean section) according to the presentation.
Inform the woman of possible complications (e.g., cord prolapse)
and appropriate actions.
3 When a non-cephalic presentation is identified in labour, discuss Clinical Reasoning Treatment
the delivery options with the woman, while seeking consultation Referral
and team support as necessary, and while initiating preparations for
a possible Caesarian section.
4 When facilitating an imminent unavoidable breech delivery, Procedures Skills Treatment
optimize the process by avoiding traction on the fetus, ensuring that
the back remains up, and ensuring head flexion through delivery.
5 After a vaginal breech delivery, anticipate that the newborn is more Clinical Reasoning Hypothesis generation
likely to require resuscitation.

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

Pre-labour rupture of membranes

Key Feature Skill Phase

1 For pregnant women presenting with vaginal fluid loss, look for and Clinical Reasoning Hypothesis generation
Diagnosis
diagnose pre-labour rupture of membranes using history,
abdominal exam to verify presentation, speculum exam (avoid doing
vaginal examination unless indicated for management), and fluid
inspection and analysis (e.g., nitrazine, ferning test).
2 For a woman with signs and symptoms suggestive of pre-labour Clinical Reasoning Hypothesis generation
rupture of membranes (PROM) but negative confirmatory tests, do Selectivity Treatment
not exclude the possibility of PROM, and plan appropriate
fetal/maternal surveillance for signs of fever and/or infection.
3 For all women with PROM at term, rule out contraindications to Clinical Reasoning History
vaginal delivery, and, if there are no contraindications, offer Treatment
induction of labour through an informed discussion within the
context of risk factors (e.g., GBS status), patient preference, and
system demands (e.g., staffing availability).
4 In a woman with PROM in whom labour has not been induced:
a) Monitor for signs of infection (e.g., fever, fetal tachycardia,
Clinical Reasoning Diagnosis
odour) even for those patients on prophylactic antibiotics
b) Treat suspected or confirmed chorioamnionitis aggressively Selectivity Treatment
and early (e.g., IV antibiotics), and do not rely on the previous
prophylactic treatment
5 In a woman with preterm PROM:
a) Initiate treatment as per local protocol (e.g., admission,
Clinical Reasoning Treatment
steroids, IV antibiotics, and monitoring)
Plan appropriate definitive treatment depending on gestational age Clinical Reasoning Referral
and the capacity of the facility and team, and considering the
indications for consultation or for transfer to another care facility
6 When a baby is born after pre-labour rupture of membranes, assess Clinical Reasoning Treatment
for signs of sepsis, and initiate treatment promptly if sepsis is Selectivity
suspected.

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

Preterm labour
Key Feature Skill Phase

1 When assessing a pregnant woman who is not in labour, look for Clinical Reasoning History
Treatment
risk factors for premature labour, and manage the treatable factors
to reduce risk whenever possible.

2 When caring for a pregnant woman who is not in labour, educate Clinical Reasoning Treatment
her and her supports about signs and symptoms of preterm labour Communication
and how to seek help.
3 For a woman presenting in suspected preterm labour, confirm the Clinical Reasoning Investigation
presence or absence of labour, using appropriate techniques (e.g.,
assessment of contractions, sterile speculum exam, fetal fibronectin,
cervical assessment).
4 For a woman in preterm labour, manage according to the Clinical Reasoning Treatment
gestational age and fetal surveillance to minimize neonatal
morbidity and mortality by:
• Mobilizing the team to ensure availability of resources,
including early consultation, that may be needed for the
mother and the infant
• Administering appropriate medications (e.g., antenatal
corticosteroids, tocolytics, antibiotics, magnesium
sulphate)
• Arranging for transfer if necessary, at the appropriate time
5 Following the birth of a preterm infant, particularly one who Communication Treatment
Patient-centered Approach Follow-up
requires intensive care, provide support and advocacy for the
woman and family, in the context of an ongoing therapeutic
relationship.

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

Trial of labour after Caesarian

Key Feature Skill Phase

1 In a woman who has had a Caesarean section, assess the risks and Clinical Reasoning Diagnosis
benefits of a trial of labour after Caesarian (TOLAC) and discuss in Communication Treatment
order to identify those who are good candidates, those who are not
good candidates, or where it would be contraindicated. Document
the discussion, including risks and benefits identified.

2 For a woman who is a candidate for TOLAC, offer TOLAC and Clinical Reasoning Treatment
help her make an informed decision by fully discussing the risks and Patient-centered Approach
advantages while showing flexibility and understanding of her
preferences and concerns.
3 In a woman who has had a Caesarean section and who goes into Clinical Reasoning Treatment
labour, be flexible in the management approach and adapt it to the Patient-centered Approach
circumstances, while still respecting the plans and preferences of the
woman as much as possible (e.g., manage a spontaneous precipitous
labour in a woman who had planned a repeat Caesarean section,
discuss conversion of a planned TOLAC to a Caesarean section).
4 Before planning or managing a TOLAC, ensure that the resources Clinical Reasoning Hypothesis generation
necessary for an unexpected immediate operative delivery are Communication Treatment
available and in place, ensure that the woman and her supports are
well prepared for the complications that could necessitate this
eventuality, and that all discussions and decisions about the
TOLAC have been fully documented.
5 For a woman choosing a TOLAC, provide appropriate maternal Clinical Reasoning Treatment
and fetal surveillance, close monitoring of the progress of labour,
and careful use of induction and uterotonics if indicated.

6 When managing a TOLAC, carefully assess maternal and fetal Clinical Reasoning Diagnosis
well-being and recognize any signs of imminent or actual uterine
rupture requiring maternal and fetal resuscitation and urgent
conversion to Caesarean section if needed.

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

Induction of labour
Key Feature Skill Phase

1 When considering induction of labour, specifically assess the factors Clinical Reasoning Diagnosis
that will influence the decision (e.g., accurate expected date of Communication Treatment
delivery, indications, contraindications, cervical ripeness, maternal
preference) and document the factors clearly to provide justification
for decisions.
2 When planning induction of labour:
a) Induce labour only when there is a compelling and
Clinical Reasoning Treatment
convincing indication and no contraindication
b) Prioritize and schedule the induction based on indication Selectivity Treatment
and resources
c) Select the facility with appropriate resources to manage fetal Clinical Reasoning Treatment
and maternal needs
3 When recommending induction of labour, obtain and document Clinical Reasoning Treatment
clear and detailed informed consent from the woman for accepting Communication
or declining the induction.

4 When inducing labour:

a) Select the appropriate method of cervical ripening (e.g., Clinical Reasoning Treatment
balloon catheters, prostaglandins) and/or induction (e.g.,
prostaglandins, oxytocin), based on obstetrical and medical history,
Bishop score, patient preference, and team considerations.

b) Assess the effect of the induction on maternal and fetal well- Clinical Reasoning Treatment
being.

c) Select women for whom the outpatient management of Clinical Reasoning Treatment
cervical ripening is appropriate.
5 During induction of labour, look for and manage complications of Clinical Reasoning History
induction (e.g., tachysystole, abnormal fetal surveillance). Treatment

6 When a selected method of induction is unsuccessful, modify the Clinical Reasoning Treatment
management plan accordingly.

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

Peripartum mental health

Key Feature Skill Phase

1 Enquire about the mental health of all women throughout the Clinical Reasoning History
peripartum period, assessing to identify discrete signs or symptoms
or factors leading to a higher risk (e.g., substance abuse, intimate
partner violence, previous mental health disorder, history of sexual
abuse), and add an appropriate mood assessment tool (e.g.,
Edinburgh Postnatal Depression Scale, Generalized Anxiety
Disorder scale) when indicated.

2 When concerns are raised about mental health in the peripartum Clinical Reasoning History
period, actively explore the situation with the woman and her Treatment
supports, and provide education about normal and common
psychological changes during pregnancy, as well as the signs that
may suggest a mental health disorder.
3 For women in the peripartum period with an apparent mental Clinical Reasoning Diagnosis
health disorder, assess to rule out possible underlying causative or
contributing medical conditions (e.g., anemia, thyroid dysfunction).
4 For a woman with a mental health disorder in the peripartum Clinical Reasoning Diagnosis
period, determine the risk of harm to self, infant, or others. When Treatment
this risk is present, ensure urgent management to reduce the risk of
harm. Educate the woman and her supports regarding a possible
rapid escalation of symptoms, and available resources.
5 For a woman with a mental health disorder in the peripartum Communication Treatment
Referral
period:
a) Maintain the therapeutic relationship, provide counselling,
refer to the available resources, and advocate for rapid access when
needed
b) Use medication if indicated, balancing the risk of untreated Clinical Reasoning Treatment
mental health issues against the risk of medications to the fetus or
newborn, and recognizing the benefits of continued breastfeeding if
desired

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

Gestational hypertension/preeclampsia
Key Feature Skill Phase

1 At the beginning of all pregnancies, identify and assess the risk Clinical Reasoning Diagnosis
Treatment
factors for gestational hypertension/preeclampsia and consider
initiating preventive therapy for those at high risk.

2 Consider the diagnosis of preeclampsia at prenatal visits, even if the Clinical Reasoning Hypothesis generation
blood pressure is not obviously elevated, and especially when the
woman has new poorly-defined constitutional symptoms.
3 When preeclampsia is suspected, look for confirmatory evidence Clinical Reasoning Diagnosis
(symptoms, signs, basic investigations) to establish or rule out the Treatment
diagnosis. Classify according to current nomenclature and re-assess
regularly for progression of disorder.
4 For gestational hypertension or non-severe preeclampsia, follow Clinical Reasoning Treatment
closely and manage according to maternal and fetal well-being and Follow-up
gestational age.
5 For a woman with a diagnosis of preeclampsia with adverse Clinical Reasoning Treatment
conditions or severe preeclampsia, manage actively by:
• Initiating MgSO4 in a timely fashion and other
medications as appropriate (e.g., anti-hypertensives)
• Assessing the need for prompt delivery, and arranging for
delivery and/or consultation when indicated
6 For any woman with gestational hypertension or preeclampsia who Clinical Reasoning Follow-up
has delivered, continue management and monitor for progression or
complications throughout the postpartum period.

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

Gestational diabetes
Key Feature Skill Phase

1 In all pregnant women, screen for gestational diabetes using the Clinical Reasoning Diagnosis
appropriate test at the appropriate gestational age, and interpret the
results according to guidelines for gestational diabetes (i.e., not
regular diabetic guidelines).
2 For a woman with gestational diabetes, plan for blood glucose Clinical Reasoning Treatment
control to avoid extremes of hyperglycemia and hypoglycemia, and
do not confuse treatment targets and guidelines with those for non-
gestational diabetes.
3 For a pregnant woman who is receiving specific care for diabetes Clinical Reasoning Treatment
(gestational or pre-gestational) from other providers, maintain your Follow-up
planned antepartum care for the patient, and integrate the
recommended diabetic care into the overall management plan.
4 When caring for a woman with gestational diabetes, closely monitor Clinical Reasoning Follow-up
fetal growth and well-being (e.g., ultrasound, non-stress tests), as
well as the maternal status, in order to recognize indications for
induction.
5 When providing intrapartum care to a woman with gestational
diabetes:
Clinical Reasoning Treatment
a) Anticipate potential fetal macrosomia and if present,
anticipate and plan for labour dystocia and shoulder dystocia
b) Manage blood sugars actively, using insulin when indicated Clinical Reasoning Treatment
for optimal care, continuing as necessary into the postpartum

6 Following a gestational diabetic’s delivery:

a) Monitor the newborn closely for hypoglycemia, in the
Clinical Reasoning Treatment
immediate postpartum period
b) Plan to include screening for diabetes in the postpartum care Clinical Reasoning Follow-up
of the woman

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

Breastfeeding
Key Feature Skill Phase

1 During prenatal care, enquire about newborn feeding plans. Clinical Reasoning History
Patient-centered Approach Treatment
Promote exclusive breastfeeding, help establish reasonable
expectations, and provide adequate information to develop a plan
for feeding that respects the mother’s preferences and informed
choice.

2 For a woman who is not breastfeeding her newborn, provide Clinical Reasoning Treatment
support for her decision, and provide information about feeding Patient-centered Approach
with human milk substitute.
3 For all pregnant women, assess and, when indicated, examine for Clinical Reasoning Diagnosis
issues that may affect breastfeeding (e.g., inverted nipples, previous Treatment
surgery), and suggest interventions and resources.
4 For all births, including Caesarean section, facilitate early skin-to Clinical Reasoning Treatment
skin contact and a comfortable and effective latch.
5 When breastfeeding is challenging, first assess the latch and Clinical Reasoning History
Physical exam
determine whether it is effective, and then look for other barriers to
successful breastfeeding (e.g., lack of support, postpartum
depression, breast pain, tongue tie, prematurity).

6 When any concerns or difficulties with breastfeeding arise, Clinical Reasoning Treatment
Referral
especially in the immediate newborn period, facilitate early access to
suitable professional support.
7 Facilitate the continuation of breastfeeding when conditions arise, Clinical Reasoning Treatment
such as:
• The woman has a breast infection or a nipple lesion
• The woman or newborn requires medications,
investigations, or hospitalization

8 When a newborn/infant is exclusively breastfed, educate the family Clinical Reasoning Treatment
regarding normal weight gain, stool and voiding patterns, and how
to assess the adequacy of feeding.

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

First week of life

Key feature Skill Phase

1. When caring for newborns:
a) Look for and recognize the subtle signs that they may be unwell Clinical Reasoning Diagnosis
(e.g., respiratory status, colour, tone, feeding), assess for etiology
(e.g., hypoglycemia, maternal drug effect, sepsis) and arrange for
diagnostic tests and ongoing care.
b) Identify those who appear well but may be at a higher risk of Clinical Reasoning Hypothesis generation
complications (e.g., infant of diabetic woman, intrapartum
infection, operative birth, drug withdrawal, social stressors), in
order to plan close observation and management.
c) Perform a thorough physical examination (e.g., palate, pulses, Clinical Reasoning Physical exam
heart sounds, hips, testes, anus) to detect congenital
abnormalities.
2. Prior to discharging any newborn, ensure the following: Clinical Reasoning Treatment
o Adequate feeding plan has been established
o Newborn screening (e.g., bilirubin, metabolic, hearing test) has
been completed or arranged
o Family has been educated regarding care of the newborn (e.g., car
seat, infant sleeping, acceptable weight loss) respecting cultural
differences
o Follow-up has been planned with a health care professional
within a few days of discharge, especially for firstborns, families
with psychosocial stressors, or if there were any perinatal issues
3. When the parents (or other caregivers, including health care Selectivity Diagnosis
professionals) of a newborn express concern that the baby is unwell,
listen carefully, and fully assess the baby to detect any subtle
indicators of serious illness (e.g., sepsis).

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

Working in teams in intrapartum care

Key Feature Skill Phase

1 Acknowledge all team members (including the patient and her Communication Treatment
Professionalism
supports) and as well as their roles and contributions, and
respectfully listen to and respond to others’ opinions, especially
when they differ from your own.

2 Promote collaboration by accepting and giving help where required, Professionalism Treatment
contribute where most useful even when not in primary roles, and
follow the leadership of others or assume the leadership for a
defined period or situation.
3 Respect the professional autonomy of the individual members of Professionalism Treatment
the team, while promoting collaborative decisions and actions for
the benefit of the patient.
4 When a team is working under difficult conditions, try to promote Professionalism Treatment
and maintain the effectiveness of the team by remaining calm, Clinical Reasoning
helping others in their roles and tasks whenever appropriate,
resolving differences actively by considering the best interests of the
patient, and by inspiring confidence whenever possible.
5 Maintain clear verbal and written communications (including Communication Treatment
documentation), confirm that the information has been received
(closed loop), and facilitate the participation of all in debriefing
sessions.

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 Priority Topics and Key Features for Intrapartum and Perinatal Care

Limits—practising according to personal and facility limits

Key Feature Skill Phase

1 When a woman requires care that is beyond your personal or Professionalism Treatment
facility limits, advocate firmly to obtain this care in a timely fashion
from an appropriate resource.

2 Whenever the clinical course of a woman is not going as expected, Clinical Reasoning Treatment
review the provisional diagnosis and management plan, consider
alternatives, and change if necessary (e.g., regularly reassess/re-
evaluate potentially unstable patients, reflect on your clinical
decisions).
3 Whenever you recognize that a diagnosis or management plan
needs to be modified:
Clinical Reasoning Referral
a) Seek additional information or help without delay.
b) Discuss the changes with the woman, her supports, and the Communication Treatment
team. Clinical Reasoning

c) Document the changes and the discussion. Communication Treatment

4 When caring for pregnant women, reflect on clinical experiences to Professionalism Diagnosis
Treatment
identify gaps in clinical skills, and close those gaps with self- or
group-learning.
5 After an unexpected or unusual event, debrief effectively with Communication Follow-up
appropriate team members, including the woman and her supports.

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Priority Topics and Key Features for the Assessment of Competence in Mental
Health

Out of the 24 priority topics developed by the Working Group on the Assessment of Competence in Mental
Health, 16 overlapped with the existing topics for family medicine and were used to update their key features
(see Part III).

The remaining topics are listed here as a resource.

1. Bipolar disorder
2. Comorbid illnesses in mental health context
3. Developmental disability and delay
4. Family and circle of support in mental health context
5. Screening and early detection of mental health problems
6. Teamwork in mental health
7. Trauma informed care
8. Using community mental health resources

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 Priority Topics and Key Features for the Assessment of Competence in Mental Health

Bipolar disorder
Key Feature Skill Phase

1 In any patient with depression, consider the possibility of bipolar Clinical Reasoning History
Hypothesis generation
disorder. Ask about family history, past symptoms and episodes.

2 Recognize that standard antidepressant treatment in a person with Clinical Reasoning Treatment
possible bipolar disorder may trigger mania or rapid mood cycling. Follow-up
Monitor closely.
3 1When considering a diagnosis of bipolar disorder,
a) Assess fully for other diagnostic possibilities such as
Clinical Reasoning History
substance use, post-traumatic stress disorder, situational duress or
Hypothesis generation
personality disorder
b) Avoid applying the diagnostic label too early, especially in Clinical Reasoning Diagnosis
younger patients
c) Consider consultation if the diagnosis is uncertain Clinical Reasoning Referral
Communication

4 When caring for a patient with bipolar disorder,

a) Maintain a strong therapeutic relationship in order to Professionalism Follow-up
Patient-centred Approach
negotiate adequate treatment during episodes of increasing
symptoms
b) Look for and recognize the indicators of impending crisis Clinical Reasoning History
and need for intervention, including involuntary treatment when Selectivity Treatment
appropriate
c) Negotiate and plan proactive care for relapse and recovery Communication Treatment
which may include involvement of others Patient-centred Approach Follow-up

d) Monitor response to and side effects of medication Clinical Reasoning Treatment

Follow-up

e) Monitor and manage self medicating with alcohol or Clinical Reasoning Treatment
substances Patient-centred Approach Follow-up

See also: Depression

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 Priority Topics and Key Features for the Assessment of Competence in Mental Health

Comorbid illnesses in mental health context

Key Feature Skill Phase

1 At every medical encounter inquire about both the patient’s Patient-centred Approach History
physical and mental health in order to provide proactive ‘whole
person’ care.

2 When caring for a patient with mental health/alcohol or substance

use problems consider medical co-morbidities and,
Clinical Reasoning Follow-up
a) Monitor the impact of the treatment on the person’s overall
health (e.g. medications for schizophrenia causing increased cardio-
vascular risk).
b) Ensure their access to preventive care and medical services Professionalism Treatment
Patient-centred Approach Referral

c) Pay attention to the effects of stress and adversity on cardio- Patient-centred Approach Hypothesis generation
metabolic risk Follow-up

d) Assess the impact of acute and chronic pain Patient Centre History

e) Identify specific risk factors for illness (e.g. smoking, obesity, Clinical Reasoning History
sleep apnea)
3 When a comorbid illness is diagnosed in a patient with mental
health/alcohol or substance use problems:
Communication Diagnosis
a ) Clearly communicate the diagnosis, treatment plan and
Patient-centred Approach Treatment
relevant information. Answer questions and involve the patient in
their care.
b) Recognize that they have the same interest in their medical Professionalism Diagnosis
problems as any other patient, but more time and support may be Patient-centred Approach
required to understand and process information
c) Facilitate access to care and effectively coordinate treatment Professionalism Treatment
Communication Referral
with other available services in order to mitigate system barriers and
stigma
d) Monitor progress, maintain the therapeutic alliance and Patient-centred Approach Follow-up
Professionalism
clarify your own role in their ongoing care

When caring for patients with a chronic illness routinely inquire Clinical Reasoning History
Patient-centred Approach Follow-up
about the impact of medical problems on their life, family, mood
and anxiety level. Recognize that depressed mood and anxiety can
be a consequence of medical problems.

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 Priority Topics and Key Features for the Assessment of Competence in Mental Health

Developmental disability and delay

Key Feature Skill Phase

1 When caring for children, regularly and systematically assess Clinical Reasoning History
Physical
physical and neuropsychological development, to facilitate the early
detection and management of developmental problems.

2 When parents are concerned about a child’s development even after Clinical Reasoning History
an assessment with no evidence of developmental delay, plan regular Patient-centred Approach Follow-up
reviews to:
• assess the child’s development over time
• pay special attention to the child’s mental health
• explore the impact on the family
3 For a child whose development shows variation from expectations,
regularly reassess their physical and mental health. Look for Clinical Reasoning History
Selectivity Hypothesis generation
possible causes with a particular emphasis on those that may be
reversible or treatable.
4 When concerns are raised about a child’s development or Clinical Reasoning History
behaviour, with parental consent, seek information from all those Communication
caring for the child (e.g. parents, daycare, school).
5 When a developmental problem is suspected, or identified in a Clinical Reasoning Treatment
Patient-centred Approach Follow-up
child, develop a management plan with the parents that includes
appropriate:
use of community support services
consultation services or specialized treatment
follow-up to monitor progress and ongoing or new
concerns
attention to puberty and adolescent transition
6 When providing care for an adult with developmental disability, Patient-centred Approach Treatment
Communication Follow-up
establish a means of communication that facilitates:
t building a trusting relationship
t assessment of behaviour changes
t assessment of physical and mental health
t personal care planning over the long term

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 Priority Topics and Key Features for the Assessment of Competence in Mental Health

Family and circle of support in mental health context

Key Feature Skill Phase

1 When providing care to a patient with mental health and addiction Patient-centred Approach History
problems seek to understand who is “family” and/or the patient’s
“circle of support”.

2 When a patient decides to exclude family from the circle of support, Patient-centred Approach History
ascertain the reasons and address when appropriate.
3 When considering communication with the family or circle of Communication History
support, obtain the consent of the patient or mandated substitute, Professionalism Treatment
respecting their rights to privacy and confidentiality.
4 When providing care to a patient with mental health and alcohol
and substance use problems: Patient-centred Approach History
a) assess the impact of the patient’s illness on the family,
b) assess the impact of the family on the patient’s illness Patient-centred Approach History

c) assess the capacity of the family to contribute to the care, and Patient-centred Approach History
the family’s need for support Clinical Reasoning Treatment

d) review the situation regularly Patient-centred Approach Follow-up

Clinical Reasoning

5 When working with a family for the ongoing care and recovery of a
patient,
Selectivity Treatment
a) Set clear goals for meetings with family and remain flexible in
Patient-centred Approach
order to gather unplanned or unexpected information
b) Find a balance between collective and individual Patient-centred Approach Treatment
interventions and decisions Professionalism

c) Recognize family relationships are complex and members Patient-centred Approach Treatment
may respond differently Communication

6 Identify needs for specific intervention or support for the family Professionalism History
Patient-centred Approach Treatment
members of a patient. If appropriate, provide or arrange for this
intervention in a timely fashion, while paying attention to privacy,
boundary, and ethical issues.
7 When family therapy is indicated, determine the optimal resource Clinical Reasoning Treatment
Patient-centred Approach Referral
according to the goals of therapy, the level of expertise required, the
resources available, boundary issues, and family preferences.
8 When concerns about a patient or a family member are raised by
Clinical Reasoning History
proxy, develop a management plan only after a full assessment of
Professionalism Treatment
the situation, including:
t the presence of safety issues, particularly for children and
other vulnerable people
t the family situation from the proxy’s and the patient’s point
of view,
t the presence of mental health problems, alcohol or
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 Priority Topics and Key Features for the Assessment of Competence in Mental Health

substance use and other health issues

t the availability of appropriate community or referral
resources
t ethical considerations and individual rights
9 When providing care for more than one family member, be alert to Professionalism Treatment
conflicting objectives and confidentiality issues. Consult a colleague,
refer a patient or transfer care as needed.

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 Priority Topics and Key Features for the Assessment of Competence in Mental Health

Screening and early detection of mental health problems

Key Feature Skill Phase

1 When patients present for care, either during periodic health

examinations or opportunistically,
Clinical Reasoning History
a) Assess mental health and alcohol and substance use, as these
issues are prevalent and often undetected
b) Identify patients who may be at higher risk of mental health Clinical Reasoning Hypothesis generation
issues
c) Screen those patients systematically, using validated tools as Clinical Reasoning Investigation
necessary
2 In a patient presenting with new or ill-defined symptoms or a Clinical Reasoning History
change in behaviour or level of functioning, assess mental health,
and alcohol and substance use.
3 For patients with a history of mental health problems or disordered Clinical Reasoning Hypothesis generation
alcohol or substance use, look for relapse or reoccurrence, as these
are chronic diseases.
4 For all patients with mental health or alcohol or substance use
concerns, use an empathetic and non-judgemental approach to Communication Treatment
Patient-centred Approach Follow-up
facilitate open communication.
5 When following patients with mental health, and alcohol and Clinical Reasoning
History
substance use problems, ensure appropriate screening for physical
Hypothesis generation
problems or illness.

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 Priority Topics and Key Features for the Assessment of Competence in Mental Health

Teamwork in mental health

Key Feature Skill Phase

1 When a team approach to care of a person with mental health or

alcohol and substance use concerns is needed,
Clinical Reasoning Treatment
a) Establish patient centred goals of care Patient-centred Approach

b) Include the patient and /or the family in the creation and Patient-centred Approach Treatment
activities of the team
c) Facilitate team membership and roles as situations evolve Professionalism Follow-up
Communication

2 When sharing care of a person with mental health, alcohol or

substance use concerns, Professionalism Treatment
Communication
a) Encourage a coordinated approach to management
b) Understand the roles and responsibilities of the team Professionalism Referral
members
c) Establish clear and ethical communication Communication Treatment
Professionalism

d) Ensure that the patient understands and agrees with these Patient-centred Approach Treatment
arrangements, including their own responsibilities Communication

3 Anticipate the effect a team approach may have on your therapeutic Patient-centred Approach Follow-up
alliance, and work with the patient to maintain the alliance in an Professionalism
appropriately modified fashion.
4 When working within a team,
a) Facilitate the contributions of others Professionalism Follow-up
Communication

b) Use an open and respectful communication style Communication Treatment

c) Pay attention to careful and accurate record keeping Communication Follow-up

Treatment

d) Support recovery focused care planning Clinical Reasoning Treatment

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 Priority Topics and Key Features for the Assessment of Competence in Mental Health

Trauma informed care

Key Feature Skill Phase

1 In all patients, with or without mental health, alcohol or substance

use issues,
Clinical Reasoning Hypothesis generation
a) Consider the possibility of undisclosed trauma
b) Inquire in an empathic manner about experiences across the Communication History
lifespan that may have been traumatic
2 For a patient with issues related to trauma, take the time to develop
a trusting therapeutic relationship that will provide a safe space for Patient-centred Approach Treatment
Communication Follow-up
disclosure.
3 For patients with a known history of trauma, adapt routine clinical Patient-centred Approach Follow-up
encounters to avoid re-traumatizing the patient.
4 For patients with a history of trauma, reinforce their sense of Treatment
autonomy and control by developing, in partnership with the Patient-centred Approach
patient, coping strategies and a management plan that utilize their Communication
strengths and capacities.
5 For a patient who is at risk for ongoing trauma, support the patient Treatment
Clinical Reasoning
to develop and implement a safety plan to reduce risk.
Patient-centred Approach

6 When caring for a patient with issues related to trauma, recognize Professionalism Treatment
and address your own emotional responses.

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 Priority Topics and Key Features for the Assessment of Competence in Mental Health

Using community mental health resources

Key Feature Skill Phase

1 When caring for a patient with mental health and/or alcohol or

substance use problems:
Professionalism Treatment
a) Identify your community resources and referral pathways
b) Identify those patients who could benefit from the Clinical Reasoning Diagnosis
community resources and services
c) Match the patient’s preferences, abilities and needs to the Patient-centred Approach Treatment
appropriate and available resource
d) Advocate to address service gaps Professionalism Treatment

e) Consider a full range of possible resources (e.g. recreational, Clinical Reasoning Treatment
occupational, spiritual etc.) Patient-centred Approach

2 When referring to one or more community resources,

a) Review with patient what they can expect Patient-centred Approach Referral

b) Facilitate access to the resources by providing necessary Communication Referral

information and documentation Professionalism

c) Communicate directly with the resources when appropriate Communication Follow-up

Professionalism

3 When a patient has been referred to or is being cared for by other Professionalism Follow-up
community resources, follow up to maintain your ongoing
therapeutic relationship. Ensure that the expected care is being
provided.

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Core Procedures

Genitourinary and Women’s Health Procedures

Integumentary Procedures Placement of transurethral catheter
Abscess incision and drainage Cryotherapy or chemical therapy genital warts
Wound debridement Aspirate breast cyst
Insertion of sutures; simple, mattress, and Pap smear
subcuticular Diaphragm fitting and insertion
Laceration repair; suture and gluing Insertion of intrauterine device
Skin biopsy; shave, punch, and excisional Endometrial aspiration biopsy
Excision of dermal lesions, e.g., papilloma, nevus,
or cyst Obstetrical Procedures
Cryotherapy of skin lesions Normal vaginal delivery
Electrocautery of skin lesions Episiotomy and repair
Skin scraping for fungus determination Artificial rupture of membranes
Use of Wood’s lamp
Release subungual hematoma Musculoskeletal Procedures
Drainage acute paronychia Splinting of injured extremities
Partial toenail removal Application of sling—upper extremity
Wedge excision for ingrown toenail Reduction of dislocated finger
Removal of foreign body, e.g., fish hook, splinter, Reduce dislocated radial head (pulled elbow)
or glass Reduce dislocated shoulder
Pare skin callus Application of forearm cast
Application of ulnar gutter splint
Local Anesthetic Procedures Application of scaphoid cast
Infiltration of local anesthetic Application of below-knee cast
Digital block in finger or toe Aspiration and injection, knee joint
Aspiration and injection, shoulder joint
Eye Procedures Injection of lateral epicondyle (tennis elbow)
Instillation of fluorescein Aspiration and injection of bursae, e.g., patellar,
Slit lamp examination subacromial
Removal of corneal or conjunctival foreign body
Application of eye patch Resuscitation Procedures
Oral airway insertion
Ear Procedures Bag-and-mask ventilation
Removal of cerumen Endotracheal intubation
Removal of foreign body Cardiac defibrillation
Nose Procedures Injections and Cannulations
Removal of foreign body Intramuscular injection
Cautery for anterior epistaxis Subcutaneous injection
Anterior nasal packing Intradermal injection
Venipuncture
Gastrointestinal Procedures
Peripheral intravenous line; adult and child
Nasogastric tube insertion Peripheral venous access—infant
Fecal occult blood testing Adult lumbar punctur
Anoscopy/proctoscopy
Incise and drain thrombosed external hemorrhoid

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