ℹ️ This is the case information for the doctor.
Name
John Johnson
Age
82 years
Address
1 Duckworth Grove
Social history
Retired mechanical engineer
Past history
Investigation results
Medication
Booking note
Follow up appointment for results.
ℹ️ This is the information for the person role playing the patient.
Name
John Johnson
Age
82 years
Address
1 Duckworth Grove
Social history
Retired mechanical engineer
Past history
Medication
"I've come back for the results of the heart test I had done a while ago, doctor. I've been feeling more tired than usual lately."
Questions on learning of your diagnosis:
ℹ️ To mark data gathering & diagnosis select from the descriptors below.
Positive descriptors
Negative descriptors
Data gathering was systematic and targeted ensuring patient safety:
Data gathering was incomplete, lacking structure and focus:
Makes effective use of existing information and considers the wider context:
Fails to use the information provided or understand the wider context:
The presence or absence of relevant red flags was established:
Fails to assess key information necessary to determine risk:
Information gathered placed the problem in its psychosocial context:
The social and psychological impact of the problem was not adequately determined:
A working diagnosis was reached using a structured, evidence-based approach:
The evidence collected was inadequate to support the conclusions reached:
Uses an understanding of probability based on prevalence, incidence, and natural history to aid decision-making:
Choice of diagnosis and/or investigations does not reflect disease likelihood:
ℹ️ To mark clinical management & medical complexity select from the descriptors below.
Positive descriptors
Negative descriptors
Offers management options that are safe and appropriate:
Fails to provide appropriate and/or safe management choices:
Continuity of care is prioritised:
Ongoing care is uncoordinated:
Empowers self-care and independence:
Management fails to foster self-care and patient involvement:
Prescribes safely considering local and national guidance:
Unsafe prescribing ignoring best practice:
Assesses risk:
Poor understanding of risk:
Manages multiple health problems concurrently:
Focuses on individual health problems without considering interactions between them:
ℹ️ To mark relating to others select from the descriptors below.
Positive descriptors
Negative descriptors
Communicates in a person-centred way:
Communication is doctor centred and lacks empathy:
Makes effective use of existing information and considers the wider context:
Consults rigidly, providing generic explanations and management plans:
Checks the patient’s understanding of the consultation including any agreed plans:
Does not seek to confirm understanding:
Demonstrates an empathic approach, and a willingness to help and care for the patient:
Lacks empathy and fails to recognise emotional cues:
Treats patients fairly and with respect:
Decisions fail to prioritise the patient’s rights and interests:
Takes ownership of decisions utilising the wider team:
Does not take ownership or utilise the wider team effectively:
ℹ️ Insights from the examiner
Open questions at the start help John share his story and priorities. Good examples:
“I can see you have had some tests done, was that what you came about today?”
This is a good start because it tells John you have read his notes, whilst avoiding making assumptions as to John’s agenda for today’s consultation. Making assumptions about the consultation agenda can result in doctors managing the wrong problem i.e. the problem that is not the patient’s priority.
“We haven’t met before and I can see you have had some tests recently, can you tell me more about why you had them?”
You haven’t met John before and so this fact can be used as a lever to get John to tell you his story. A rich story will help you to efficiently collect key information about his symptoms, ideas, concerns and expectations.
Use simple, jargon-free language tailored to John’s lay understanding. An example might be:
“The heart test you had—your ECG—shows your heart is beating in an irregular way called atrial fibrillation.”
“This condition is common, especially as people get older, and it means your heart sometimes beats unevenly.”
That simple explanation may be all that John wants to know in terms of technical details. Pause to let John tell you what he wants to know. Deliver info in short chunks checking you are answering his questions and personalising your response to his situation. E.g.
“It can reduce your energy levels and perhaps that is why you have not been able to enjoy your garden as much. The good news is there is treatment that can help and hopefully that will help restore your energy levels”
The above is a ‘sunny – gloomy’ pair. A bit of bad news, followed by some good news. Positively framing bad news in this way can help patients to cope psychologically.
Notice and respond to cues about concerns and understanding:
“It’s great you’re curious—many people don’t know much about AF.”
“A lot of people have heard of warfarin, but there are now newer medications that might suit you better and don’t need frequent blood testing.”
Reference: RCGPSCA Toolkit
Check for patient goals using the information you have collected:
“I can see you want to get back to gardening, or is there something else you hope for?”
Agree on shared objectives:
“Let’s aim to reduce your stroke risk and help you feel more energetic for activities you enjoy.”
Reference: Shared decision making – NICE NG197
Here are some examples of letting the conversation flow naturally, building on John’s responses:
Acknowledge and build on each answer, helping the patient to follow your train of thought.
Reference: Roger Neighbour's The Inner Consultation
Explore how AF is affecting daily life and wellbeing:
“You mentioned you love gardening—how much are you able to do compared to before?”
“Has your tiredness stopped you from seeing friends, shopping, or doing other hobbies?”
“How is your mood?”
This helps to gauge urgency and tailor management.
Reference: Patient-centred care: NICE
Clear, concise explanations help understanding:
“Your ECG shows atrial fibrillation, which is when your heart beats irregularly. This can make you feel tired and, if untreated, increases the risk of stroke
“To reduce that risk, we use medicines to thin the blood. The older type, warfarin, needs lots of blood tests, but newer ones don’t.”
“We’ll keep an eye on side effects and how you’re feeling, but you won’t need to come in as often.”
Reference: Patient info leaflet
Share thought processes to aid understanding and involvement:
“Given your age and the results, you have a higher than average chance of a stroke with AF, so anticoagulation is usually recommended.”
“We usually use a checklist—called a risk score—to make sure this is safe for you, perhaps we can go through this together.”
“The tiredness is likely to improve once the AF is managed, especially if it’s the main cause.”
Offer a balanced menu of management choices, including practical options:
As John expects frequent blood tests for anticoagulation ,explain
“That’s the case with warfarin, but with newer anticoagulants like apixaban or rivaroxaban, you won’t need to come in very often at all.”
“We’ll just check bloods every year, unless there’s a problem, which people usually find much easier.”
Reference: NICE AF management
Check for understanding and encourage active participation. For example:
“Can I check—does it make sense why we’re recommending this treatment, and how it might help you?
“What questions do you have about these options?
“How do you feel about the idea of taking a medication to thin the blood and help protect against stroke?”
Reference: NICE: Shared decision making
Offer a tailored solution combining clinical evidence and John’s concerns:
“Considering your concerns about travel for blood tests, a newer anticoagulant would avoid the need for frequent visits. Is that something you’d find helpful?”
“As you’re keen to get back to gardening, and we’ve agreed we should try to reduce your chances of a stroke starting on a blood thinner and another medicine to keep your heart rate from racing might be the best option from those we’ve discussed. We would need to monitor how you feel and keep an eye out for any side effects. What more would you like to know about that?
“Would you like a leaflet about AF, and I’ll arrange for you to see me again in the next few weeks to check in—does that sound like a good plan to you?”
“If you’d like, I can also arrange a phone call from our social prescriber about local support groups.”
Use your understanding of John’s values and lifestyle to build the plan; explicitly incorporate his willingness to try anticoagulation but acknowledge and address his concern about practicalities.
Other helpful references
