ℹ️ This is the case information for the doctor.
Name
James Parker
Age
33 years
Address
15 Bluebell Crescent
Social history
• Occupation: Secondary school English teacher.
• Smoking status: Never smoked.
Past history
• No significant past medical history
Investigation results
None
Medication
None
Booking note
Fit note requested. Not feeling well. No prior sickness related absences on record.
ℹ️ This is the information for the person role playing the patient.
Name
James Parker
Age
33 years
Address
15 Bluebell Crescent
Social history
• Occupation: Secondary school English teacher.
• Smoking status: Never smoked.
Past history
• No significant past medical history
Medication
None
" I'd like to get a fit note for work. I've beeen reallly struggling in the last few weeeks and I'm not in a good place at the moment"
Open Story
• “I split up from my partner recently after five years together. Things had been really difficult for a while.”
• “It’s been a tough few weeks…I’m not sleeping well, can’t really eat, and I just feel really low most of the time.”
• “Work has been stressful anyway, but this has made it worse.”
• “I think I just need a couple of weeks out to try and get my head straight.”
• “I haven’t really been doing much outside work lately – I used to swim and run, but I haven’t felt up to it.”
Symptom details:
• Low mood most of the day.
• Tearful at times, including during the consultation.
• Poor sleep: “It takes me ages to fall asleep, and I keep waking up thinking about everything.”
• Appetite reduced: “I don’t really feel like eating.”
• Not enjoying things he used to: “Everything just feels flat.”
• No thoughts of self-harm or suicide: “Sometimes I wonder what the point of things is, but I wouldn’t harm myself.”
Ideas:
“I think it’s mostly the breakup that’s triggered all this. It’s been building up for months, but things are really overwhelming now.”
Concerns:
“I’m worried I won’t be able to cope at work and things will fall apart…I’m concerned about finding somewhere new to live as well, and just being on my own. I don’t really have anyone to talk to.”
Expectations:
“I’d like a fit note for a couple of weeks so I can try to get myself together.”
“I'd consider counselling but I’m not sure about taking tablets…but maybe you could explain more about them?”
“I’d prefer to stick to one doctor if possible. I really don’t want to have to explain everything again.”
Family history:
No family history of mental health problems. Parents alive and well, live in the North of England. Contact is every few weeks by phone.
Psychosocial background information:
• Occupation: Secondary school English teacher.
• Living situation: Until recently, lived with his partner of five years. Now temporarily staying at a friend’s flat while looking for somewhere more permanent.
• Relationship status: Just separated from long-term partner (relationship ended a few weeks ago).
• Social support: Social group mostly shared with ex-partner. Feels unable to discuss the breakup with them. Currently feeling isolated, with no close family nearby.
• Smoking status: Never smoked.
• Alcohol intake: Normally 1–2 units per week (glass of wine with dinner). Recently increased to 3-4 units per night (“it helps me take the edge off in the evenings”). No other substances.
• Physical activity: Used to swim and run regularly but has not taken part in any sport or exercise for many months or years.
• Hobbies/Interests: Previously enjoyed reading, music, watching films, and outdoor activities, but little interest in these at present.
• Finances: Some worries about money due to the potential need to rent or seek new accommodation.
Affect/mood: Appears withdrawn, tired, flat affect; becomes tearful when discussing the breakup. Describes symptoms quietly and hesitantly.
Behaviour: Initially tense, becomes more open and trusting if the doctor is empathetic and listens. If the doctor is brusque or makes assumptions (e.g., suggests going straight back to work or dismisses the impact of the breakup), becomes visibly upset and more withdrawn.
Requests: Calm but quietly insistent about needing time off; will clarify if the doctor suggests less than 2 weeks off that this would not be helpful (“I’m worried that wouldn’t be enough for me to feel better”).
Attitude to management: Reassured if the doctor validates his feelings and offers support. Willing to discuss options including counselling or self-help. Open but uncertain about antidepressants; would like them explained carefully if suggested.
If continuity is offered: Relieved and appreciative if the doctor acknowledges importance of follow-up with the same person.
If asked about suicidal thoughts: Denies, but admits life does not feel enjoyable. Will give clear negative answers if asked sensitively.
ℹ️ To mark data gathering & diagnosis select from the descriptors below.
Positive descriptors
Negative descriptors
Datagathering was systematic and targeted ensuring patient safety.
• Uses open questions to explore James’s reasons for requesting the fit note, recent life events, emotional wellbeing, and how symptoms are affecting daily function.
• Follows up with clear, focused questions to clarify symptom severity, triggers, social circumstances, and his expectations for time off and support.
Data gathering was incomplete, lacking structure and focus.
• Jumps straight to fit note logistics without exploring context or the emotional impact of the breakup.
• Omits key questions on mood symptoms, leaves important psychosocial information unaddressed, or uses unfocused/untargeted closed questions.
Makes effective use of existing information and considers the wider context.
• Integrates the background that James hasn’t been seen for over a year and recognises his isolation since the breakup.
• Considers wider issues such as housing, lack of support network, increased alcohol intake, and workplace pressures that could affect his mental health.
Fails to use the information provided or understand the wider context.
• Ignores or overlooks the significance of James’s prolonged absence from medical care and his current social situation.
• Misses the relevance of factors such as relationship breakdown, housing worries, or work environment to his current mental health difficulties.
The presence or absence of relevant red flags was established
• Asks directly about thoughts of self-harm or suicide, risk to self or others, significant weight loss, and loss of function at work.
• Clarifies absence of psychotic symptoms or significant risk factors, providing reassurance about immediate safety.
Fails to assess key information necessary to determine risk.
• Fails to check for risk of suicide or self-harm, or does not ask about other red flag symptoms such as psychosis or inability to cope.
• Does not confirm safety or enquire about changes in behaviour that increase clinical risk.
A working diagnosis was reached using a structured, evidence based approach.
• Gathers information on mood, sleep, appetite, energy, concentration, interests, and functional impact to support a diagnosis of moderate depression or adjustment disorder.
• Uses logical, structured questioning to rule out other causes and clarify the probable diagnosis.
The evidence collected was inadequate to support the conclusions reached.
• Reaches conclusions without systematically gathering symptoms or understanding functional impairment.
• Draws unsupported conclusions or bases diagnosis on assumption rather than evidence collected.
Uses an understanding of probability based on prevalence, incidence, and natural history to aid decision-making.
• Recognises that in a 33-year-old with recent stressful life events, depression or adjustment disorder are the most likely causes.
• Takes account of the increased risk of depressive episodes following relationship breakdown and the lifestyle/context clues (isolation, overwork).
Decision making does not demonstrate an understanding of probability based on prevalence, incidence, and natural history.
• Suggests or focuses on unlikely causes despite the classic context and presentation.
• Does not use the typical age, context, or symptom pattern to inform assessment.
The social and psychological impact of the problem was appropriately explored.
• Asks about how his mood, motivation, and poor concentration affect his teaching and daily life.
• Checks how James feels about support at work, his former hobbies, and his current sense of meaning or purpose.
The social and psychological impact of the problem was not adequately determined.
• Omits questions about how symptoms affect functioning at work, social isolation, or capacity to perform activities of daily living.
• Misses the relevance of his reduced enjoyment of previously important activities or the impact on his identity as a teacher and partner.
ℹ️ To mark clinical management & medical complexity select from the descriptors below.
Positive descriptors
Negative descriptors
Offers management options that are safe and appropriate
• Presents safe management choices, including a fit note for work absence, explanation of graded return options, and discussion on talking therapies (e.g. counselling, IAPT referral) as well as watchful waiting where appropriate.
• Explains pros and cons of antidepressants, addressing misconceptions and uncertainties, and ensures support regarding alcohol, sleep hygiene, and practical steps around housing.
Fails to provide appropriate and/or safe management choices
• Focuses solely on issuing the fit note without exploring underlying needs or additional supportive measures.
• Avoids discussing treatment options (e.g. talking therapy, medication) or fails to address increased alcohol intake, sleeping difficulties, or safety concerns.
Empowers self-care and independence
• Explains self-help resources (e.g., online CBT, NHS mood tools) and encourages healthy routines such as exercise, reduced alcohol use, and re-establishing social contact.
• Engages James in decisions about his mental health, supporting autonomy while encouraging gradual steps to recovery.
Management fails to foster self-care and patient involvement
• Does not involve James in decision-making or provide practical advice on self-care, lifestyle, or emotional well-being.
• Misses opportunities to encourage activity resumption or peer support.
Prescribes safely considering local and national guidance
• Considers current guidelines for depression management, discusses safe use of antidepressants only after explaining risks and benefits, and screens for problematic alcohol use.
• Advises on avoiding self-medicating with alcohol and ensures clear safety-netting for worsening symptoms.
Unsafe prescribing ignoring best practice
• Offers antidepressants without exploring other interventions or ensuring safe alcohol use.
• Ignores contraindications and fails to provide information about treatment duration, side effects, or monitoring requirements.
Refers appropriately being mindful of resource
• Makes appropriate referral to talking therapies (IAPT/counselling), discusses local support groups, and considers signposting to social prescribing or housing advice as relevant.
• Reserves urgent referrals for crisis only if indicated and does not overload secondary services unnecessarily.
Sends patients for specialist input unnecessarily
• Refers to secondary mental health care without clear indication or consideration of stepped care pathways.
• Misses opportunities to signpost local voluntary, housing, or online resources despite identified needs.
Arranges appropriate follow up and continuity of care
• Clearly arranges a timely follow-up, with instructions for earlier review if symptoms deteriorate, and reinforces support available between appointments. Invites James to follow up with the same GP, and acknowledges the value of continuity in building trust for ongoing support.
• Safety nets, advising when to seek urgent care (if suicidal ideation develops or functioning declines further).
Unclear or inadequate follow up
• Does not specify when or how James should next be reviewed, nor when and how to seek further help if things worsen.
• Leaves responsibility for re-contacting the GP entirely to James without reassurance or structure.
Tailors management options responsively according to circumstances, priorities, and preferences
• Actively involves James in choosing management steps, eliciting his views on medication, talking therapy, and the fit note.
• Adjusts advice to fit with James's current capacity, preferences for continuity, and support structures available.
Management options fail to adequately consider patient preference and circumstance
• Recommends rigid or standardised approaches, failing to take account of James's reluctance about certain treatments or his desire for GP continuity.
• Does not explore how individual circumstances (e.g., breakup, isolation) should influence the management plan.
ℹ️ To mark relating to others select from the descriptors below.
Positive descriptors
Negative descriptors
Shows ability to communicate in a person-centred way
• Acknowledges James’s emotional distress, exploring feelings of low mood, isolation, and grief following his recent breakup.
• Adapts language and explanations to ensure he feels heard and respected, validating the impact of loss and change in his life.
Communication is doctor-centred and lacks empathy
• Provides technical advice about depression or workplace policy without recognising James’s distress.
• Fails to acknowledge or explore the emotional weight of his recent experiences or his need to feel listened to.
Treats patients fairly and with respect
• Respects James’s autonomy and wishes regarding both treatment choices (hesitation about antidepressants) and the desire for follow-up with the same clinician.
• Shows non-judgemental understanding about increased alcohol use and his choice not to discuss issues with mutual friends.
Decisions fail to prioritise the patient’s rights and interests
• Imposes treatment options without regard for James’s concerns or preferences, or dismisses his desire for continuity.
• Criticises his coping strategies or blames him for isolation, failing to account for the complexity of his social situation.
Explores the patient’s agenda, health beliefs, and preferences
• Invites James to discuss his thoughts on the causes of his distress, preferred ways to get help, and expectations for the consultation and work absence.
• Explores his openness to talking therapies and reasons for uncertainty about medication.
Fails to recognise the patient’s agenda and impact of the problem
• Focuses on fit note logistics without uncovering James’s ideas, concerns, or expectations around recovery.
• Does not appreciate his wish for time off to “collect his thoughts,” or his hope for continuity with a single GP.
Recognises what matters to the patient and works collaboratively to enhance patient care
• Works with James to develop a shared plan—e.g., discussing how long off work might help, exploring practical next steps, and jointly considering follow-up or talking therapies.
• Explains management options in plain language, inviting questions and negotiating a plan reflecting his needs.
Fails to work with the patient to plan care
• Decides unilaterally about time off, fails to adapt advice to what James feels would help, or overlooks offers to discuss therapy or continuity of care.
• Misses cues about James’s priorities (emotional space, non-medication options, housing worries).
Demonstrates flexibility of communication adapting to the patient and scenario
• Adjusts consultation style to be gentle, supportive, and responsive when James becomes tearful.
• Uses simple explanations—avoiding jargon—making time for emotional support and clarifying complex choices.
Consults rigidly, providing generic explanations and management plans
• Delivers standardised advice on depression or work leave, ignoring James’s distress, cues, or hesitation.
• Fails to listen actively or react to changes in his affect or needs during the consultation.
Demonstrates an empathic approach, and a willingness to help and care for the patient
• Responds to signs of sadness and vulnerability with warmth, normalises distress following relationship loss, and offers practical follow-up and support.
• Creates a safe space so James feels comfortable sharing personal struggles without judgment.
Lacks empathy and fails to recognise emotional cues
• Ignores James’s emotional cues, such as becoming tearful or finding it hard to articulate distress.
• Provides information mechanically, with no offer of comfort, reassurance, or practical help for emotional needs.
ℹ️ Insights from the examiner
A 33-year-old teacher, James Parker, requesting a two-week fit note for anxiety and depression after a recent breakup, feeling low, isolated, struggling at work, and uncertain about management options.
Demonstration of empathetic listening and sensitivity in responses is central to gaining the rapport that is necessary to make progress in a case like this. You can show that you have listened well by echoing the key issues, encouraging James to 'tell you all about it'. Getting James into a place where he is willing to talk is key to time management in this case, because there is a lot of information to gather and it will be most efficiently gathered through his story telling. Faililng candidates often slip into a closed list of questions that returns a limited subset of the information you need.
"It sounds like things have been very tough, and you're feeling really low since the breakup."
Depression can muddle thinking so it is particulary important to keep your language clear, and concise, avoiding asking multiple questions at a time. Asking multiple questions is a common issue, do you do this? The patient doesn't know which one to respond to, consequently you may only get part of the information you are after back, or the patient answers a different question entirely. Some consulters don't even realise they have this trait until they listen to themselves back, of their trainer points it out.
Avoid jargon like “PHQ-9” or “IAPT” without explanation, and try to normalise distress.
From what you’ve described, it sounds like you’re experiencing symptoms of low mood and anxiety following some big life changes. I’m thinking about how best we can support you to feel stronger again. Shall we look through some options together?"
Acknowledge both verbal and non-verbal cues. If James seems tearful, give him space
"I can see that just talking about this brings up a lot."
...pause and wait for eye contact to resume before progressing with the consultation. Not giving the space he needs can show through as a lack of empathy.
If he says he’s worried about coping at work or feeling isolated, pick up and respond to these:
"You mentioned feeling quite alone—has it been hard not having anyone to confide in right now?"
RCGP SCA Toolkit: Active Listening
Keep James Involved in buildling goals:
"Is your main goal to get some space to think, or are you hoping to talk through other support as well?"
This helps manage expectations and development of a shared understanding of priorities (fit note, support, what would help him feel less overwhelmed).
The highest scoring candidates are fluent and their consultation has a logical flow. Keep questions flowing logically from James's answers:
"You mentioned work has been tough—are there particular aspects that have become unmanageable?"
"You said you used to enjoy swimming and running—do you feel there’s anything you’d like to try to get back to, or does that feel a long way off?"
“Many people find stress affects their appetite—how much weight have you lost, if any?”
Understanding impact is importnat so that you can assess severity and build a management plan that is tailored to his circumstance.
"How have these feelings affected your work?"
"What about outside work—do you manage to keep up with things at home?"
For a detailed summary of treatment options see NICE CKS depression management
Suitable options in this case might include
1. Fit note for 2 weeks, with a collaborative reassessment.
2. Talking therapies (referral/self-referral to counselling, IAPT—provide accessible explanations).
3. Lifestyle advice: Re-engaging with physical activity, even brief walks or swimming. Exercise has been shown to have a greater effect than many antidepressant medications.
4. Sleep hygiene measures (e.g., regular sleep times, avoiding screens late).
5. Alcohol use: Gently address increased use; suggest keeping it within low risk limits.
6. Online resources: e.g., NHS Every Mind Matters, MoodGym, local mental health resources.
7. Consideration of antidepressants if symptoms persist or are severe—discuss pros and cons, address concerns.
8. Social prescribing: signposting to local wellbeing hubs, housing support, or other community resources.
9. Safety net: clear explanation of how to get urgent help if mood worsens or thoughts change.
Give realistic expectations around waiting times for counselling and utilise access to counselling through employers such as James school or teaching union.
• NICE: Depression in adults
• RCGP SCA Toolkit: Relating to Others
• BMJ: Depression in primary care
• Mind: Self-help resources
• Simulated Consultations Sociolinguistics
