ℹ️ This is the case information for the doctor.
Name
David Johnson
Age
67
Address
27 Willow Road, Manchester, M14 7EA
Social history
Smoking status: Ex-smoker.
Alcohol intake: Teetotal
Past history
2 unprovoked DVTs 15 years ago and 3 years ago
No other medical history on records
Investigation results
No recent blood tests. Last monitoring for DOAC over 18 months ago.
Medication
Edoxaban 60 mg daily (blood thinner) – last prescribed 4 months ago. null.
No other regular medications.
No known drug allergies.
Booking note
Patient has not had monitoring for DOAC (Edoxaban) for 18 months despite repeated requests. Medication supply reduced to 14 days pending blood test, but patient still did not attend. Stopped taking DOAC two months ago. Advised to book appointment with GP. (Pharmacist)
ℹ️ This is the information for the person role playing the patient.
Name
David Johnson
Age
67
Address
27 Willow Road, Manchester, M14 7EA
Social history
Smoking status: Ex-smoker.
Alcohol intake: Teetotal
Past history
2 unprovoked DVTs 15 years ago and 3 years ago
No other medical history on records
Medication
Edoxaban 60 mg daily (blood thinner) – last prescribed 4 months ago. null.
No other regular medications.
No known drug allergies.
They told me to book an appointment about my blood thinner tablets, Doctor. I keep getting hassled for blood tests.
Initial demeanour:
Further instructions
ℹ️ To mark data gathering & diagnosis select from the descriptors below.
Positive descriptors
Negative descriptors
Data gathering was systematic and targeted ensuring patient safety.
Initiates the conversation with open questions about recent contact and medication changes, then transitions to structured closed questions on bleeding, clot symptoms, and medication adherence.
Clarifies the patient’s understanding of anticoagulation use and ensures questions cover risk and systemic safety features.
Data gathering was incomplete, lacking structure and focus.
Does not clarify reasons for medication cessation or skips targeted questions around bleeding or thromboembolic risks.
Fails to use a logical progression, leading to missed safety-critical details (such as current or recent symptoms or adherence patterns).
Makes effective use of existing information and considers the wider context.
References information from previous consultations, including the pharmacy’s concerns, previous DVT episodes, and medication monitoring lapses.
Contextualises risk based on past events, prior blood results, and discusses living situation and supports to inform medical decision making.
Fails to use the information provided or understand the wider context.
Does not refer to previous DVT diagnoses or the long therapy gap noted in records.
Overlooks significance of medication history and patient’s social circumstances, missing an opportunity for a holistic approach.
A working diagnosis was reached using a structured, evidence-based approach.
Recognises David’s high ongoing risk for recurrence of VTE due to multiple unprovoked DVTs.
Structures questions and risk assessment logically to weigh the risks of cessation, bleeding, and appropriate need for ongoing anticoagulation.
Fails to systematically assess and recognise high levels of risk from non treatment.
Fails to recognise David’s high ongoing risk for recurrence of VTE due to multiple unprovoked DVTs.
Quesitoning is scattergun and lacks a logical pattern or focus.
Uses an understanding of probability based on prevalence, incidence, and natural history to aid decision-making.
Assesses that recurrence risk of VTE is high in patients with previous unprovoked episodes, underpinning advice on need for life-long anticoagulation.
Recognises lower probability of major new adverse effects as patient has taken Edoxaban for 3 years with no issues.
Choice of diagnosis and/or investigations does not reflect disease likelihood.
Fails to identify that stopping anticoagulation in this context carries significant risk of recurrence.
Overestimates risks of ongoing use or pursues investigations that are not clinically indicated.
Revises hypotheses as necessary in light of additional information.
Adjusts approach after learning about the real reason for non-adherence (blood test aversion, system frustration), and does not pursue unnecessary investigation for other causes of non-compliance or complicating medical issues.
Updates the plan and advice based on patient’s evolving responses regarding willingness to restart medication if blood monitoring can be minimised.
Rigid consulting with new information not adequately considered and integrated into the working diagnosis.
Does not modify their approach after David clarifies he will not attend for blood tests, or continues to insist on standard monitoring without personalising care.
Fails to reflect a patient-centred shift in risk management following new patient disclosures.
Information gathered placed the problem in its psychosocial context.
Explores David’s feelings about blood tests, previous negative experiences, anxieties, and beliefs about longevity, risk, and medical monitoring.
Elicits the impact of medication monitoring on patient’s quality of life, independence, and his support network since his wife’s death.
The social and psychological impact of the problem was not adequately determined.
Neglects to address fear or aversion to needles, impact on mental well-being, or attitudes to risk and preventive medicine.
Fails to recognise possible loneliness, social isolation, and their relevance to treatment adherence or engagement.
ℹ️ To mark clinical management & medical complexity select from the descriptors below.
Positive descriptors
Negative descriptors
Offers management options that are safe and appropriate.
Considers the full spectrum of management options: continuation of Edoxaban with monitoring, cautious restarting, or ongoing non-pharmacological prevention if the patient refuses monitoring.
Explains rationale for each option, including the possibility of life-long anticoagulation in unprovoked DVT; outlines limitations of alternative anticoagulants (e.g., Warfarin needing even more monitoring).
Fails to provide appropriate and/or safe management choices.
Omits discussing key risk/benefit choices or presents a single rigid option.
Provides inadequate explanation of available anticoagulant options or ignores monitoring requirements.
Continuity of care is prioritised.
Arranges follow-up to check on medication adherence and wellbeing, and sets expectation for a structured review (e.g., annual review, earlier if concerns arise).
Recognises that the management of a chronic condition (such as long-term anticoagulation) requires regular touchpoints, even when patient is resistant to some interventions.
Ongoing care is uncoordinated.
Fails to arrange or suggest any future contact for clinical monitoring, side-effect review, or mental health follow-up.
Leaves responsibility solely with the patient, without planned active review or clear shared next steps.
Empowers self-care and independence.
Encourages and supports actions the patient can take to reduce VTE risk (mobility, hydration, recognising signs of VTE/bleeding).
Provides info leaflets or resources to support patient autonomy and understanding.
Management fails to foster self-care and patient involvement.
Does not equip the patient to notice or act upon important symptoms, making them reliant solely on medical intervention.
Makes decisions for the patient, rather than in partnership, and provides minimal advice about self-management.
Prescribes safely considering local and national guidance.
Reviews the necessity of safe prescribing: notes requirement for kidney function monitoring and highlights risk if no tests are performed.
Documents discussion, rationale for prescribing or not, and agrees a plan which is defensible and aware of the gaps in recommended practice.
Unsafe prescribing, ignoring best practice.
Prescribes Edoxaban or other anticoagulant unsafely without adequate monitoring, or safety-netting ignoring known risks.
Arranges appropriate follow-up.
Suggests a proactive plan for review (e.g., annual medication review, or sooner if symptoms emerge or patient is willing for monitoring).
Ensures the patient knows how to access care urgently if “red flag” symptoms develop.
Unclear or inadequate follow-up.
Leaves follow-up entirely open-ended or the patient uncertain about what happens next; does not prompt active review.
Fails to make arrangements for checking adherence, monitoring, or providing a future “touchpoint” to reconsider key decisions.
Tailors management options responsively according to circumstances, priorities, and preferences.
Involves David in every step of the management decision, actively eliciting what would make treatment palatable.
Offers creative solutions, such as thinking about whether tests could be done less frequently, or exploring if anything would make tests more acceptable to him.
Management options fail to adequately consider patient preference and circumstance.
Insists on guideline-driven monitoring or medication regardless of the patient’s priorities.
Fails to ask open questions about what would help, or to explore alternatives based on the patient’s needs and values.
ℹ️ To mark relating to others select from the descriptors below.
Positive descriptors
Negative descriptors
Shows ability to communicate in a person-centred way
Clearly explains the reason for the call and the importance of discussing his anticoagulation, focusing on his individual experience with the medication and his feelings about repeated blood test requests.
Takes time to clarify David’s understanding, listens to his frustrations, and adapts pace and tone to maintain rapport.
Fails to communicate with David as an indiviidual
Provides factual information on Edoxaban and blood monitoring but fails to address David’s frustrations about being “hassled.”
Misses opportunities to engage David’s viewpoint, focusing instead on medication guidelines.
Treats patients fairly and with respect
Acknowledges David’s autonomy in deciding whether to take his medication or attend monitoring, and never pressures him or dismisses his choices.
Maintains a neutral, respectful tone, ensuring David feels comfortable expressing his boundaries.
Dismissive of concerns
Dismisses David’s concerns about blood tests or treats his reluctance as non-compliance.
Adopts a paternalistic, judgmental stance, implying there is only one correct choice and undermining David’s self-determination.
Shows understanding of medical-legal principles and regulatory standards
Explains the need for monitoring in the context of treatment risks, David’s capacity and understanding, and supports informed shared decision-making.
Clearly explains the potential consequences and checks David can weigh them, showing respect for consent and autonomy.
Shows understanding of medical-legal principles and regulatory standards
Proceeds without confirming David’s comprehension of safety issues, risks, or alternatives.
Explores the patient’s agenda, health beliefs and preferences
Explores why David dislikes blood tests beyond simple dislike, seeking to understand his previous experiences, beliefs about health, and reluctance to medical monitoring.
Asks how blood test requirements affect his willingness to engage with treatment.
Shows little interest in the patients agenda and beliefs.
Accepts “I don’t want to have blood tests” at face value, relying on closed or leading questions.
Misses the opportunity to uncover deeper reasons, such as anxieties, previous trauma, or concerns about health system interactions.
Recognises what matters to the patient and works collaboratively to enhance patient care
Collaborates to find a solution tailored to what David values—minimal intrusion, independence, clarity about follow-up, and fewer reminders.
Acknowledges David’s priorities and negotiates a mutually acceptable follow-up plan, including his right to decline at any time.
Plans are untailored ignoring patient preference
Suggests a standard plan without negotiation or adaptation; ignores cues about what matters to David in his day-to-day life.
Imposes generic follow-up as protocol, instead of tailoring to David’s needs.
Demonstrates flexibility of communication adapting to the patient and scenario
Shifts explanation style and consultation structure to match David’s needs, simplifying clinical language and giving options where possible.
Uses questions to explore David’s feelings, and changes approach if previous efforts do not elicit useful information.
Consults rigidly to a script
Sticks to a fixed, scripted approach; asks technical or repetitive questions despite a clear negative response.
Fails to adjust style based on David’s cues about pace, emotional state, or readiness to engage.
ℹ️ Insights from the examiner
This case is a classic example of tension between patient autonomy and duty of care. The clinical question is how best to manage a high VTE-risk patient who refuses blood test monitoring required for safe DOAC therapy, while the ethical challenge is balancing respect for patient preferences with professional and medicolegal obligations.
Below, feedback and strategies are grounded in the four pillars of biomedical ethics: Autonomy, Beneficence, Non-maleficence, and Justice, and directly address how to perform strongly in the SCA for both clinical and ethical domains.
Clinical Aspects
Ethical Framework Integration
Clinical Aspects
Ethical Framework Integration
Clinical Aspects
Ethical Framework Integration
Clinical Aspects
Ethical Framework Integration
Clinical Aspects
Clinical Aspects
Ethical Framework Integration
History
Clinical focus: Understand current risks, values, and adherence barriers.
Ethical integration: Respect and facilitate autonomy; avoid assumptions.
Explanation
Clinical focus: Provide a clear account of the risks and benefits of both action and inaction.
Ethical integration: Be transparent about ethical complexity.
Negotiation
Clinical focus: Offer all safe alternatives and supportive measures.
Ethical integration: Affirm the patient’s choice while constructively exploring possible improvements.
Plan
Clinical focus: Document decisions, provide safety-netting, and coordinate with the wider team.
Ethical integration: Acknowledge professional limits and relevant guidelines.
Psychosocial
Clinical focus: Address emotional and social triggers that may contribute to resistance.
Ethical integration: Maintain a holistic, non-judgemental, and supportive approach.
