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
Case at a glance
This case involves a patient at high risk of venous thromboembolism (VTE) who has stopped taking edoxaban because he does not want the blood-test monitoring required for safe treatment.
The consultation explores the tension between:
The consultation should not focus only on persuading the patient to restart medication. The clinician must understand why monitoring is unacceptable, assess capacity, explain the risks of action and inaction, explore alternatives and agree the safest achievable plan.
GP trainee performance focus
A strong GP trainee should demonstrate that they can:
What this case is testing
Patient priorities and concerns
The patient may be concerned about:
The clinician’s priorities are to:
Central challenge
The central challenge is to respect a capable refusal while ensuring that the patient understands the potential consequences.
The clinician needs to avoid:
Must-not-miss issue or diagnosis
The must-not-miss issue is serious harm from either:
Red flags or high-risk features
High-risk features include:
Common GP trainee pitfalls
What good looks like
A strong consultation is respectful, structured and ethically transparent. The trainee explores the patient’s reasoning, explains risks clearly, assesses capacity, offers alternatives and keeps the relationship open even if the patient continues to refuse monitoring.
“It’s your decision, and I want to make absolutely sure you have all the facts to choose what’s best for you. My job is to help you weigh up the risks and benefits, and make choices that are as safe as possible.”
Learner checkpoint
Have I understood why the patient is refusing monitoring before trying to solve the problem?
Start with an open question
Use open, non-leading questions and allow the patient to explain without interruption.
“Can you tell me more about what makes blood tests difficult for you?”
Then signpost the consultation:
“I’d like to understand what makes the blood tests difficult, explain the risks of stopping the medication, and then see whether there is a safer option that fits better with your priorities.”
Time-efficient data gathering
Gather a clear, systematic and contextual history.
Ask:
High-yield questions
Reason for stopping edoxaban
Understanding of treatment and monitoring
Practical barriers
Explore whether monitoring is difficult because of:
Emotional and psychological barriers
Ask about:
Clinical risk
Ask about:
Functional, psychosocial or contextual assessment
Explore how anticoagulation and monitoring affect:
Ask about support from:
Explore ideas, concerns and expectations
Clarify what the patient wants from the consultation.
“What would a good outcome from today’s discussion look like for you?”
Possible goals include:
Recognise and respond to cues
Look for cues such as:
Respond sensitively:
“It sounds as though this treatment has become a burden. Can you tell me more about what feels most difficult?”
If bereavement or low mood is mentioned, explore how this is affecting treatment decisions.
Useful consultation phrases
“I understand that the blood tests feel like a lot of hassle, and I want to understand what makes them particularly difficult for you.”
“The blood tests help us check that the medicine remains safe for you, particularly by checking how your kidneys are working and looking for problems that may not cause symptoms at first.”
“A refusal does not mean you lack capacity. I just need to check that you understand the key information and have been able to weigh it up.”
“This puts me in a difficult position. I want to respect your wishes, but I also need to keep you safe according to medical guidance. Could we explore whether there’s any way we could work together on this?”
“Even if it’s a ‘no’ for now, you can always change your mind, and we’re here to help if you do.”
Consultation flow and signposting
Summarising and checking understanding
Summarise before moving into decisions:
“You stopped edoxaban because the blood-test monitoring feels too burdensome. I’ve also heard that this affects your independence and how worthwhile the treatment feels to you. We need to balance that against the risk of another clot, and also the risk of taking anticoagulation without the checks that keep it safe.”
Check:
Data gathering self-check
Before agreeing a plan, the trainee should know:
Assessment domain mapping
Data gathering
Clinical management
Relating to others
Prioritised differential diagnosis or clinical reasoning
This is not primarily a diagnostic case. The clinical reasoning task is to balance:
The consultation should make the ethical reasoning explicit rather than presenting it as a simple compliance problem.
Clinical reasoning script
“There are risks on both sides. If you stop anticoagulation, there is a risk of another clot, including a DVT or pulmonary embolism. If you take anticoagulation without monitoring, we may miss changes such as kidney problems or bleeding risk that could make the medication unsafe. My role is to explain those risks clearly and help us find the safest plan you can accept.”
Red flags and risk assessment
Assess for symptoms that may suggest recurrent VTE or bleeding.
Urgent advice is needed if the patient develops:
Also consider whether risk has changed because of:
Decision points
Key decisions include:
Management priority
The management priority is to agree the safest achievable plan while respecting a capable refusal.
This means:
Management options
1. Explain risks of not monitoring while taking anticoagulation
Explain the risks of continuing anticoagulation without monitoring, including:
2. Explain risks of stopping anticoagulation
Explain the risks of stopping, including:
The explanation should be balanced and proportionate.
3. Assess capacity
Assess whether the patient can:
Do not assume refusal means lack of capacity.
4. Explore practical alternatives
Consider whether it is possible to:
Example phrase:
“Would fewer blood tests help you feel better about monitoring?”
5. Agree a realistic monitoring plan if refusal continues
If the patient remains reluctant, agree the safest realistic plan. This may include:
Do not imply that a clinically unsafe option is risk-free.
6. Seek wider support or advice
The plan may include discussion with:
Coordination helps avoid future conflict, duplication or confusion.
Personalised plan
A suitable plan should reflect:
The plan may include:
Shared decision-making
Affirm the patient’s right to make an informed choice.
“It’s your decision, and I want to make absolutely sure you have all the facts to choose what’s best for you.”
Explain that a capable adult can refuse treatment if they can understand, retain and weigh the relevant information and communicate their decision.
Discuss:
Safety-netting
The patient should seek urgent medical advice if he develops:
Example phrase:
“If you notice any unusual bruising, bleeding, leg swelling, chest pain or breathlessness, please call us or 111 straight away.”
Explain what to do in an emergency and ensure he knows how to access help outside normal practice hours.
Ethical, legal and safeguarding considerations
This case can be understood through four ethical principles:
Be transparent about the dilemma:
“I wish there was a perfect solution that fitted the guidelines and your wishes exactly. Let’s work out together what feels right for you while keeping things as safe as possible.”
A capable refusal should be respected, but care should not be withdrawn.
Documentation points
Document clearly:
Common unsafe management plans
Avoid:
Follow-up and coordination with other professionals
Coordinate the decision respectfully with:
Arrange follow-up to review:
Learner checkpoint
Have I respected the patient’s autonomy while clearly documenting capacity, risks, safety-netting and the safest achievable plan?
Relevant guidance areas
NICE guidance
GMC, DVLA or safeguarding guidance
RCGP and SCA resources
Patient information websites
Professional and local resources mentioned
Key principles to remember
Transferable learning for future cases
When a patient refuses monitoring or treatment:
Supervisor or examiner lens
A supervisor or examiner is likely to look for:
Final learner takeaway
A capable refusal is not a failed consultation: explore, inform, assess capacity, negotiate what is safe, document clearly and keep the door open.
