Abstract
The Simulated Consultation Assessment (SCA) is due to commence in November 2023. This section of the journal has been developed to help GP trainees practice their consulting skills in anticipation of the SCA. The section includes a ‘Doctor’s sheet’ and a ‘Patient’s sheet’ to facilitate practicing consultations with your trainer and colleagues. An ‘Examiner’s sheet’ describes the areas trainees need to display in each of the marking domains and finishes with key points and tips for the trainee.
Doctor’s sheet
Patient: John Dickens Age: 70 years
Past medical history
Hypertension
Raised cholesterol
Medications
Amlodipine 5 mg once daily (OD)
Atorvastatin 40 mg OD, commenced last week
Clopidogrel 75 mg OD, commenced last week
Recent investigations
Total cholesterol 5.8 mmol/L
Non-HDLc 4.9 mmol/L
Renal and liver functions tests (LFTs) normal
Blood pressure 134/76
Patient’s sheet
Name: John Dickens Age: 70 years
Background
The patient was diagnosed with a posterior circulation transient ischaemic attack (TIA) last week.
Opening line
I’d like to request my medications. The prescription clerk suggested that I speak to you first as I had a mini-stroke last week.
Behaviour
Worried about the recent turn of events.
Information given freely
The patient was diagnosed with a TIA when he attended the emergency department following an episode of slurred speech and dizziness. He recovered after about 5 minutes and was seen by the stroke team the next day, who started him on new medication.
Information provided on appropriate exploration and demonstration of empathy
Mr Dickens is quite scared about having a ‘full blown stroke’. Although his magnetic resonance imaging (MRI) scan did not demonstrate a stroke, he was informed that the risk of having one is high over the next few weeks.
He is therefore worried about managing on his own if he did have a stroke. He lives on his own since his wife passed away with breast cancer last year and has just started to come to terms with the loss.
If asked specifically, he will mention that he does not recall being told not to drive and has driven to the surgery, which is under a mile from home. He mentions that he is keen to drive as he does not want to be stuck at home. He has a good circle of friends and attends the local bridge club twice a week.
He is amenable to walking home and have a friend drop his car home later but wonders if this is necessary.
Examiner’s sheet
Data gathering
The candidate should explore the patient’s understanding of TIA and the role of secondary prevention. They should check if the patient is not driving and that he is aware not to drive for at least a month after a TIA. They should take a good social history and ensure that the patient has adequate help and support while he is not driving.
Red flags
The candidate needs to be aware of the signs and symptoms related to a posterior circulation TIA and ensure that the patient did not have further episodes the preceding week.
Clinical management
The candidate should be able to explore the patient’s concerns surrounding TIAs/strokes. They should discuss the importance of secondary prevention and explain the rationale behind the medications prescribed. Follow-up arrangements for clinical review, as well as repeat blood tests (lipid profile and liver function tests), should be made.
Interpersonal skills
The candidate should be aware that the patient must not drive for at least 1 month after a TIA and should discuss this sensitively. One should not assume that Mr Dickens is breaking the Driver and Vehicle Licensing Agency (DVLA) guidance wilfully – he may not have understood the implications of driving after a TIA (or may not have been adequately informed about it). Solutions to circumvent this should be discussed to help Mr Dickens in this situation.
The candidate must demonstrate empathy appropriately given that Mr Dickens has had a recent bereavement and is now confronted with a serious diagnosis.
Discussion with trainee
This is a classic example of being able to manage patients’ concerns while adhering to DVLA regulations. The scenario lends itself for further discussion to cover various clinical and non-clinical aspects. The following questions can be used as prompts for further discussion:
What are the signs and symptoms of a posterior circulation TIA? What are the differential diagnoses for a posterior circulation TIA? For how long must a person with TIA/stroke not drive? Should they inform the DVLA? What if the patient had multiple TIAs? What would you do if Mr Dickens refused to comply with DVLA regulations? Is the prescribed dose of atorvastatin appropriate for secondary prevention? How reliable is the FAST (face, arms, speech, time) score for posterior circulation strokes? Do you know any other screening tools?
Top tips
Acquaint yourselves with the DVLA regulations for driving after TIA, stroke, myocardial Infarction, etc. Always try to put yourself in the patient’s shoes to understand the impact of an illness on various facets on a person’s life Document clearly that you have advised the patient regarding issues related to DVLA guidance (i.e. matters with high medico-legal significance)
