CCE-CE-024 - GP Exams

Case ID: SKN-001
Case Name: Peter Johnston
Age: 65
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: S77 (Malignant Neoplasm of Skin)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand their concerns and expectations 1.2 Communicates effectively regarding diagnosis and management 1.4 Demonstrates empathy and reassurance regarding the condition
2. Clinical Information Gathering and Interpretation	2.1 Gathers an appropriate history focusing on risk factors (sun exposure, family history, previous skin cancers) 2.2 Identifies red flag features of malignant skin lesions
3. Diagnosis, Decision-Making and Reasoning	3.1 Differentiates between benign and malignant skin lesions 3.2 Justifies the need for further investigations (e.g., biopsy)
4. Clinical Management and Therapeutic Reasoning	4.1 Provides a patient-centred management plan 4.2 Outlines treatment options, including surgical and non-surgical management
5. Preventive and Population Health	5.1 Provides education on sun safety and skin cancer prevention 5.2 Encourages skin checks and self-examination
6. Professionalism	6.1 Manages patient concerns with sensitivity and professionalism
7. General Practice Systems and Regulatory Requirements	7.1 Discusses the role of Medicare-covered skin checks and referrals
8. Procedural Skills	8.1 Discusses biopsy and excision procedures 8.2 Ensures safe procedural consent
9. Managing Uncertainty	9.1 Communicates appropriately when the diagnosis is uncertain and discusses watchful waiting vs. biopsy
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies and manages a patient with a confirmed or suspected malignancy

CASE FEATURES

Emphasis on patient education regarding prevention and early detection
Elderly male with a suspicious skin lesion
History of sun exposure and previous non-melanoma skin cancers
Concern about malignancy and its implications
Requires appropriate diagnostic workup and management

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face-to-face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

Take a focused history
Explain your differential diagnosis
Address Peter’s concerns
Provide management plan

SCENARIO

Peter Johnston, a 65-year-old retired builder, presents to your general practice with a concern about a skin lesion on his forearm. He reports that it has been growing over the past six months, is sometimes itchy, and has started bleeding occasionally when scratched. He has a history of multiple actinic keratoses and one previous basal cell carcinoma excised five years ago.

Peter has spent a lifetime working outdoors without consistent sun protection. He is worried about the possibility of skin cancer, as a close friend was recently diagnosed with melanoma. He wants to know if this lesion is dangerous and what his treatment options are.

On visual inspection, the lesion appears irregular in shape, with mixed pigmentation and a slightly raised, rough surface. You suspect a malignant skin neoplasm and need to determine the appropriate next steps.

PATIENT RECORD SUMMARY

Patient Details

Name: Peter Johnston
Age: 65
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

None known

Medications

Aspirin 100mg daily
Atorvastatin 20mg nocte
Ramipril 5mg daily

Past History

Hypertension
Hypercholesterolaemia
Previous basal cell carcinoma excised from the nose (5 years ago)
Multiple actinic keratoses treated with cryotherapy

Social History

Retired builder, worked outdoors for over 40 years

Family History

Father had a squamous cell carcinoma removed in his 70s
No family history of melanoma

Smoking

Non-smoker

Alcohol

Social drinker (1-2 standard drinks on weekends)

Vaccination and Preventative Activities

Up to date with routine vaccinations

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

Opening Line

“Doctor, I’ve noticed this spot on my arm getting bigger and I’m worried it might be skin cancer.”

General Information

The lesion has been there for about six months and seems to be growing slowly.
It started as a small rough patch but has changed in shape and size over time.
It sometimes gets itchy and has bled a couple of times when scratched.

Specific Information

(To be provided only when asked relevant questions)

Background Information

There’s no significant pain, but a mild burning sensation at times.
Peter has had a previous basal cell carcinoma (BCC) removed from his nose five years ago.
He has spent most of his life working outdoors as a builder and didn’t consistently use sunscreen.
He is worried because a close friend was recently diagnosed with melanoma.

History of the Lesion

Located on the left forearm, near the wrist.
About 1.5 cm in diameter, irregular borders.
Colour varies from light brown to dark brown, with some reddish areas.
The surface is rough and slightly raised.
It hasn’t scabbed over or healed completely.

Risk Factors

Extensive sun exposure over a lifetime.
Rarely used sunscreen, especially during his working years.
Has had multiple actinic keratoses treated with cryotherapy before.
His father had a squamous cell carcinoma (SCC) removed in his 70s.

Other Symptoms and Concerns

No significant weight loss or fatigue.
No lumps in the armpits or elsewhere.
Hasn’t noticed any other new or changing moles.

Patient’s Emotional Cues and Responses

(If the Candidate Downplays the Risk)

(Looks concerned, frowns slightly)
“But I’ve read that skin cancers can be aggressive. Are you sure this isn’t something serious?”

If the Candidate Mentions Biopsy or Further Tests

(Slightly nervous, shifts in seat)
“A biopsy? Does that mean you think it could be cancer? How painful is it?”

If the Candidate Mentions Surgery

(Looks anxious, voice slightly strained)
“Surgery? Does that mean you’re going to cut it out completely? Will I need a big operation?”

If the Candidate Provides Reassurance

(Nods, sighs with relief)
“So you’re saying if we catch this early, I’ll be okay?”

Patient’s Concerns (To be asked during the consultation)

“Is this something serious? Could it be melanoma?”
- Peter is particularly worried about melanoma because of his friend’s recent diagnosis.
“Will I need surgery?”
- He is concerned about scarring and the extent of any procedure needed.
“What happens if I ignore it?”
- He is uncertain about whether all skin cancers need to be removed.
“How do I prevent this from happening again?”
- He is open to learning about sun protection and regular skin checks.

Emotional and Body Language Notes for Role-Player

Initially appears mildly anxious but not overly distressed.
Becomes visibly more concerned if cancer is mentioned.
Looks down or fidgets if surgery or biopsy is discussed.
Feels slightly reassured when the candidate explains things clearly.
If reassured effectively, leans back slightly and relaxes towards the end.

Scenario Progression Guide for Role-Player

Start with the opening line and wait for the candidate’s initial response.
If asked, provide details of the lesion’s history and risk factors.
If the candidate suggests investigations, show mild concern but willingness to proceed.
If surgery is mentioned, express apprehension but ask for clarification.
If prevention is discussed, show engagement and ask follow-up questions.
Conclude with a mix of curiosity and relief, depending on how well the candidate has addressed concerns.

Closing Prompt

(If the Candidate Hasn’t Addressed Preventative Measures)

“I suppose I should have been more careful in the sun. What should I be doing now to stop this from happening again?”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history from Peter regarding his skin lesion.

The competent candidate should:

Use open-ended questions to gather a detailed history, including the lesion’s duration, size changes, colour, border, and symptoms (itching, bleeding, ulceration, pain).
Explore risk factors, including cumulative sun exposure, occupational exposure, personal and family history of skin cancer, and sun protection habits.
Assess systemic symptoms (weight loss, night sweats, fatigue) that may indicate advanced malignancy.
Explore psychosocial concerns, including fear of a cancer diagnosis and its implications.
Use clear, non-leading language to explore the patient’s concerns and expectations.

Task 2: Explain your differential diagnosis and justify the need for further investigations.

The competent candidate should:

Provide a structured differential diagnosis, including:
- Malignant: Melanoma, squamous cell carcinoma (SCC), basal cell carcinoma (BCC).
- Pre-malignant: Actinic keratosis.
- Benign: Seborrhoeic keratosis, dermatofibroma, pyogenic granuloma.
Discuss red flag features (asymmetry, irregular borders, colour variegation, diameter >6mm, evolving changes).
Explain the importance of early diagnosis and why a biopsy (punch, shave, or excision) is recommended.
Ensure the patient understands why investigations are necessary, addressing concerns empathetically.

Task 3: Address Peter’s concerns regarding the diagnosis and possible treatment options.

The competent candidate should:

Acknowledge the patient’s concerns about cancer, explaining that while malignancy is a possibility, early detection improves outcomes.
Explain investigation and treatment options, including:
- Biopsy for histological confirmation.
- Treatment options (excision with margins, Mohs surgery for facial lesions, radiotherapy for non-surgical candidates).
- Prognosis based on lesion type and stage.
Discuss scarring and cosmetic concerns with reassurance.
Provide emotional support, ensuring Peter has a clear plan moving forward.

Task 4: Provide a patient-centred management plan, including treatment and preventive strategies.

The competent candidate should:

Develop a stepwise plan, including:
- Urgent biopsy if malignancy is suspected.
- Referral to dermatology or a skin cancer clinic if indicated.
- Surgical or non-surgical treatment based on histology.
Educate on sun protection strategies:
- Slip, Slop, Slap, Seek, Slide (protective clothing, sunscreen, hat, shade, sunglasses).
- Avoid peak UV times.
- Perform regular self-skin checks and attend annual skin checks with a GP or dermatologist.
Address long-term follow-up needs for high-risk individuals.

SUMMARY OF A COMPETENT ANSWER

Comprehensive history, including lesion changes, risk factors, and psychosocial impact.
Clear, structured differential diagnosis, distinguishing between benign, pre-malignant, and malignant lesions.
Empathetic communication, addressing patient fears and explaining diagnostic uncertainty.
Justification for biopsy, explaining risks and benefits of various investigative methods.
Patient-centred management, balancing treatment, prevention, and long-term follow-up.

PITFALLS

Failing to take a structured history, missing key risk factors or lesion changes.
Overlooking psychosocial concerns, dismissing the patient’s anxiety about cancer.
Providing vague explanations and failing to justify the need for a biopsy.
Overly alarming language, causing unnecessary distress without evidence-based reassurance.
Not addressing prevention, missing an opportunity for long-term patient education.

REFERENCES

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare, and the full impact of their illness experience on their lives.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers an appropriate history focusing on risk factors and lesion characteristics.
2.2 Identifies red flag features of malignant skin lesions.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between benign and malignant skin lesions.
3.2 Justifies the need for further investigations (e.g., biopsy).

4. Clinical Management and Therapeutic Reasoning

4.1 Provides a patient-centred management plan.
4.2 Outlines treatment options, including surgical and non-surgical management.

5. Preventive and Population Health

5.1 Provides education on sun safety and skin cancer prevention.
5.2 Encourages skin checks and self-examination.

6. Professionalism

6.1 Manages patient concerns with sensitivity and professionalism.

7. General Practice Systems and Regulatory Requirements

7.1 Discusses the role of Medicare-covered skin checks and referrals.

8. Procedural Skills

8.1 Discusses biopsy and excision procedures.
8.2 Ensures safe procedural consent.

9. Managing Uncertainty

9.1 Communicates appropriately when the diagnosis is uncertain and discusses watchful waiting vs. biopsy.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and manages a patient with a confirmed or suspected malignancy.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD