CASE INFORMATION

Case ID: CCE-2025-REFERRAL-01
Case Name: John Smith
Age: 52
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: A85 (Other referrals NEC NOS)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
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 relevant information about the patient’s condition and need for referral. 2.2 Identifies red flags that necessitate urgent specialist referral.
3. Diagnosis, Decision-Making and Reasoning	3.1 Justifies the need for referral based on clinical findings and patient history. 3.3 Considers alternative management strategies before referring.
4. Clinical Management and Therapeutic Reasoning	4.1 Provides a structured referral including appropriate clinical details. 4.3 Offers interim management strategies while awaiting specialist review.
5. Preventive and Population Health	5.1 Ensures appropriate screening and follow-up plans are in place.
6. Professionalism	6.1 Adheres to ethical and professional standards in patient care and referral processes.
7. General Practice Systems and Regulatory Requirements	7.1 Understands Medicare and referral processes in the Australian healthcare system.
9. Managing Uncertainty	9.1 Balances clinical decision-making with patient preferences when referral options are uncertain.

CASE FEATURES

Need for clear communication about interim management.
Middle-aged male requiring a referral to a specialist.
No clear diagnosis yet; multiple concerns need addressing.
Discussion of appropriate referrals based on symptoms and urgency.
Consideration of wait times, costs, and patient preferences.
Managing patient expectations about referral pathways in the public vs private system.

INSTRUCTIONS

You have 15 minutes to complete this consultation.

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

You are not required to perform a physical examination.

A patient record summary is provided for your information.

Perform the following tasks:

Take an appropriate history.
Outline the differential diagnosis and key investigations required.
Address the patient’s concerns.
Develop a safe and patient-centred management plan.

SCENARIO

John Smith, a 52-year-old male, presents to your clinic requesting a referral to a specialist. He has been experiencing chronic back pain for the past six months, which is now affecting his daily activities and work. He has seen a physiotherapist with minimal improvement and believes he needs an MRI and a specialist opinion.

John is concerned about the wait times in the public system and is unsure if he should go private. He also worries about costs but is willing to explore his options. He has no red flag symptoms (e.g., no weakness, no bowel/bladder involvement), but his pain is persistent and not fully relieved by medications or physiotherapy.

PATIENT RECORD SUMMARY

Patient Details

Name: John Smith
Age: 52
Gender: Male

Allergies and Adverse Reactions

No known drug allergies

Medications

Ramipril 5mg daily

Past History

Mild hypertension
No previous surgeries

Social History

Works as a truck driver (struggles with sitting for long hours due to pain).

Family History

Father had type 2 diabetes and hypertension.
Mother had osteoarthritis.

Smoking / Alcohol

Non-smoker
Alcohol: Occasional beer on weekends

Vaccination and Preventative Activities

Up to date with vaccinations.
Last health check: 2 years ago.

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.

ROLE-PLAYER SCRIPT

Opening Line

“Hi Doctor, I need a referral to a specialist for my back pain. I think I need an MRI too.”

General Information

(Provide this information freely if the candidate asks open-ended questions.)

Pain Duration: You’ve had back pain for six months, and it’s getting worse.
Pain Characteristics: The pain is constant, dull, and aching, sometimes sharp when you move the wrong way.
Location: It’s mostly in the lower back, sometimes spreading to the buttocks but not down the legs.
Severity: It’s about 6/10 on most days, but can go up to 8/10 after a long day at work.

Specific Information

(Only provide if asked directly.)

Background Information

Aggravating Factors: Sitting for long periods makes it worse, and it bothers you at night sometimes.
Relieving Factors: You find temporary relief with painkillers, heat packs, and changing positions.
Previous Management: You’ve tried physiotherapy and over-the-counter pain relief, but nothing is working long-term.

Physiotherapy & Other Treatments

You attended six physiotherapy sessions, but they didn’t help much.
The physio gave you stretches and exercises, but you stopped doing them because they didn’t seem to work.

Impact on Daily Life

You’re a truck driver, and the pain makes it hard to sit for long periods.
You sometimes need to stop driving early because of discomfort.
The pain is affecting your sleep when it’s bad.
You’re worried about taking time off work but might have to if this continues.

Concerns & Expectations

You believe you need an MRI to find out what’s wrong.
You’re frustrated that nothing has worked so far.
You’re not sure how long a public referral will take and worried about the cost of private options.
You’re considering chiropractic or alternative treatments if a referral takes too long.

Emotional Cues

(Adjust your tone and expressions accordingly.)

Frustrated: “I just want this pain gone. I feel like no one is taking it seriously.”
Anxious: “I can’t afford to stop working, but I don’t know how much longer I can take this.”
Skeptical: “Physio didn’t really help. Are you sure I don’t just need surgery?”

Questions for the Doctor

(Ask naturally during the consultation.)

“Do I need an MRI before I can see a specialist?”
“How long will it take to get an appointment through the public system?”
“Would a private referral be faster, and how much would it cost?”
“If I have to wait, what else can I do to manage the pain in the meantime?”

If the Doctor Recommends Conservative Management

(Respond based on how well the doctor explains it.)

If they explain why imaging is not needed right now: “So you’re saying an MRI wouldn’t change my treatment anyway?”
If they suggest continuing physiotherapy: “I don’t know… it didn’t really help before. What’s different this time?”
If they suggest pain management strategies: “I already take painkillers, but they don’t fix the problem.”
If they suggest a referral without imaging: “Are you sure the specialist will take me seriously without an MRI?”

If the Doctor Suggests a Referral

(React depending on the referral type.)

Public Referral:
- “Three to six months? I can’t wait that long!”
- “Is there any way to speed it up?”
Private Referral:
- “How much will it cost to see someone privately?”
- “Would private health insurance cover this?”

Closing the Consultation

If satisfied: “Okay, I’ll try the plan you suggested and see how it goes.”
If unsure: “I’ll think about it, but I still think I need an MRI.”
If worried: “I don’t want to wait too long. What should I do if the pain gets worse?”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient regarding their back pain and request for a referral.

The competent candidate should:

Use open-ended questions to explore the patient’s symptoms, including onset, duration, character, severity, and aggravating/alleviating factors.
Identify red flags for serious spinal pathology (e.g., neurological symptoms, fever, weight loss, history of malignancy).
Assess the impact on daily life, including work and sleep disturbances.
Explore previous treatments, including physiotherapy, medications, and alternative therapies.
Discuss patient concerns and expectations, including their belief that they need an MRI and specialist referral.
Use empathetic communication to acknowledge frustration and provide reassurance.

Task 2: Explain your assessment and justify whether imaging and/or referral is required.

The competent candidate should:

Explain that most cases of mechanical back pain do not require imaging unless red flags are present.
Educate the patient on current guidelines that support conservative management before considering imaging.
If referral is indicated, explain appropriate pathways (e.g., physiotherapy, pain management, specialist referral).
Address the patient’s concerns about MRI availability and specialist wait times.
Provide clear safety-netting advice, including when to return if symptoms worsen.

Task 3: Develop a management plan tailored to the patient’s needs and expectations.

The competent candidate should:

Recommend first-line conservative management (e.g., exercise, physiotherapy, NSAIDs, heat therapy).
Encourage continued physiotherapy and address non-compliance.
Provide education on pain management (e.g., simple analgesia, lifestyle modifications).
Consider a referral to a musculoskeletal specialist or pain clinic if appropriate.
Discuss the pros and cons of private vs public referral and associated costs.
Provide written and verbal information on self-management strategies.

SUMMARY OF A COMPETENT ANSWER

Thorough history-taking including red flag symptoms, functional impact, and previous treatments.
Clear explanation of why imaging may not be necessary and when to consider referral.
Empathetic discussion of patient concerns about pain, work impact, and treatment options.
Evidence-based management plan, including physiotherapy, analgesia, and activity modification.
Safety-netting advice for worsening symptoms or red flags.

PITFALLS

Failing to explore red flag symptoms, missing serious underlying pathology.
Automatically agreeing to an MRI without explaining why imaging is not always necessary.
Not addressing the patient’s concerns about pain control, work limitations, and referral options.
Overlooking a multidisciplinary approach, neglecting physiotherapy, lifestyle changes, or medication review.
Lack of clear safety-netting, failing to advise when to seek urgent care.

REFERENCES

MARKING

Each competency area is assessed 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, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a structured history, identifying red flag symptoms and impact on function.

3. Diagnosis, Decision-Making and Reasoning

3.1 Uses evidence-based reasoning to determine whether imaging or referral is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a safe and effective management plan, including conservative treatment and appropriate referral.

5. Preventive and Population Health

5.1 Provides education on self-management strategies to prevent chronic pain.

6. Professionalism

6.1 Respects the patient’s autonomy while guiding decision-making with evidence-based practice.

7. General Practice Systems and Regulatory Requirements

7.1 Explains the public vs private referral process, including costs and wait times.

9. Managing Uncertainty

9.1 Reassures the patient about not needing immediate imaging, while providing clear follow-up instructions.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises red flags requiring urgent intervention.

Competency at Fellowship Level

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