CASE INFORMATION

Case ID: CCE-2025-012
Case Name: Michael Thompson
Age: 52 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L18 (Chronic Pain), N94 (Back Pain), P85 (Psychological Factors in Somatic Illness)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand their concerns and expectations. 1.2 Develops a respectful and empathetic doctor-patient relationship. 1.4 Provides appropriate patient-centred explanations.
2. Clinical Information Gathering and Interpretation	2.1 Gathers relevant history, including biopsychosocial factors and functional impact. 2.2 Selects and interprets appropriate investigations for chronic pain assessment.
3. Diagnosis, Decision-Making and Reasoning	3.1 Develops a differential diagnosis based on clinical findings. 3.5 Identifies red flag symptoms requiring urgent referral.
4. Clinical Management and Therapeutic Reasoning	4.1 Formulates a safe, evidence-based, multimodal pain management plan. 4.3 Provides appropriate follow-up and medication review.
5. Preventive and Population Health	5.2 Addresses risk factors for opioid dependence and lifestyle modifications.
6. Professionalism	6.1 Maintains patient confidentiality and professional integrity.
7. General Practice Systems and Regulatory Requirements	7.1 Prescribes and manages medications in accordance with PBS and regulatory guidelines.
9. Managing Uncertainty	9.2 Develops a plan for a patient with unclear pain symptoms.
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and acts on complications of chronic pain, including psychological impacts.

CASE FEATURES

52-year-old male with chronic lower back pain for the past five years, following a workplace injury.
Describes pain as constant, dull, and sometimes sharp with movement.
Difficulty sleeping and reduced mobility, affecting work and daily activities.
Has tried physiotherapy and over-the-counter analgesics, but requests stronger pain relief.
Currently taking opioids prescribed by a previous GP but worried about long-term effects and dependence.
Concerned about his ability to continue working and the impact on his mental health.
Requires a multimodal approach balancing pain relief, physical rehabilitation, psychological support, and medication safety.

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 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

Michael Thompson, a 52-year-old construction worker, presents with chronic lower back pain following a workplace injury five years ago. He describes the pain as constant, dull, and occasionally sharp with certain movements.

PATIENT RECORD SUMMARY

Patient Details

Name: Michael Thompson
Age: 52 years
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Oxycodone 10mg BD (prescribed 1 year ago, self-managing dose)
Paracetamol 1g PRN
Ibuprofen 400mg PRN

Past History

Workplace back injury (5 years ago, no surgery performed)
No history of fractures, inflammatory conditions, or malignancy
No prior mental health conditions diagnosed

Social History

Works as a construction worker, currently on reduced duties due to pain.
No smoking, drinks alcohol occasionally.

Family History

No family history of chronic pain or autoimmune disease.
Father had depression and alcohol dependence.

Vaccination and Preventative Activities

Up to date with 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.

SCRIPT FOR ROLE-PLAYER

Opening Line

“Doctor, my back pain has been really bad, and I don’t think my current medications are enough. I need something stronger.”

General Information

(Freely Shared if Asked Open-Ended Questions)

The pain started five years ago after a workplace injury while lifting heavy materials.
Since then, it has been constant, with some days worse than others.
The pain is mostly in the lower back, sometimes radiating down the right leg.
You feel stiff in the mornings, and it takes time to loosen up.

Specific Information

(Only Revealed if the Candidate Asks Targeted Questions)

Background Information

You struggle to stand or walk for long periods and have difficulty lifting objects.
You take oxycodone regularly but feel it’s less effective now.
You have tried physiotherapy but stopped because it didn’t seem to help much.
You have difficulty sleeping due to pain.
Work has been tough because you’re slower and in constant discomfort.
You worry about how long you can keep working.

Pain Characteristics

The pain is mostly in the lower back, sometimes radiating down the right leg.
It feels like a deep, aching discomfort, with occasional sharp pain when bending or twisting.
No numbness, weakness, or loss of bowel/bladder control.
No significant weight loss or night pain.
Pain is worse after physical activity and improves slightly with rest.

Psychosocial Impact

You feel frustrated and worried about your future.
You’ve been feeling down, especially since work has been difficult.
Your wife thinks you’re more irritable than before.
You don’t exercise much anymore because of pain.
You used to enjoy going fishing and playing golf, but you haven’t done that in years.
Financially, you’re struggling since your hours at work have been reduced.

Medication Concerns

You know opioids can be addictive and are worried about dependence.
You don’t want to be on them forever but don’t see an alternative.
You’ve tried cutting back, but the pain worsens.
You sometimes take an extra dose on particularly bad days.
You haven’t tried antidepressants, nerve pain medications, or injections.

Emotional Cues & Concerns

You feel hopeless and worry that this pain will never improve.
You are scared about not being able to work anymore and becoming a burden.
You are frustrated that past treatments didn’t work and worried about withdrawal if you stop oxycodone.
You don’t want to be labelled as a “drug seeker” but feel you’re running out of options.

Questions for the Candidate

(Drop these in naturally throughout the consultation)

“Do I need stronger painkillers? The oxycodone doesn’t seem to work as well anymore.”
“Am I addicted to these pain meds?”
“What else can I do to manage my pain if I stop opioids?”
“Will I ever be pain-free, or is this just how my life is now?”
“If I can’t keep working, what happens next?”
“Why should I try physiotherapy again if it didn’t help before?”
“Are there any injections or surgeries that could fix this?”

How to Respond Based on the Candidate’s Answers

If the Candidate Provides a Clear Explanation and Plan:

You feel somewhat reassured but still nervous about reducing pain medication.
You may ask for clarification on next steps:
- “So, if we reduce the oxycodone, what will I take instead?”
- “How long will it take before I start feeling better?”
You agree to try non-medication strategies if explained well.

If the Candidate is Unclear or Dismissive:

You become more anxious and insistent on stronger painkillers.
You may push for immediate changes to your medication:
- “I don’t think anything else will work. Can’t you just prescribe a higher dose?”
- “If I don’t take oxycodone, how will I get through the day?”
- “I need to work—this isn’t just about comfort.”

Ending the Consultation

If the Candidate Has Done Well:

You feel more reassured and are willing to follow the plan.
You might still confirm:
- “So, we’ll try a lower dose first, and you’ll check in with me soon?”
- “If the pain doesn’t improve, can we look at other options like injections?”
You thank the doctor and leave with a clear idea of what to do next.

If the Candidate Has Not Addressed Your Concerns Well:

You remain doubtful and uneasy.
You may say:
- “I think I might get a second opinion. I just want to be sure.”
- “I still don’t know what I’m supposed to do without the painkillers.”
You leave feeling frustrated and uncertain about your next steps.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including pain characteristics, functional impact, and psychosocial factors.

The competent candidate should:

Use open-ended questions to explore the patient’s experience of pain, then follow up with targeted questions.
Assess pain characteristics, including:
- Onset and duration: Chronic pain for five years post-injury.
- Location and radiation: Lower back, sometimes radiating to the right leg.
- Severity and impact: Pain affects sleep, mobility, and work.
- Aggravating and relieving factors: Worse with standing and lifting, better with rest.
Screen for red flag symptoms:
- Neurological deficits (weakness, numbness, bowel/bladder dysfunction).
- Unintentional weight loss, night pain, fever (infection, malignancy).
Explore treatment history, including opioid use, physiotherapy, and other pain management strategies.
Assess psychosocial impact, including work capacity, mood, and relationship stress.
Address concerns about opioid dependence and alternative pain management options.

Task 2: Discuss your differential diagnosis and red flag symptoms with the patient.

The competent candidate should:

Explain that chronic pain is complex and involves biological, psychological, and social factors.
Discuss most likely differentials:
- Chronic non-specific low back pain: Most common, no clear structural pathology.
- Lumbar radiculopathy (sciatica): If pain radiates down the leg, possible nerve root compression.
- Facet joint arthritis or degenerative disc disease: Worsened by movement, relieved by rest.
- Myofascial pain syndrome: Persistent muscle tension and trigger points.
- Opioid-induced hyperalgesia: Increased pain sensitivity due to prolonged opioid use.
Identify red flag symptoms that require further investigation (MRI, urgent referral).
Address concerns about pain persistence and future work capacity.

Task 3: Explain your approach to chronic pain management, including medication review and non-pharmacological strategies.

The competent candidate should:

Emphasise a multimodal approach combining physical, psychological, and pharmacological strategies.
Discuss medication review and opioid tapering:
- Long-term opioid use is not recommended for chronic non-cancer pain due to risks of dependence, tolerance, and overdose.
- Introduce opioid tapering plan, replacing with safer alternatives (e.g., paracetamol, NSAIDs, neuropathic agents).
Explain non-pharmacological strategies:
- Physiotherapy: Core strengthening, mobility exercises.
- Pain psychology: Cognitive Behavioural Therapy (CBT) for pain coping skills.
- Lifestyle changes: Regular exercise, weight management, improved sleep hygiene.
- Interventional options: Consider injections (e.g., facet joint, epidural steroid) if appropriate.
Reassure the patient that pain management is about improving function, not just eliminating pain.

Task 4: Provide an initial management plan, including a follow-up schedule and appropriate referrals.

The competent candidate should:

Develop a collaborative pain management plan, including:
- Opioid tapering plan with close supervision.
- Referral to physiotherapy for structured exercise therapy.
- Consideration of a psychologist specialising in chronic pain management.
- Referral to a pain specialist if pain is severe or opioid dependence is a concern.
Discuss return-to-work strategies, including modified duties and liaising with an occupational therapist.
Provide education on realistic pain expectations—the goal is improving quality of life, not complete pain relief.
Arrange a follow-up appointment to monitor medication changes and assess progress.

SUMMARY OF A COMPETENT ANSWER

Takes a structured pain history, covering physical symptoms, treatment history, and psychosocial impact.
Provides a clear and logical differential diagnosis, considering structural, neuropathic, and opioid-related pain.
Identifies red flag symptoms and refers appropriately if needed.
Develops a safe, patient-centred management plan, balancing opioid reduction, physiotherapy, psychological support, and lifestyle modifications.
Uses empathetic and reassuring communication, addressing opioid concerns, function-focused management, and return-to-work strategies.

PITFALLS

Failure to assess for red flag symptoms, potentially missing serious underlying pathology.
Over-reliance on opioids without offering alternative pain management strategies.
Not addressing psychological impacts, such as depression, anxiety, or work stress.
Lack of patient education, leading to unrealistic expectations about pain relief.
Not considering non-pharmacological treatments, such as exercise therapy and CBT.

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 and interprets relevant history, including biopsychosocial factors and functional impact.
2.2 Selects and justifies appropriate investigations for chronic pain assessment.

3. Diagnosis, Decision-Making and Reasoning

3.1 Forms a logical differential diagnosis based on clinical findings.
3.5 Identifies red flag symptoms requiring urgent referral.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based, patient-centred management plan.
4.3 Provides structured follow-up and medication review.

5. Preventive and Population Health

5.2 Addresses risk factors for opioid dependence and lifestyle modifications.

6. Professionalism

6.1 Maintains confidentiality and professional integrity.

7. General Practice Systems and Regulatory Requirements

7.1 Prescribes and manages medications in accordance with PBS and regulatory guidelines.

9. Managing Uncertainty

9.2 Develops a structured approach to a patient with unclear pain symptoms.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and acts on complications of chronic pain, including psychological impacts.

Competency at Fellowship Level

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