Case Information
- Case ID: PR-006
- Patient Name: Michael Dawson
- Age: 38
- Gender: Male
- Indigenous Status: Non-Indigenous
- Year: 2025
- ICPC-2 Codes: -50 – Medication Prescription/Request/Renewal
Competency Outcomes
| Competency Domain | Competency Element |
|---|---|
| 1. Communication and Consultation Skills | Establishing rapport, clarifying the reason for the prescription request, and addressing patient concerns |
| 2. Clinical Information Gathering and Interpretation | Taking a structured history to assess medication appropriateness, compliance, and adverse effects |
| 3. Diagnosis, Decision-Making and Reasoning | Evaluating whether the requested medication is clinically indicated and safe for continued use |
| 4. Clinical Management and Therapeutic Reasoning | Ensuring evidence-based prescribing practices and considering alternative treatment options where appropriate |
| 5. Preventive and Population Health | Identifying potential medication overuse, dependence, or need for deprescribing |
| 6. Professionalism | Practising ethical prescribing and adhering to regulatory guidelines for controlled substances |
| 7. General Practice Systems and Regulatory Requirements | Ensuring compliance with PBS guidelines, SafeScript (if applicable), and prescription monitoring regulations |
| 9. Managing Uncertainty | Addressing medication safety concerns and discussing potential need for specialist review |
| 10. Identifying and Managing the Patient with Significant Illness | Recognising when medication misuse or an undiagnosed condition requires further investigation |
Case Features
- No history of substance use disorder but worried about increasing reliance on diazepam.
- 38-year-old IT consultant requesting a repeat prescription for diazepam (5mg PRN), initially prescribed for acute anxiety three months ago.
- Reports ongoing stress at work and difficulty sleeping but has not engaged in psychological therapy as previously advised.
- Admits to using diazepam 4-5 times per week, concerned about dependence but prefers medication over counselling.
- Has a past history of depression (treated with sertraline for 2 years, now ceased) and social alcohol use (4-5 drinks on weekends).
Candidate Information
Instructions
The candidate is expected to review the following patient record and scenario. The examiner will ask a series of questions based on this information. The candidate has 15 minutes to complete this case.
The approximate time allocation for each question:
- Question 1: 3 minutes
- Question 2: 3 minutes
- Question 3: 3 minutes
- Question 4: 3 minutes
- Question 5: 3 minutes
Patient Record Summary
Patient Details
- Name: Michael Dawson
- Age: 38
- Gender: Male
- Indigenous Status: Non-Indigenous
Allergies and Adverse Reactions
- No known drug allergies
Medications
- Diazepam 5mg PRN, last script 3 months ago
- Previously on sertraline 50mg daily, ceased 1 year ago
Past History
- Generalised anxiety disorder, diagnosed 3 years ago
- Depression (resolved, no active treatment)
- No history of substance use disorder
Social History
- Works as an IT consultant, high stress, long hours
- Lives alone, limited social support
- Alcohol use: 4-5 drinks on weekends
- No illicit drug use reported
Family History
- Father had alcohol dependence
- No family history of psychiatric illness
Vaccination and Preventive Activities
- Influenza vaccine: Up to date
- COVID-19 booster: Received
Scenario
Michael Dawson, a 38-year-old IT consultant, presents requesting a repeat prescription for diazepam (5mg PRN), initially prescribed three months ago for acute anxiety and sleep issues.
He reports ongoing work stress and difficulty sleeping, using diazepam 4-5 times per week, and acknowledges concern about reliance but prefers medication over therapy.
He has no illicit drug use history but drinks alcohol socially (4-5 drinks on weekends).
On assessment:
- Mental State Exam:
- Mood: Anxious, slightly restless
- Affect: Concerned but engaged
- Thought process: Logical, no delusions
- Sleep: Poor, difficulty initiating sleep
- Suicidal ideation: Denies any current suicidal thoughts
Key issues to address:
- Potential risk of medication dependence
- Appropriateness of benzodiazepine continuation
- Alternative anxiety management strategies
THE COMPETENT CANDIDATE
The competent candidate should be able to:
Q1. How would you assess the appropriateness of continuing diazepam for this patient?
The competent candidate should:
- Conduct a comprehensive medication review, considering indication, duration, efficacy, and safety of diazepam.
- Recognise benzodiazepine use beyond 2-4 weeks increases risk of dependence, tolerance, and withdrawal symptoms.
- Assess for signs of dependence using DSM-5 criteria:
- Increased use over time (now using 4-5 times per week).
- Psychological reliance (prefers medication over therapy).
- Withdrawal symptoms when not using the drug.
- Explore co-existing factors that influence prescribing decisions, including:
- Alcohol use (4-5 drinks on weekends), family history of alcohol dependence.
- Previous generalised anxiety disorder (GAD) and past depression.
- Impact of stress, sleep issues, and coping strategies.
- Identify red flags for misuse:
- Escalating dose requests or running out early.
- Seeking multiple prescribers or reluctance to discuss alternatives.
- Ensure PBS and SafeScript compliance, checking previous prescribing records and any signs of doctor-shopping.
- Determine if continued benzodiazepine use is justified, considering risks versus benefits and need for alternative management.
SUMMARY OF A COMPETENT ANSWER
- Comprehensive medication review including usage pattern, efficacy, and side effects.
- Screening for benzodiazepine dependence using DSM-5 criteria.
- Assessment of underlying anxiety, alcohol use, and psychosocial factors.
- Identifying red flags for misuse or escalating use.
- Regulatory compliance (SafeScript, PBS prescribing criteria).
PITFALLS
- Failing to assess for dependence or misuse despite long-term use.
- Not considering safer alternative treatments (e.g., psychological therapy, SSRIs).
- Ignoring regulatory requirements such as SafeScript monitoring.
- Simply renewing the prescription without reassessment.
REFERENCES
- RACGP Guide to Prescribing Benzodiazepines
- Australian Prescriber on Benzodiazepine Dependence Management
- National Institutes of Health on Psychotropic Prescribing
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.
1.3 Engages the patient to discuss their medication use and concerns.
2. Clinical Information Gathering and Interpretation
2.1 Takes a structured and hypothesis-driven history.
2.3 Screens for risk factors, including medication dependence.
3. Diagnosis, Decision-Making and Reasoning
3.1 Identifies key clinical features supporting or opposing continued prescribing.
3.5 Uses clinical reasoning to determine an appropriate management plan.
7. General Practice Systems and Regulatory Requirements
7.1 Adheres to PBS and SafeScript prescribing guidelines.
Competency at Fellowship Level
☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD