CCE-CE-043 - GP Exams

CASE INFORMATION

Case ID: CCE-2025-001
Case Name: John Matthews
Age: 52
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: P17 (Tobacco Abuse), Z27 (Health Risk Behaviour)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand their ideas, concerns, and expectations. 1.2 Uses motivational interviewing techniques. 1.5 Communicates risk effectively and facilitates behaviour change.
2. Clinical Information Gathering and Interpretation	2.1 Takes a targeted history of tobacco use, comorbidities, and readiness to quit. 2.2 Assesses the impact of smoking on physical and mental health.
3. Diagnosis, Decision-Making and Reasoning	3.1 Identifies tobacco use disorder and assesses nicotine dependence. 3.3 Considers differential diagnoses, including other risk behaviours and comorbid conditions.
4. Clinical Management and Therapeutic Reasoning	4.2 Develops a tailored smoking cessation plan using pharmacotherapy and behavioural strategies. 4.4 Provides follow-up support and relapse prevention strategies.
5. Preventive and Population Health	5.1 Explores smoking cessation in the context of broader preventive health strategies. 5.3 Provides education on smoking-related health risks and benefits of quitting.
6. Professionalism	6.2 Maintains a non-judgmental and patient-centred approach.
7. General Practice Systems and Regulatory Requirements	7.2 Provides information on available smoking cessation services, including Quitline and community programs.
9. Managing Uncertainty	9.1 Addresses patient ambivalence and explores barriers to quitting smoking.
10. Identifying and Managing the Patient with Significant Illness	10.2 Screens for and manages smoking-related illnesses such as COPD and cardiovascular disease.

CASE FEATURES

Middle-aged male with long-term tobacco use.
Strong ambivalence about quitting despite multiple previous attempts.
Patient is open to discussing options but reluctant to commit.
History of hypertension and mild COPD.
Concerns about stress management and weight gain if he quits.
Partner is a non-smoker and wants him to quit.

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 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 Matthews, a 52-year-old man, presents for a routine check-up.

He has been smoking since his late teens and currently smokes 20 cigarettes per day. He has tried to quit several times but has always relapsed within a few weeks. He expresses frustration about past failures and concern about weight gain and stress if he quits.

John has a history of mild COPD, diagnosed two years ago, and is on an as-needed bronchodilator. He also has hypertension, well controlled with an ACE inhibitor.

PATIENT RECORD SUMMARY

Patient Details

Name: John Matthews
Age: 52
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Ramipril 5mg daily
Salbutamol inhaler as needed

Past History

Hypertension (diagnosed 5 years ago)
Mild COPD (diagnosed 2 years ago)

Social History

Works as a project manager, high stress job
Drinks alcohol occasionally

Family History

Father: Died of lung cancer at 68 (heavy smoker)
Mother: Alive, hypertension

Smoking

20 cigarettes per day for 35 years

Alcohol

3-4 standard drinks per week

Vaccination and Preventative Activities

Received annual influenza vaccine
Up to date with routine immunisations

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

“I know I should quit, Doc, but I just don’t think I can do it.”

General Information

You are John Matthews, a 52-year-old man and are here for a routine check-up.

You are here because your partner, Susan made you come. She is a non-smoker and frequently reminds you about quitting, which you find annoying.

Specific Information

Smoking History

You have been smoking since your late teens.
You smoke about 20 cigarettes per day and have been doing so for over 35 years.
Your first cigarette is within 30 minutes of waking up, usually with your morning coffee.
You’re frustrated with past failures and worried that quitting will make you feel stressed and lead to weight gain.
You smoke after meals, when drinking alcohol, and during work breaks.
You feel irritable and restless if you go too long without a cigarette.
You have tried quitting at least five times, mostly using nicotine replacement therapy (patches and gum), but relapsed due to cravings and stress.
You attempted to quit cold turkey once but only lasted three days before relapsing.
You have never tried prescription medications like varenicline or bupropion.

Health Concerns

You have a mild morning cough that you dismiss as “just a bit of phlegm.”
You get short of breath with exertion but attribute it to “getting older.”
You recall your GP mentioning reduced lung function last year, but you haven’t noticed much difference.
Your father was a heavy smoker and died of lung cancer at 68, but you don’t think that necessarily means it will happen to you.
Your partner keeps warning you about the risks, which you find irritating.

Readiness to Quit

You rate your motivation to quit as 5/10 and your confidence in succeeding as 4/10.
You think you “should” quit but don’t feel ready.
You believe smoking helps you cope with stress at work.
You are concerned about gaining weight if you stop smoking.
You worry that quitting will make you feel irritable and affect your productivity.
You think quitting would be easier if you didn’t have a stressful job.
You are curious about new methods but skeptical they will work.

Emotional Cues and Body Language

At the start, you sit back with arms crossed, showing hesitation.
When discussing past quit attempts, you sound frustrated and discouraged.
When the doctor talks about health risks, you seem slightly defensive, brushing off concerns.
When discussing new quit strategies, you lean forward slightly, showing some interest.
If the doctor suggests realistic steps, you begin to engage more and nod occasionally.

Questions for the Candidate

If the doctor starts discussing quitting, you should ask the following questions in a natural, skeptical tone:

“What’s different this time? Why would this quit attempt work?”
- You have tried before and failed. You need to understand why this approach would be any better.
“I’ve tried patches and gum before – what else is there?”
- You are curious about other options but doubt anything will work.
“What if I gain weight or get too stressed without smoking?”
- You see smoking as a stress reliever and worry about putting on weight.
“How long will the cravings last?”
- You remember struggling with cravings in past attempts and want to know if they ever go away.

If the doctor provides reasonable answers and acknowledges your concerns, you become more receptive to discussing a gradual approach. However, if the doctor dismisses your worries or pressures you, you become more resistant.

Closing Thoughts

If the doctor engages well with you, acknowledges your concerns, and offers realistic options, you respond positively, saying:
“Alright, I’ll think about it. Maybe I could try something different this time.”

If the doctor is too pushy, you become defensive and say:
“I appreciate the advice, Doc, but I’m just not ready right now.”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including smoking habits, past quit attempts, and readiness to change.

The competent candidate should:

Use open-ended questions to explore John’s smoking history, including age of initiation, cigarettes per day, triggers, and dependency indicators (e.g. time to first cigarette).
Identify previous quit attempts, including methods used, duration of abstinence, reasons for relapse, and perceived effectiveness.
Assess nicotine dependence using indicators such as craving intensity, withdrawal symptoms, and failed attempts to cut down.
Explore motivational factors using a framework such as the Stages of Change Model (pre-contemplation, contemplation, preparation, action, maintenance).
Identify barriers to quitting, such as stress management, weight gain concerns, and lack of confidence.
Screen for comorbid conditions related to smoking, including COPD, cardiovascular disease, and mental health issues.

Task 2: Discuss the health risks of continued smoking and benefits of cessation.

The competent candidate should:

Provide patient-centred education on the risks of continued smoking, tailoring information to John’s personal health concerns.
Emphasise the impact on COPD progression, explaining how smoking accelerates lung function decline.
Discuss cardiovascular risks, linking smoking to hypertension, stroke, and heart disease.
Highlight the long-term benefits of cessation, including improved lung function, reduced cancer risk, and enhanced quality of life.
Use motivational interviewing techniques (e.g. reflective listening, evoking change talk) to strengthen John’s willingness to quit.
- 5As
- FLAGS
- FRAMES
- RULES & OARS

Task 3: Address the patient’s concerns and explore potential barriers to quitting.

The competent candidate should:

Acknowledge John’s previous struggles and validate his frustrations.
Address weight gain concerns by discussing healthy eating and exercise strategies.
Provide stress management alternatives, such as mindfulness, breathing exercises, and structured problem-solving techniques.
Explore social support and triggers, including partner involvement and workplace challenges.
Assess psychological readiness and explore past triggers for relapse.
Reframe the quit attempt as an opportunity for lifestyle improvement, rather than a source of stress.

Task 4: Develop a patient-centred smoking cessation plan, including pharmacological and non-pharmacological strategies.

The competent candidate should:

Tailor a multi-modal quit plan using a combination of non-pharmacological, pharmacolocial, behavioural support, and follow-up.
Provide non-pharmacological support, such as:
- Quitline referral (13 7848) for ongoing behavioural counselling.
- Cognitive behavioural therapy (CBT)-based strategies to manage cravings and triggers.
- Digital health resources, such as the My QuitBuddy app (Australian Department of Health).
Offer pharmacological options including:
- Nicotine replacement therapy (NRT) (e.g. patches, gum, lozenges) for gradual withdrawal.
- Varenicline (Champix) or bupropion (Zyban) if suitable and not contraindicated.
Arrange structured follow-up at 1, 2, and 4 weeks post-quit date for relapse prevention.
Use positive reinforcement to highlight progress and address setbacks proactively.

SUMMARY OF A COMPETENT ANSWER

Comprehensive history-taking covering smoking patterns, past quit attempts, and readiness to change.
Use of motivational interviewing to explore John’s ambivalence, motivations, and barriers.
Clear explanation of health risks with a patient-centred focus on COPD, cardiovascular disease, and quality of life.
Empathetic response to concerns about stress, weight gain, and previous failures.
Structured quit plan incorporating pharmacotherapy, behavioural support, and follow-up strategies.
Referral to support services, such as Quitline and community programs.

PITFALLS

Failing to explore past quit attempts in sufficient detail, missing key triggers for relapse.
Overloading the patient with risks without personalising the discussion to his specific health concerns.
Dismissing John’s concerns about weight gain and stress, leading to resistance.
Recommending a generic quit plan without tailoring to the patient’s needs and preferences.
Lack of follow-up planning, reducing long-term success rates.

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.
1.5 Communicates risk effectively and facilitates behaviour change.

2. Clinical Information Gathering and Interpretation

2.1 Takes a targeted history of tobacco use, comorbidities, and readiness to quit.
2.2 Assesses the impact of smoking on physical and mental health.

3. Diagnosis, Decision-Making and Reasoning

3.1 Identifies tobacco use disorder and assesses nicotine dependence.
3.3 Considers differential diagnoses, including other risk behaviours and comorbid conditions.

4. Clinical Management and Therapeutic Reasoning

4.2 Develops a tailored smoking cessation plan using pharmacotherapy and behavioural strategies.
4.4 Provides follow-up support and relapse prevention strategies.

5. Preventive and Population Health

5.1 Explores smoking cessation in the context of broader preventive health strategies.
5.3 Provides education on smoking-related health risks and benefits of quitting.

6. Professionalism

6.2 Maintains a non-judgmental and patient-centred approach.

7. General Practice Systems and Regulatory Requirements

7.2 Provides information on available smoking cessation services, including Quitline and community programs.

9. Managing Uncertainty

9.1 Addresses patient ambivalence and explores barriers to quitting smoking.

10. Identifying and Managing the Patient with Significant Illness

10.2 Screens for and manages smoking-related illnesses such as COPD and cardiovascular disease.

Competency at Fellowship Level

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