CASE INFORMATION

Case ID: CCE-2025-08
Case Name: Sarah Mitchell
Age: 36
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: S82 (Neoplasm skin, benign/unspecified)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and engages with the patient empathetically. 1.2 Uses clear, patient-centred language to discuss the skin lesion. 1.4 Elicits the patient’s ideas, concerns, and expectations.
2. Clinical Information Gathering and Interpretation	2.1 Takes a structured skin lesion history, identifying red flags. 2.2 Performs risk assessment for skin cancer based on patient history. 2.3 Differentiates benign vs. suspicious lesions using the ABCDE criteria.
3. Diagnosis, Decision-Making and Reasoning	3.1 Recognises common benign skin lesions (e.g., seborrhoeic keratosis, dermatofibroma). 3.3 Determines when excision, biopsy, or referral to a dermatologist is required.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an appropriate management plan based on clinical findings. 4.3 Provides patient education on monitoring skin changes. 4.5 Refers appropriately if a malignant lesion is suspected.
5. Preventive and Population Health	5.2 Discusses skin cancer prevention and sun safety strategies.
6. Professionalism	6.1 Ensures empathetic and non-judgemental communication.
7. General Practice Systems and Regulatory Requirements	7.2 Follows appropriate guidelines for skin lesion assessment and excision.
9. Managing Uncertainty	9.1 Recognises when lesions require monitoring vs. biopsy.
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies red flag features suggesting malignancy.

CASE FEATURES

Young woman presenting with a skin lesion of uncertain significance.
Distinguishing between benign and malignant skin lesions.
Discussing risk factors for skin cancer.
Balancing reassurance with appropriate investigation/referral.
Providing sun safety education and preventive strategies.

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

Sarah Mitchell, a 36-year-old teacher, presents with a new mole on her right shoulder, which she first noticed three months ago. She is worried it could be melanoma because it looks darker than her other moles.

She has no personal or family history of skin cancer, but she spent a lot of time outdoors in her teens and twenties and has had multiple sunburns in the past.

PATIENT RECORD SUMMARY

Patient Details

Name: Sarah Mitchell
Age: 36
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Nil regular medications

Past History

No history of skin cancer
Multiple childhood and teenage sunburns

Family History

No family history of melanoma or non-melanoma skin cancers

Smoking and Alcohol

Non-smoker
Drinks alcohol socially (1–2 drinks per week)

Vaccination and Preventative Activities

Routine vaccinations up to date

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

“Doctor, I’ve noticed a new mole on my shoulder, and I’m really worried. Could it be skin cancer?”

General Information

You are Sarah Mitchell, a 36-year-old primary school teacher. About three months ago, you noticed a new, dark mole on your right shoulder while looking in the mirror. You don’t remember having it before, and it looks different from your other moles.

The mole is small but darker than the other freckles and moles on your skin. It hasn’t been itchy or painful, but you feel like it might have grown slightly over the past few months. You haven’t noticed any bleeding, crusting, or colour changes, but you’re still worried because you’ve never paid much attention to your moles before.

Specific Information

(Revealed When Asked)

Background Information

You spend a lot of time outdoors—as a child, you played outside a lot, and in your 20s, you loved going to the beach and hiking. You got sunburned multiple times, especially in your teenage years, when you didn’t wear sunscreen regularly. You don’t use tanning beds, but you have fair skin that burns easily.

A friend recently had a skin cancer scare, which made you more aware of your skin. You looked online and read about melanoma, and now you’re worried this could be a sign of skin cancer.

Lesion Characteristics:

Location: Right shoulder.
Size: You’re not sure, but it’s a little bigger than a freckle.
Colour: Darker than your other moles, but not black.
Shape: You can’t tell if it’s perfectly round, but it doesn’t look completely irregular.
Symptoms: No pain, bleeding, or itching.
Change over time: It might have grown slightly, but it hasn’t changed dramatically.

Risk Factors:

Frequent sun exposure as a child and young adult.
Multiple sunburns in childhood and teenage years.
No family history of melanoma or skin cancer.
Fair skin that burns easily.
No previous history of abnormal skin lesions or biopsies.

Psychosocial Impact:

You are anxious because you don’t know what to look for in a mole.
You have started checking your skin more often since noticing this mole.
You are worried that all your past sun exposure has caused permanent damage.

Emotional Cues and Body Language

Slightly anxious and leans forward when discussing concerns.
Seeks reassurance but also wants a clear, definitive answer.
Becomes more nervous if the doctor mentions biopsy or removal.
Feels reassured if the doctor explains things clearly but will still ask, “Are you sure?”

Patient Concerns and Questions

1. “Do you think this is skin cancer?”

You want a direct, confident answer.
If the doctor says “Probably not,” you will ask, “Then why does it look different?”
If the doctor suggests monitoring, you will ask, “How do I know if it changes?”

2. “Should I get this removed?”

You expect the doctor to suggest biopsy or removal if there’s any doubt.
If the doctor recommends monitoring, you will ask, “Wouldn’t it be safer just to take it off?”

3. “How do I know if a mole is dangerous?”

You want to understand what signs to look for, especially if you develop new moles in the future.

4. “What else can I do to prevent skin cancer?”

You want practical sun protection advice.
If the doctor says to avoid the sun, you will ask, “But I love being outdoors—what should I do?”

5. “If I’ve had so much sun exposure, does this mean I’m at higher risk?”

You’re concerned about your long-term skin cancer risk.
If the doctor reassures you, you will ask, “Should I start getting regular skin checks?”

Possible Reactions Based on the Doctor’s Approach

If the doctor reassures you with clear explanations:

You feel relieved but may still ask for monitoring advice.
You agree to follow-up if needed.

If the doctor dismisses your concerns too quickly:

You insist on a biopsy or removal.
You might say, “I’d rather be safe than sorry.”

If the doctor explains skin cancer risks well and suggests preventive strategies:

You engage in discussion about sun protection and are open to regular skin checks.

If the doctor mentions biopsy/removal without explanation:

You become nervous and ask, “Does this mean you think it’s cancer?”

Your Expectations from This Consultation

You want to know if this mole is dangerous—is it normal or concerning?
You need reassurance but also a clear plan for what to do next.
You expect some form of examination or testing, not just verbal reassurance.
You want to know how to prevent skin cancer in the future.
You don’t want to be dismissed, but you also don’t want unnecessary procedures.

End of Consultation Cues

If the doctor provides a clear explanation and plan, you feel relieved and reassured.
If the doctor brushes off your concerns, you push for further investigation.
If the doctor recommends monitoring, you will ask, “How often should I check it?”
If the doctor suggests removal, you will want to know how the procedure works and whether it will leave a scar.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including lesion characteristics, risk factors, and concerns.

The competent candidate should:

Elicit a structured history of the skin lesion, including:
- Onset, duration, and changes over time (size, colour, shape, symptoms).
- Associated symptoms (itching, pain, bleeding, ulceration).
- Previous similar lesions or skin conditions.
Assess risk factors for skin cancer, including:
- Personal and family history of melanoma or non-melanoma skin cancer.
- Sun exposure history, including childhood sunburns, outdoor activities, tanning bed use.
- Skin type (fair skin, tendency to burn, freckling).
Explore patient concerns and expectations, including:
- “What worries you most about this mole?”
- “What do you know about skin cancer?”
- “Are you hoping to have this removed today?”

Task 2: Formulate a differential diagnosis, distinguishing between benign and malignant skin lesions.

The competent candidate should:

Differentiate between benign and malignant skin lesions:
- Benign:
  - Seborrhoeic keratosis – stuck-on appearance, waxy, rough texture.
  - Dermatofibroma – firm, dimple sign present, common on extremities.
  - Intradermal naevus – symmetrical, uniform colour, stable over time.
- Malignant or pre-malignant:
  - Melanoma – irregular shape, multiple colours, recent growth.
  - Basal cell carcinoma (BCC) – pearly, ulcerating, slow-growing.
  - Squamous cell carcinoma (SCC) – scaly, rapidly growing, tender.
Use ABCDE criteria to assess suspicious moles:
- Asymmetry, Border irregularity, Colour variation, Diameter >6mm, Evolving features.
Determine need for biopsy or referral based on clinical suspicion.

Task 3: Explain the likely diagnosis to the patient, addressing concerns empathetically.

The competent candidate should:

Acknowledge patient concerns:
- “I understand that noticing a new mole can be worrying, and it’s good that you’ve come in for assessment.”
Explain the most likely diagnosis based on history and examination:
- “Based on what I see, this mole does not have features concerning for melanoma, but we will monitor it closely.”
Reassure while explaining the need for further steps:
- “If a mole changes in shape, size, or colour, or starts to bleed, we would consider a biopsy.”
Provide patient education on skin monitoring:
- “It’s important to check your skin regularly and take photos for comparison.”
Ensure patient understanding using teach-back techniques.

Task 4: Develop a management plan, including monitoring, biopsy, excision, or referral as appropriate.

The competent candidate should:

Short-term management:
- If the lesion is clearly benign, reassure and advise self-monitoring.
- If uncertain, arrange dermatoscopy and possible biopsy.
Long-term preventive care:
- Educate on sun safety, including sunscreen use, protective clothing, avoiding peak UV hours.
- Encourage regular skin checks, especially given past sunburn history.
Referral pathway if malignancy suspected:
- Urgent dermatology referral for suspected melanoma.
- Biopsy or excision in general practice if appropriate.
Safety-netting and follow-up:
- “If you notice any changes in this or other moles, return for review.”
- “If biopsy is done, we will follow up with the results and discuss next steps.”

SUMMARY OF A COMPETENT ANSWER

Takes a structured history, assessing risk factors and lesion characteristics.
Differentiates between benign and malignant skin lesions, using clinical criteria.
Provides a clear, empathetic explanation, addressing patient concerns.
Develops an appropriate management plan, including monitoring, biopsy, or referral.
Offers preventive care and sun safety advice, ensuring long-term skin health.

PITFALLS

Failing to assess risk factors thoroughly, missing an at-risk patient.
Overlooking red flag signs, delaying necessary biopsy or referral.
Reassuring the patient too quickly without a clear follow-up plan.
Not educating the patient on skin self-examination and sun protection.
Unnecessary excision of clearly benign lesions, causing patient anxiety.

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

Competency Areas Assessed

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 comprehensive history of the skin lesion and associated risk factors.
2.2 Identifies risk factors for skin cancer and the need for further investigation.
2.3 Differentiates between benign and malignant lesions using clinical criteria.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises common benign skin lesions.
3.3 Determines when biopsy or referral to a dermatologist is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate management plan, including monitoring or excision.
4.3 Provides patient-centred education on skin health and prevention.
4.5 Refers for specialist assessment if needed.

5. Preventive and Population Health

5.2 Discusses sun protection strategies and regular skin checks.

7. General Practice Systems and Regulatory Requirements

7.2 Follows appropriate guidelines for skin lesion assessment and excision.

Competency at Fellowship Level

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