CASE INFORMATION

Case ID: CCE-2025-10
Case Name: Mark Davidson
Age: 54
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: D29 (Disease of mouth/tongue/lip)

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 explore symptoms and concerns. 1.4 Elicits the patient’s ideas, concerns, and expectations.
2. Clinical Information Gathering and Interpretation	2.1 Takes a structured oral health history, identifying risk factors. 2.2 Identifies possible benign, infectious, inflammatory, and malignant causes of oral lesions. 2.3 Determines the need for further investigations (e.g., biopsy, imaging).
3. Diagnosis, Decision-Making and Reasoning	3.1 Recognises red flag features for oral malignancy. 3.3 Differentiates between self-limiting and serious conditions requiring urgent referral.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an appropriate management plan based on clinical findings. 4.3 Provides patient education on oral hygiene, lifestyle modification, and monitoring. 4.5 Refers to a dentist, ENT specialist, or oral surgeon if indicated.
5. Preventive and Population Health	5.2 Discusses smoking and alcohol cessation to reduce oral disease risk.
6. Professionalism	6.1 Ensures empathetic and non-judgemental communication.
7. General Practice Systems and Regulatory Requirements	7.2 Follows appropriate guidelines for suspected oral malignancy referrals.
9. Managing Uncertainty	9.1 Recognises when lesions require monitoring vs. biopsy.
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies oral conditions requiring urgent intervention (e.g., oral cancer, severe infections).

CASE FEATURES

Middle-aged man presenting with a persistent oral lesion.
Risk factors for oral disease, including smoking and alcohol use.
Distinguishing between benign, infectious, inflammatory, and malignant causes.
Addressing patient anxiety about oral cancer.
Discussing lifestyle changes and appropriate referral pathways.

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

Mark Davidson, a 54-year-old truck driver, presents with a non-healing ulcer on the side of his tongue that he first noticed six weeks ago. He initially thought it was caused by accidentally biting his tongue, but it hasn’t gone away and feels rough to the touch. It is not particularly painful, but it sometimes stings when eating spicy or hot food.

PATIENT RECORD SUMMARY

Patient Details

Name: Mark Davidson
Age: 54
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Perindopril 5 mg OD (for hypertension)

Past History

Hypertension (well controlled)
No prior history of oral conditions or cancers

Family History

Father had lung cancer at 68
No known family history of oral cancer

Smoking and Alcohol

Smokes 10 cigarettes per day for the past 30 years.
Drinks alcohol regularly (4–5 standard drinks on weekends).

Social History

Works full-time as a truck driver, long hours on the road.

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 got this ulcer on my tongue that hasn’t gone away, and I’m worried it could be cancer.”

General Information

You are Mark Davidson, a 54-year-old truck driver. You noticed a small sore on the side of your tongue about six weeks ago, and it hasn’t healed. You thought it might be from accidentally biting your tongue, but it still feels rough and sore, especially when you eat spicy or hot foods.

You’ve had mouth ulcers before, but they usually heal within a week or so. This one is different because it’s not going away. It doesn’t hurt much, but it feels irritated at times.

Specific Information

(Revealed When Asked)

Background Information

You are worried about oral cancer because you smoke daily and drink on weekends. You’ve looked online, and some pictures of oral cancer look similar to what you have. That has made you more anxious. You know smoking is bad, but quitting has always seemed too hard, and you haven’t seriously tried before.

You’ve been putting off seeing a doctor, but your friend convinced you to get it checked.

Lesion Characteristics:

Size: About 5–7 mm, with slightly raised edges.
Location: Left side of the tongue, near the middle.
Colour: White with some red areas.
Pain: Mild stinging when eating certain foods but otherwise not painful.
Changes over time: No major changes, but it hasn’t gone away.
No pus, bleeding, or foul smell from the lesion.

Associated Symptoms:

No swollen lymph nodes in the neck.
No difficulty swallowing or chewing.
No unexplained weight loss.
No numbness or tingling in the mouth.

Risk Factors:

Smokes 10 cigarettes per day, since age 20 (30 pack-year history).
Drinks 4–5 standard drinks per weekend.
Diet is not great—eats a lot of takeaway while on the road.
Rarely sees a dentist—last dental check-up was over three years ago.

Psychosocial Impact:

Worried about cancer—you saw pictures online, and now you’re scared.
Feeling guilty about smoking but unsure about quitting.
Stressed about work—you drive long hours, and this has been another worry.

Emotional Cues and Body Language

Nervous—you have read about oral cancer and are worried.
Looks for reassurance but also wants honesty.
Gets anxious if the doctor mentions biopsy or further tests.
Defensive about smoking if pushed too hard but willing to discuss it.
Frustrated if dismissed—wants a clear plan.

Patient Concerns and Questions

1. “Is this cancer?”

You want a direct answer but understand that tests may be needed.
If the doctor says “It’s unlikely but we need to check,” you will ask, “So how do we find out for sure?”

2. “Why hasn’t this healed?”

You have had mouth ulcers before, but they always healed within a week.
If the doctor suggests irritation or infection, you will ask, “So why has this one lasted so long?”

3. “Should I get this cut out?”

You expect the doctor to suggest a biopsy or removal if they are concerned.
If the doctor says it can be monitored, you will ask, “But what if it’s something bad? Shouldn’t we just take it off?”

4. “Is smoking causing this?”

You feel guilty about smoking, but quitting has always seemed too hard.
If the doctor strongly advises quitting, you will say, “I know it’s bad, but I don’t know if I can stop. What else can I do?”

5. “What happens if this is cancer?”

You are thinking ahead and want to know the next steps if this is serious.
If the doctor says they are referring you, you will ask, “What happens after that?”

Possible Reactions Based on the Doctor’s Approach

If the doctor reassures you but still explains the need for tests:

You feel relieved but understand why a biopsy or referral is needed.
You will say, “Okay, I guess it’s better to be safe than sorry.”

If the doctor dismisses your concerns too quickly:

You push for more tests, saying “I don’t want to ignore this if it could be serious.”

If the doctor strongly advises quitting smoking without support:

You become defensive, saying “I know smoking is bad, but I can’t just quit overnight.”

If the doctor offers practical smoking cessation options:

You are more open to discussing Nicotine Replacement Therapy (NRT) or cutting down gradually.

Your Expectations from This Consultation

You want to know if this could be cancer—you don’t want to be left wondering.
You expect a plan, whether that’s biopsy, referral, or monitoring.
You are open to stopping smoking but need realistic help.
You need to feel heard—you don’t want your concerns dismissed.

End of Consultation Cues

If the doctor explains things clearly and provides a plan, you feel reassured.
If the doctor brushes off your concerns, you push for more investigation.
If the doctor talks about smoking cessation realistically, you are willing to consider small changes.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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

The competent candidate should:

Elicit a detailed history of the oral lesion, including:
- Onset, duration, and changes over time (e.g., non-healing ulcer for six weeks).
- Size, colour, and associated symptoms (e.g., stinging with spicy foods).
- Previous similar lesions, history of trauma (e.g., biting tongue), or recurrent ulcers.
Assess risk factors for oral malignancy, including:
- Smoking history (10 cigarettes/day for 30 years = 30 pack-years).
- Alcohol use (4–5 drinks per weekend).
- Poor oral hygiene or infrequent dental visits.
- Family history of head and neck cancers.
Explore patient concerns and expectations, including:
- “What do you think might be causing this?”
- “Are you worried about cancer?”
- “What are you hoping to achieve from today’s consultation?”

Task 2: Formulate a differential diagnosis, distinguishing between benign, infectious, inflammatory, and malignant causes.

The competent candidate should:

Consider key differential diagnoses:
- Benign conditions:
  - Traumatic ulcer (history of tongue biting, rough dental edges).
  - Lichen planus (chronic inflammatory condition, white striations).
  - Aphthous ulcer (self-limiting, painful, round with erythematous halo).
- Infectious causes:
  - Oral candidiasis (white plaques that scrape off, seen in immunosuppression).
  - Syphilitic ulcer (chancre) (painless, history of high-risk sexual activity).
- Malignancy (must be excluded):
  - Squamous cell carcinoma (SCC) (persistent, non-healing ulcer, risk factors present).
  - Erythroplakia (red patch, high malignant potential).
Determine red flags requiring urgent investigation, including:
- Ulcer present >3 weeks.
- Non-healing lesion with indurated edges.
- Painless lesion with risk factors (smoking, alcohol).
- Associated neck lymphadenopathy.

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

The competent candidate should:

Acknowledge patient concerns:
- “I understand that having a sore that won’t heal is worrying, especially given your smoking and alcohol history.”
Explain that a definitive diagnosis requires further investigation:
- “There are many possible causes, including irritation from accidental biting, infections, or chronic inflammatory conditions.”
- “However, given that this ulcer has not healed in six weeks, we need to rule out more serious causes, including oral cancer.”
Reassure without dismissing the concern:
- “Most mouth ulcers heal on their own within two weeks, so it’s important we investigate further since this one has persisted.”
Discuss next steps clearly:
- “We will arrange a biopsy or refer you to an oral specialist to determine what this lesion is.”

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

The competent candidate should:

Immediate steps:
- Refer for urgent biopsy and specialist review (suspected oral malignancy).
- Arrange an oral examination with a dentist or ENT specialist.
- Check for regional lymphadenopathy, which may indicate metastasis.
Long-term management:
- Smoking cessation support:
  - “Stopping smoking will significantly reduce your risk of oral cancer.”
  - Offer Nicotine Replacement Therapy (NRT), Quitline referral, or pharmacotherapy (e.g., varenicline, bupropion).
- Alcohol reduction advice:
  - Discuss safe drinking guidelines and the role of alcohol in oral cancer risk.
- Oral hygiene improvement:
  - Recommend regular dental check-ups.
Safety-netting and follow-up:
- “We will follow up as soon as biopsy results are available.”
- “If you develop difficulty swallowing, pain, or swelling, return urgently.”

SUMMARY OF A COMPETENT ANSWER

Takes a structured history, assessing lesion characteristics and risk factors.
Considers a broad differential diagnosis, distinguishing between benign and malignant causes.
Provides a clear, empathetic explanation, addressing patient anxiety.
Develops an appropriate management plan, including biopsy, referral, and risk factor modification.
Discusses preventive strategies, including smoking cessation and alcohol reduction.

PITFALLS

Failing to identify red flag symptoms, leading to delayed diagnosis.
Reassuring the patient without arranging further investigation.
Not considering malignancy in a high-risk patient.
Neglecting to address smoking and alcohol as modifiable risk factors.
Not arranging urgent referral or biopsy for a persistent lesion.

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 oral lesion and associated risk factors.
2.2 Identifies risk factors for oral malignancy and need for further investigation.
2.3 Differentiates between benign, infectious, inflammatory, and malignant causes.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises red flag features for oral malignancy.
3.3 Differentiates between self-limiting and serious conditions requiring urgent referral.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate management plan, including biopsy and referral.
4.3 Provides patient-centred education on oral hygiene, lifestyle modification, and monitoring.
4.5 Refers to a dentist, ENT specialist, or oral surgeon if indicated.

5. Preventive and Population Health

5.2 Discusses smoking and alcohol cessation to reduce oral disease risk.

7. General Practice Systems and Regulatory Requirements

7.2 Follows appropriate guidelines for suspected oral malignancy referrals.

Competency at Fellowship Level

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