CASE INFORMATION

Case ID: 2025-03-DD001
Case Name: Michael Johnson
Age: 52
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: D99 (Disease digestive system NOS)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to gather information about their symptoms, concerns, and expectations. 1.2 Explains medical information in a patient-centred way. 1.4 Demonstrates active listening and empathy.
2. Clinical Information Gathering and Interpretation	2.1 Elicits a focused, hypothesis-driven history. 2.2 Identifies red flags in gastrointestinal disease.
3. Diagnosis, Decision-Making and Reasoning	3.1 Formulates a differential diagnosis based on clinical findings. 3.3 Recognises when urgent investigation is required.
4. Clinical Management and Therapeutic Reasoning	4.2 Develops an appropriate management plan. 4.4 Considers lifestyle and dietary factors in management.
5. Preventive and Population Health	5.1 Identifies modifiable risk factors for digestive health. 5.3 Provides dietary and lifestyle advice for gut health.
6. Professionalism	6.1 Respects patient autonomy and confidentiality.
7. General Practice Systems and Regulatory Requirements	7.2 Orders appropriate investigations based on clinical presentation.
9. Managing Uncertainty	9.1 Recognises when symptoms are vague and require monitoring.
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies features suggestive of a serious underlying pathology.

CASE FEATURES

Middle-aged male presenting with chronic intermittent abdominal discomfort, bloating, and altered bowel habits.
No clear diagnosis yet; needs structured assessment and exclusion of serious pathology.
Requires consideration of red flags and appropriate investigation.
Discussion around diet, lifestyle, and follow-up.

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

Michael Johnson, a 52-year-old accountant, presents with a three-month history of vague digestive symptoms, including intermittent abdominal discomfort, bloating, and a change in bowel habits. He describes alternating constipation and diarrhoea, but denies any severe pain, vomiting, or weight loss.

PATIENT RECORD SUMMARY

Patient Details

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

Allergies and Adverse Reactions

Nil known

Medications

Past History

Nil significant

Social History

Accountant, sedentary lifestyle

Family History

Father had colorectal cancer at age 58
Mother has hypertension

Smoking

Non-smoker

Alcohol

Occasional (2-3 standard drinks/week)

Vaccination and Preventative Activities

Up to date with routine 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, I’ve been having stomach issues for months now. My bowels are all over the place, and I’m starting to worry.”

General Information

You are Michael Johnson, a 52-year-old accountant.
You have been experiencing digestive issues for three months, and they seem to be getting worse.
Your main symptoms are bloating, mild abdominal cramping, and alternating constipation and loose stools.
You haven’t noticed any blood in your stools, but they seem different in texture and frequency.

Specific Information

(Revealed When Asked)

Background Information

You haven’t had any fevers, nausea, or vomiting.
Your energy levels are normal, though you sometimes feel sluggish after eating.
Your diet is high in processed food and low in fibre, but you never thought that could be a problem before.
You don’t exercise much because you sit at a desk all day for work.
You drink two to three standard drinks per week and don’t smoke.

Concerns and Emotional State

You are worried this could be bowel cancer, especially because your father was diagnosed with colorectal cancer at 58.
You have not had a colonoscopy before, and you are anxious that you might need one.
You are feeling stressed, and you wonder if stress could be making your symptoms worse.
You have tried cutting out dairy for a couple of weeks, but it didn’t seem to make a difference.
You have searched online and read about irritable bowel syndrome (IBS), but you’re not sure if that’s what you have.
You’re also wondering if you could have a food intolerance, like gluten sensitivity.

Key Symptoms to Reveal When Asked

Abdominal pain: A dull, cramping discomfort, mainly in the lower abdomen. It doesn’t wake you up at night.
Bowel habits: Some days you have hard stools, other days you have loose stools. You’ve noticed more urgency to go lately.
Appetite and weight: Your appetite is normal, and you haven’t lost any weight.
Stress: You are under a lot of pressure at work, and you wonder if stress could be contributing to this.
Triggers: You have noticed that your symptoms are worse after eating large meals, but there isn’t a clear pattern with specific foods.
Exercise: You don’t exercise regularly, and you wonder if that could be affecting your digestion.

Questions to Ask the Candidate

(You don’t need to ask all of these, but try to ask at least three naturally during the conversation.)

“Could this be bowel cancer?” – You are particularly anxious about this because of your family history.
“Do I need a colonoscopy?“ – You’re worried about the procedure but will do it if necessary.
“Could stress be making this worse?“ – You’ve read that stress can affect digestion, and you think this might be relevant.
“Is there anything I can do to fix this myself?” – You want practical advice on diet, exercise, and lifestyle changes.

Emotional Responses and Cues

At the start: You appear worried and slightly tense. You are looking for reassurance but also clear advice.
If the doctor is dismissive or vague: You might look frustrated or unconvinced, saying something like, “I feel like I need more answers.”
If the doctor takes your concerns seriously and provides clear explanations: You will gradually become more relaxed and engaged.
If a colonoscopy is suggested: You might hesitate and say, “I’ve never had one before… is it really necessary?” before accepting the recommendation if properly explained.
If lifestyle changes are suggested: You will be open to trying them, especially if they seem reasonable and practical.

Final Thoughts

You want to feel reassured but also need a clear action plan.
You would appreciate concrete advice on whether dietary changes, stress management, or medical tests are needed.
You are willing to follow up in a few weeks if needed.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including relevant risk factors and red flags.

The competent candidate should:

Use open-ended questions to elicit a detailed gastrointestinal history, including symptom duration, severity, triggers, and relieving factors.
Explore red flags: weight loss, rectal bleeding, persistent diarrhoea, nocturnal symptoms, anaemia, or family history of malignancy.
Take a detailed dietary, lifestyle, and psychosocial history, including alcohol, smoking, stress, and exercise levels.
Investigate medication use (e.g., NSAIDs, antibiotics) and recent travel history.
Assess the impact of symptoms on daily life, work, and mental health.

Task 2: Formulate a differential diagnosis and discuss key concerns with the patient.

The competent candidate should:

Consider common diagnoses: irritable bowel syndrome (IBS), functional dyspepsia, food intolerance, diverticular disease.
Rule out serious pathology: colorectal cancer, inflammatory bowel disease, coeliac disease, gastrointestinal infection.
Explain the rationale for each possible diagnosis in clear, non-technical language.
Address patient concerns empathetically, particularly regarding bowel cancer risk.
Discuss next steps in investigation and management.

Task 3: Explain initial investigations and management, including lifestyle and dietary modifications.

The competent candidate should:

Justify appropriate first-line investigations:
- Faecal occult blood test (FOBT) – for colorectal cancer screening.
- Full blood count (FBC) – to check for anaemia.
- Coeliac serology – if gluten intolerance suspected.
- Faecal calprotectin – if inflammatory bowel disease is suspected.
- Colonoscopy referral if red flags present.
Provide practical dietary advice, including increasing fibre and hydration.
Discuss stress management and exercise as contributors to gut health.
Outline a follow-up plan and safety-netting for symptom progression.

Task 4: Discuss the plan for follow-up, including safety-netting advice.

The competent candidate should:

Schedule a follow-up in 4-6 weeks to review symptom progression and test results.
Advise on red flag symptoms that require urgent review:
- Severe abdominal pain
- Rectal bleeding or black stools
- Unintentional weight loss
- Worsening symptoms despite lifestyle changes
Reinforce the importance of follow-up for cancer screening, given family history.

SUMMARY OF A COMPETENT ANSWER

Elicits a structured history, focusing on gastrointestinal symptoms, red flags, and psychosocial factors.
Considers a broad differential diagnosis, balancing common functional disorders with serious pathology.
Explains investigations clearly, justifying their necessity and addressing patient concerns.
Provides a comprehensive management plan, incorporating lifestyle changes, dietary advice, and stress management.
Uses patient-centred communication, acknowledging anxiety about bowel cancer while offering reassurance and clear next steps.
Safety-nets appropriately, ensuring the patient knows when to return for reassessment.

PITFALLS

Failing to elicit red flag symptoms, leading to missed serious pathology.
Over-reassurance without justification, ignoring family history of bowel cancer.
Not considering functional disorders, leading to over-investigation.
Over-reliance on tests without discussing lifestyle factors, missing a holistic management approach.
Failing to provide safety-netting advice, leaving the patient uncertain about when to seek urgent care.
Using medical jargon, which may increase patient anxiety.

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 Elicits a focused, hypothesis-driven history.
2.2 Identifies red flags in gastrointestinal disease.

3. Diagnosis, Decision-Making and Reasoning

3.1 Formulates a differential diagnosis based on clinical findings.
3.3 Recognises when urgent investigation is required.

4. Clinical Management and Therapeutic Reasoning

4.2 Develops an appropriate management plan.
4.4 Considers lifestyle and dietary factors in management.

5. Preventive and Population Health

5.1 Identifies modifiable risk factors for digestive health.
5.3 Provides dietary and lifestyle advice for gut health.

6. Professionalism

6.1 Respects patient autonomy and confidentiality.

7. General Practice Systems and Regulatory Requirements

7.2 Orders appropriate investigations based on clinical presentation.

9. Managing Uncertainty

9.1 Recognises when symptoms are vague and require monitoring.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies features suggestive of a serious underlying pathology.

Competency at Fellowship Level

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