CASE INFORMATION

Case ID: CCE-2024-001
Case Name: Margaret Taylor
Age: 72
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: F92 (Cataract)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Uses language appropriate to the person and the situation. 1.2 Engages the patient to explore their symptoms, concerns, and expectations. 1.3 Demonstrates empathy and active listening.
2. Clinical Information Gathering and Interpretation	2.1 Obtains a thorough ophthalmic and systemic history. 2.2 Identifies red flags that may indicate more serious pathology. 2.3 Performs appropriate assessment for visual impairment.
3. Diagnosis, Decision-Making and Reasoning	3.1 Forms an appropriate differential diagnosis. 3.2 Explains the diagnosis in a patient-friendly manner.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops a safe and evidence-based management plan. 4.2 Discusses treatment options, including surgical and non-surgical interventions.
5. Preventive and Population Health	5.1 Educates about risk factors and modifiable lifestyle changes. 5.2 Encourages regular vision checks and fall prevention strategies.
6. Professionalism	6.1 Provides patient-centred care with respect for autonomy and informed decision-making.
9. Managing Uncertainty	9.1 Recognises when referral to an ophthalmologist is appropriate.
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies potential complications of cataract and differentiates from other causes of vision loss.

CASE FEATURES

No acute red flags (e.g., no acute visual field loss, no eye pain).
72-year-old woman with progressive vision loss over the past 2 years.
Difficulty with night driving and reading small print.
Glare sensitivity and trouble distinguishing contrast.
No significant past ocular history except for presbyopia.
Concerned about losing independence and ability to drive.

INSTRUCTIONS

You have 15 minutes to complete this case.

This consultation should be conducted as if face-to-face.

You do not need to perform a physical examination, but should discuss key examination elements.

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

Margaret Taylor is a 72-year-old woman presenting with gradual worsening of vision over the past two years. She has noticed increasing glare sensitivity, especially when driving at night. She finds it difficult to read small print and recognise faces in dim lighting.

Margaret is worried about losing her ability to drive and remain independent. She wants to know if anything can be done and whether she needs surgery.

PATIENT RECORD SUMMARY

Patient Details

Name: Margaret Taylor
Age: 72
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Atorvastatin 20mg daily
Calcium + Vitamin D supplement

Past History

Hypercholesterolaemia
Osteopenia

Social History

Retired school teacher

Family History

No family history of glaucoma or macular degeneration

Smoking & Alcohol

Non-smoker
Drinks 1-2 glasses of wine per week

Vaccination and Preventative Activities

Last eye check-up was 5 years ago
Up to date with influenza and pneumococcal vaccines

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, my eyesight has been getting worse over the last couple of years. I struggle to see clearly, especially at night. I’m worried about whether I’ll still be able to drive.”

General Information

(These details can be shared freely if the candidate asks open-ended questions.)

You first noticed your vision declining about two years ago.
It has been gradually getting worse, especially in dim lighting.
You find it difficult to read small print, even with your reading glasses.

Specific Information

(Only if Asked)

Background Information

You struggle recognising faces from a distance.
Driving at night is particularly challenging because of glare from headlights.
You don’t have pain, redness, flashes, floaters, or sudden vision loss.
You are worried about losing your ability to drive and becoming dependent on others.
You don’t want surgery unless absolutely necessary.

Vision History

You have used reading glasses for 10 years, but they don’t seem to help as much now.
No history of eye trauma, previous surgery, or eye infections.
No history of glaucoma, macular degeneration, or diabetes.

Systemic Health

You have high cholesterol, managed with atorvastatin.
You have osteopenia and take calcium and vitamin D supplements.
No diabetes, stroke, or neurological conditions.

Daily Activities and Impact of Vision Loss

You are a retired school teacher and live alone.
You still do your own shopping, cooking, and household tasks but struggle to read labels.
You like gardening, but your poor vision makes it harder to see weeds or small plants.
Watching TV is fine, but you can’t read subtitles easily anymore.

Driving Concerns

You still drive, mainly during the day, but avoid driving at night.
You feel anxious about driving in unfamiliar areas.
You worry that you might be forced to stop driving altogether.
If you lose your ability to drive, you will have to rely on family and taxis for transport.

Emotional Cues

You are mildly anxious but open to discussion.
You feel frustrated about your declining vision.
You are worried about your independence.
You are reluctant about surgery but will listen to options.

Questions for the Doctor

“Is this something serious? Will I go blind?”
(You are scared but hope the doctor will reassure you.)
“Do I need surgery? Are there any other options?”
(You don’t want surgery unless absolutely necessary.)
“Will I have to stop driving?”
(You are very concerned about losing your independence.)
“How long will it take to recover if I get surgery?”
(You worry about how the recovery will affect your daily life.)

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient.

The competent candidate should:

Establish the onset, duration, and progression of vision symptoms.
Ask about specific visual disturbances (blurry vision, glare, night vision issues, difficulty reading).
Inquire about impact on daily activities, including driving and independence.
Explore previous eye conditions, history of glasses/contact lens use, and past eye surgeries.
Identify systemic risk factors (diabetes, hypertension, steroid use).
Take a medication history, including eye drops.
Assess patient concerns and expectations, particularly regarding surgery and driving.

Task 2: Explain the likely diagnosis and differential diagnoses.

The competent candidate should:

Explain that the most likely diagnosis is cataracts, which is a gradual, progressive clouding of the lens.
Discuss how cataracts cause worsening vision, glare, and difficulty with night driving.
Consider differential diagnoses:
- Glaucoma (if peripheral vision loss is present).
- Macular degeneration (if central vision is affected).
- Diabetic retinopathy (if the patient has diabetes).
Reassure the patient that cataracts are treatable and not an emergency.

Task 3: Discuss the management plan, including surgical and non-surgical options.

The competent candidate should:

Explain non-surgical options:
- Updated glasses prescription for mild cases.
- Stronger lighting and magnifiers for reading.
- Lifestyle modifications (avoiding night driving).
Discuss surgical options:
- Cataract surgery is the only definitive treatment.
- It involves removal of the cloudy lens and replacement with an artificial lens.
- The procedure is safe, performed under local anaesthetic, and has a high success rate.
- Recovery is quick, with improved vision within a few days.
Address driving concerns:
- Cataract severity may impact fitness to drive.
- A vision test may be required for licensing.
Provide reassurance and allow the patient time to consider options.

SUMMARY OF A COMPETENT ANSWER

Thorough history, including vision symptoms, daily impact, and risk factors.
Clear and structured explanation of cataract diagnosis and differentials.
Discussion of non-surgical and surgical options, addressing patient concerns.
Consideration of driving implications and patient independence.
Patient-centred approach with reassurance and shared decision-making.

PITFALLS

Failing to take a full vision history (missing key symptoms like glare or night blindness).
Not considering differentials (e.g. glaucoma or macular degeneration).
Giving an overly technical explanation without addressing patient concerns.
Not discussing driving restrictions and legal implications.
Rushing into surgery discussion without explaining non-surgical options.

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, and impact on life.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers relevant history, including symptoms, risk factors, and impact on function.

3. Diagnosis, Decision-Making and Reasoning

3.1 Forms an appropriate differential diagnosis.
3.2 Explains the diagnosis and prognosis in patient-friendly language.

4. Clinical Management and Therapeutic Reasoning

4.1 Discusses non-surgical and surgical management options.
4.2 Provides appropriate follow-up and referrals (e.g. ophthalmologist).

5. Preventive and Population Health

5.1 Discusses vision safety, including driving restrictions if required.

6. Professionalism

6.1 Respects patient autonomy and involves them in decision-making.

7. General Practice Systems and Regulatory Requirements

7.1 Understands vision requirements for driving and referral pathways for surgery.

Competency at Fellowship Level

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