CASE INFORMATION

Case ID: CCE-ONC-001
Case Name: Robert Dawson
Age: 62
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: D75 – Malignant Neoplasm of Colon/Rectum

COMPETENCY OUTCOMES

Competency Domain	Competency Element
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 symptoms, ideas, concerns, expectations, and the impact of illness. 1.4 Communicates effectively in routine and difficult situations.
2. Clinical Information Gathering and Interpretation	2.1 Applies a structured approach to history-taking. 2.2 Identifies red flags and considers differential diagnoses.
3. Diagnosis, Decision-Making, and Reasoning	3.1 Synthesises clinical information to make an appropriate diagnosis.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based management plan. 4.2 Provides clear patient education and follow-up instructions.
5. Preventive and Population Health	5.1 Recognises the role of screening and early detection.
6. Professionalism	6.1 Provides ethical and patient-centred care.
7. General Practice Systems and Regulatory Requirements	7.1 Understands referral pathways and MDT approach in oncology.
9. Managing Uncertainty	9.1 Provides structured safety-netting advice.
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and appropriately manages serious illness.

CASE FEATURES

Challenges include patient anxiety and possible denial.
Male patient, 62 years old, presenting with rectal bleeding and weight loss.
Concerns about cancer due to family history.
Needs clear communication and support in understanding his condition.
Requires appropriate referral and structured follow-up.

INSTRUCTIONS

You have 15 minutes to complete this case.

You should treat this consultation as if it is face-to-face.

You are not required to perform a physical 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

Robert Dawson, a 62-year-old male, presents to your clinic with concerns about rectal bleeding, recent weight loss, and a change in bowel habits over the past 3 months.

He reports noticing dark red blood in his stools on multiple occasions and experiencing lower abdominal discomfort. His stools have become narrower, and he has had episodes of constipation alternating with diarrhoea.

He is worried that he may have cancer but is hesitant to undergo investigations due to fear of the diagnosis.

PATIENT RECORD SUMMARY

Patient Details

Name: Robert Dawson
Age: 62
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Amlodipine 5mg daily
Atorvastatin 20mg daily

Past History

Hypertension
Hypercholesterolaemia

Social History

Married, two adult children

Family History

Father: Bowel cancer at 67 years old.
Mother: Hypertension.

Smoking

30 pack-years, quit 5 years ago.

Alcohol

2-3 standard drinks per day.

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.

ROLE-PLAYER SCRIPT

Opening Line

“Doctor, I’ve been having some blood in my stools, and I’ve lost some weight. I’m really scared it might be cancer.”

General Information

You are Robert Dawson, a 62-year-old retired accountant. You are generally in good health but have noticed concerning symptoms over the past three months. You have come in today because your wife insisted you see a doctor.

Presenting Symptoms:

Rectal bleeding: Started about 3 months ago. The blood is dark red and mixed in with stools, rather than just on the toilet paper. It does not occur every time but has been happening more frequently over the last few weeks.
Changes in bowel habits: Over the last 3 months, you have experienced alternating constipation and diarrhoea. Sometimes, your stools feel narrower than usual, almost like a pencil shape.

Specific Information

(Only if asked)

Background Information

Weight loss: You have lost about 5kg in 4 months, without trying.
Abdominal discomfort: You feel a dull ache in the lower abdomen, which comes and goes. No severe pain.
Fatigue: You feel a little more tired than usual, but nothing extreme.
No other symptoms: No nausea, vomiting, fever, or black/tarry stools.

Past Medical History:

Hypertension (diagnosed at 50, well-controlled on amlodipine).
Hypercholesterolaemia (diagnosed at 55, managed with atorvastatin).
No history of diabetes or gastrointestinal conditions.

Family History:

Father had bowel cancer at 67 years old and passed away at 70.
Mother had high blood pressure but no cancer history.

Social History:

You retired five years ago and live with your wife. You have two adult children.
You quit smoking five years ago after a 30 pack-year history.
You drink 2-3 standard alcoholic drinks per day, mostly wine with dinner.
You do not exercise regularly but try to walk a few times a week.

Preventive Health:

You have never had a colonoscopy.
You received a bowel cancer screening kit in the mail two years ago but did not use it because you felt healthy.

Bowel Habits & Bleeding:

You have no history of haemorrhoids or previous rectal bleeding.
You have not had any black or tarry stools.
You don’t strain much when going to the toilet.
You have not noticed mucus in your stools.

Weight Loss & Fatigue:

The weight loss was not intentional, and you have not changed your diet or exercise routine.
You still have a normal appetite and can eat full meals.

Screening & Investigations:

You were offered a colonoscopy in the past but declined because you felt fine.
You heard colonoscopy is uncomfortable, and you are worried about complications.
You don’t know much about bowel cancer and are afraid of being diagnosed too late.

Emotional Cues & Concerns

You are anxious and worried about cancer but hesitant to undergo tests because you fear bad news.
You feel guilty for not doing the bowel cancer screening when you had the chance.
You need reassurance but also clear, honest communication from the doctor.
You are worried about survival if this is cancer.

Patient Concerns & Expectations

“Could this just be haemorrhoids? I’ve read online that rectal bleeding is often harmless.”
“What happens if I don’t do anything about this? Could it go away on its own?”
“What tests do I need, and how soon?”
“If it is cancer, how serious is it? Will I need surgery or chemotherapy?”
“I’ve heard colonoscopies are painful. Is there another way to check?”
“If my father had bowel cancer, does that mean I was always going to get it?”

Your Behaviour & Mannerisms

You appear slightly tense and worried, frequently crossing your arms and avoiding eye contact.
Your voice is shaky at times, and you sigh deeply when talking about your father’s cancer history.
When discussing colonoscopy, you shift uncomfortably in your chair and say you’re not keen on the idea.
If the doctor is empathetic and reassuring, you gradually open up and become more receptive to investigations.
If the doctor is too blunt or dismissive, you shut down and say, “Maybe I’ll think about it and come back later.”

How to Respond to the Doctor’s Explanations

If the doctor explains that rectal bleeding can have many causes and is not always cancer, you feel a little relieved but still need to know what needs to be done next.

If the doctor explains that colonoscopy is the best test, you initially say:
“I’ve heard it’s really uncomfortable. Is there another way?”

If the doctor explains colonoscopy well and offers reassurance, you accept the referral but say:
“I’m still nervous, but if it’s the best way to find out, I’ll do it.”

If the doctor pushes too hard without reassurance, you refuse the test and say:
“I don’t think I’m ready for that yet.”

How to Challenge the Candidate

If the doctor only mentions cancer without other possibilities, you say:
“But could this be something else? What are the chances it’s not cancer?”

If the doctor is vague about the next steps, you ask:
“So what exactly happens now? Do I need a test today, or can I wait?”

If the doctor does not address your anxiety, you ask:
“What if it’s already too late? My dad didn’t make it.”

Key Emotional Responses Based on Doctor’s Approach

Doctor’s Approach	Your Response
Empathetic, clear, and informative	You feel reassured and agree to investigations.
Pushy and forceful about tests	You resist and may refuse tests.
Minimises concerns or rushes the consult	You feel dismissed and unsure about what to do next.
Provides a balanced discussion (mentions possibilities beyond cancer)	You feel calmer and more open to testing.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history from the patient regarding their symptoms and concerns.

The competent candidate should:

Use open-ended questions to explore symptom onset, duration, and progression (e.g., rectal bleeding, weight loss, altered bowel habits).
Clarify the nature of rectal bleeding (colour, frequency, relation to bowel movements).
Inquire about bowel habit changes (constipation, diarrhoea, stool calibre).
Assess for systemic symptoms (fatigue, appetite changes, night sweats).
Explore risk factors (family history of colorectal cancer, smoking, alcohol, diet).
Address the patient’s fears and concerns regarding possible cancer.

Task 2: Explain your differential diagnosis to the patient in a clear and reassuring manner.

The competent candidate should:

Explain possible causes of rectal bleeding (e.g., haemorrhoids, diverticular disease, inflammatory bowel disease, colorectal cancer).
Use patient-friendly language while balancing honesty and reassurance.
Discuss alarm symptoms (weight loss, persistent bleeding, anaemia).
Acknowledge the patient’s anxiety and provide supportive communication.

Task 3: Outline the necessary investigations and justify their importance.

The competent candidate should:

Recommend a colonoscopy as the gold standard investigation.
Discuss alternative tests (e.g., faecal occult blood test, CT colonography).
Explain the importance of early diagnosis and screening.
Address common concerns about colonoscopy (e.g., discomfort, risks).
Offer a stepwise approach if the patient is hesitant (e.g., stool tests first).

Task 4: Develop a safe and patient-centred management plan.

The competent candidate should:

Ensure appropriate referrals (gastroenterologist for colonoscopy).
Provide lifestyle advice (increase fibre, reduce red meat, smoking cessation).
Arrange follow-up to discuss results and next steps.
Offer emotional support and resources (e.g., Cancer Council information).

SUMMARY OF A COMPETENT ANSWER

Thorough history-taking, including bowel habits, rectal bleeding characteristics, weight loss, and family history.
Clear and compassionate explanation of differential diagnoses.
Patient-centred discussion of investigations, particularly colonoscopy.
Reassuring yet proactive approach to cancer risk assessment.
Collaborative management plan, including referrals, lifestyle changes, and follow-up.

PITFALLS

Failing to address the patient’s anxiety, leading to reluctance for investigations.
Not discussing colorectal cancer risk appropriately.
Over-reassurance without considering red flags (e.g., unexplained weight loss).
Neglecting lifestyle factors (diet, smoking, alcohol).
Not arranging a follow-up to discuss test results and ongoing care.

REFERENCES

MARKING

Each competency area is assessed on a 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 Applies a structured approach to data gathering and investigation selection.

3. Diagnosis, Decision-Making and Reasoning

3.1 Prioritises and synthesises information to make appropriate clinical decisions.

4. Clinical Management and Therapeutic Reasoning

4.1 Formulates and implements a management plan based on the best available evidence.

5. Preventive and Population Health

5.1 Promotes preventive health strategies and screening.

6. Professionalism

6.1 Demonstrates patient-centred care and shared decision-making.

7. General Practice Systems and Regulatory Requirements

7.1 Appropriately refers and follows up on investigations.

9. Managing Uncertainty

9.1 Demonstrates a structured approach to managing uncertain diagnoses.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and escalates care for suspected malignancy appropriately.

Competency at Fellowship Level

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