CASE INFORMATION

Case ID: CCE-CE-009
Case Name: James O’Connor
Age: 52
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: Y06 (Erectile Dysfunction), P76 (Depressive Disorder), T90 (Hypertension), W78 (Obesity)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand their concerns and expectations 1.2 Uses active listening and empathy to explore the patient’s illness experience 1.5 Provides clear and sensitive explanations of potential diagnoses and management options
2. Clinical Information Gathering and Interpretation	2.1 Takes a thorough history to identify underlying causes of men’s health issues 2.2 Identifies red flags for serious underlying conditions 2.3 Orders and interprets appropriate investigations to confirm diagnosis and assess risk factors
3. Diagnosis, Decision-Making and Reasoning	3.1 Recognises clinical features suggestive of common men’s health conditions (e.g., erectile dysfunction, depression, metabolic syndrome) 3.3 Considers and rules out alternative diagnoses
4. Clinical Management and Therapeutic Reasoning	4.2 Provides appropriate counselling, lifestyle advice, and treatment options 4.4 Arranges specialist referral if indicated (e.g., urology, endocrinology, psychology)
5. Preventive and Population Health	5.2 Provides education on lifestyle modifications and risk reduction strategies
6. Professionalism	6.2 Demonstrates sensitivity in discussing personal and potentially stigmatising health concerns
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate screening and follow-up for men’s health issues
9. Managing Uncertainty	9.1 Addresses patient concerns about long-term health implications and psychological impact
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and initiates management for cardiovascular risk factors and psychological distress

CASE FEATURES

Worried that his symptoms could be a sign of something serious (e.g., testosterone deficiency or heart disease).
52-year-old man presenting with fatigue, low mood, and erectile dysfunction (ED).
Longstanding hypertension and obesity, poorly managed.
Recent stress related to work and family responsibilities.
Concerned about his masculinity, relationships, and overall health.

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

James O’Connor, a 52-year-old accountant, presents to your general practice with fatigue, low mood, and difficulties with erections over the past six months.

He has hypertension and obesity (BMI 32) but has not been taking his prescribed medication regularly. He admits that he has been under a lot of stress at work and has been arguing more with his wife due to relationship strain.

PATIENT RECORD SUMMARY

Patient Details

Name: James O’Connor
Age: 52
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Amlodipine 5mg daily (poor adherence)

Past History

Hypertension (diagnosed 5 years ago, poorly controlled)
Obesity (BMI 32, sedentary lifestyle, poor diet)

Social History

Occupation: Accountant, long working hours, high stress
No smoking, drinks alcohol occasionally (4-6 drinks per week)
No history of recreational drug use

Family History

Father had a heart attack at age 55
No family history of prostate cancer

Vaccination and Preventative Activities

Last health check 3 years ago

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 feeling exhausted lately, and I’ve also noticed that I’m having some problems in the bedroom. It’s really starting to worry me.”

General Information

(Can be shared freely if the candidate asks open-ended questions like “Tell me more about that.”)

You have been feeling constantly tired for the past six months, and you don’t feel as sharp at work.
You have difficulty getting and maintaining an erection, and it’s getting worse over time.
Your libido has dropped, and you feel less interested in sex than before.
You feel stressed with work and family responsibilities, and it’s affecting your mood.
You have gained weight over the past few years, mainly due to poor diet and lack of exercise.
You feel embarrassed and frustrated about your erectile issues and haven’t spoken to your wife about it yet.

Specific Information

(Only Reveal When Asked Directly)

Sexual and Relationship Concerns

You used to have a normal sex life, but now you struggle to maintain an erection long enough for intercourse.
You rarely get morning erections anymore.
You have not experienced any pain, penile deformity, or premature ejaculation.
You have no history of sexually transmitted infections (STIs).
You are worried your wife will think you’ve lost interest in her.
You have been avoiding intimacy, making excuses to avoid sex.

Cardiovascular and Metabolic Health

You were diagnosed with high blood pressure five years ago but sometimes forget to take your medication.
You rarely exercise because you’re too tired after work.
Your diet is high in processed food and takeaway meals due to long work hours.
You drink alcohol occasionally (4-6 drinks per week) but do not smoke or use drugs.
You have no chest pain, shortness of breath, or palpitations, but you’re worried about heart disease since your father had a heart attack at 55.

Mood and Mental Health

You feel flat and unmotivated most of the time.
You sometimes feel irritable and snap at your family.
You struggle to focus at work, and you feel like you’re not performing as well as you used to.
You haven’t lost interest in everything, but you feel like you don’t enjoy things as much as before.
You sleep okay but still wake up tired.

Concerns and Emotional Reactions

You feel embarrassed and frustrated about your erectile dysfunction (ED).
You are worried this could be low testosterone or a sign of serious illness like heart disease or diabetes.
You feel ashamed to talk to your wife because you think she’ll lose attraction to you.
You are concerned about taking medication for ED because you’re not sure if it’s safe for your heart.
You don’t want this to be permanent and are hoping there is a way to fix it.

Concerns and Questions for the Candidate

(Ask these naturally during the consultation, especially when discussing diagnosis or management.)

“Could this mean I have low testosterone?”
“Is this a sign of heart disease? My dad had a heart attack at 55.”
“Can I take medication like Viagra, or is that dangerous for me?”
“Is this all just in my head? Am I depressed?”
“Is there anything I can do to fix this, or is it just part of getting older?”
“Could my blood pressure medication be causing this?”
“Would losing weight or exercising more actually make a difference?”

Role-Playing Emotional Cues

(Act these out realistically to simulate a real patient encounter.)

Embarrassment: Speak hesitantly or avoid eye contact when discussing sexual issues.
Frustration: Sigh, shake your head, or cross your arms when explaining how this has affected your confidence.
Anxiety: Look tense and worried when asking about heart disease and long-term health.
Hopelessness: Speak softly or slump in your seat when asking if this will be permanent.
Relief (if reassured well): Breathe out deeply, sit up straighter, and nod when the doctor explains things clearly.

What You Are Expecting From the Doctor (Candidate)

To take your concerns seriously. You need reassurance that this is a common issue and can be treated.
To give a clear explanation. You don’t understand what’s causing this and want simple, honest answers.
To provide a plan. You want to know if this is fixable and what you can do about it.
To help you regain confidence. You want to feel normal again and not have this affect your marriage.
To discuss lifestyle changes. You suspect your weight and blood pressure might be involved, but you need guidance.
To explain medication options. You are open to trying medication but want to make sure it’s safe for your heart.

Potential Curveballs

(Optional, if the Candidate Handles the Basics Well)

“Would testosterone supplements help me?”
“Should I get my prostate checked?”
“Could this be diabetes? My mate had ED, and he ended up having diabetes.”
“Would counselling help, or is this just a physical problem?”
“If I don’t fix this, will it get worse?”

End of Consultation

(If the candidate provides a clear plan and reassurance, respond positively.)

“Okay, that makes sense. I just want to feel like myself again. I’ll try what you suggested and see how it goes.”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, exploring the patient’s symptoms and risk factors.

The competent candidate should:

Use open-ended questions to explore fatigue, low mood, erectile dysfunction (ED), and its impact on quality of life.
Assess onset, duration, severity, and variability of ED.
Identify red flags for serious conditions, including:
- Cardiovascular disease (chest pain, exertional dyspnoea, family history).
- Endocrine causes (decreased libido, loss of body hair).
- Neurological causes (numbness, weakness, bladder/bowel changes).
Explore psychosocial factors, such as relationship strain, work stress, and low self-esteem.
Review lifestyle factors, including diet, exercise, alcohol, smoking, and medication adherence.
Ask about mental health symptoms, such as low motivation, loss of enjoyment, irritability, and sleep disturbances.

Task 2: Outline your differential diagnosis, discussing the most likely causes and serious considerations.

The competent candidate should:

Consider vascular causes as the most likely diagnosis due to:
- Hypertension and obesity (risk factors for endothelial dysfunction and atherosclerosis).
- Gradual onset and progressive nature of ED.
Discuss other differential diagnoses, including:
- Endocrine causes (testosterone deficiency, diabetes, thyroid dysfunction).
- Psychogenic ED (situational, performance anxiety, stress-related).
- Medication-induced ED (amlodipine, SSRIs, antihypertensives).
- Neurological causes (multiple sclerosis, spinal cord disease, autonomic dysfunction).
Rule out cardiovascular disease, given family history of early myocardial infarction.

Task 3: Address the patient’s concerns regarding his symptoms, masculinity, and long-term health risks.

The competent candidate should:

Acknowledge the emotional impact of ED, validating concerns about masculinity and relationships.
Provide reassurance that ED is common and treatable, explaining that it is often linked to underlying health factors.
Explain the link between ED and cardiovascular risk, highlighting the importance of addressing modifiable factors.
Discuss safe treatment options, including lifestyle changes and medication.
Address misconceptions about testosterone therapy, explaining that most cases of ED are not due to low testosterone.
Explore relationship concerns, offering support such as counselling if needed.

Task 4: Provide a structured management plan, including investigations, treatment, and follow-up.

The competent candidate should:

Order appropriate investigations, including:
- Fasting blood glucose and HbA1c (screen for diabetes).
- Lipid profile (assess cardiovascular risk).
- Serum testosterone (morning sample) and sex hormone-binding globulin (SHBG) (assess hypogonadism).
- Thyroid function tests (rule out thyroid disease).
- Renal and liver function tests (assess metabolic health).
Initiate lifestyle interventions:
- Encourage weight loss, regular exercise, and dietary modifications.
- Advise smoking cessation and alcohol moderation.
- Review blood pressure control and reinforce medication adherence.
Discuss pharmacological options, including:
- PDE5 inhibitors (e.g., sildenafil, tadalafil), ensuring cardiovascular safety.
- Referral to a cardiologist if high cardiovascular risk.
Address mental health concerns, offering:
- Referral to psychology for stress and relationship support if indicated.
- Consider screening for depression and anxiety.
Plan follow-up:
- Review in 4–6 weeks to assess symptom improvement and response to interventions.
- Monitor cardiovascular and metabolic risk factors over time.

SUMMARY OF A COMPETENT ANSWER

Thorough history-taking, covering vascular, hormonal, neurological, and psychosocial causes of ED.
Clear differential diagnosis, prioritising vascular dysfunction while ruling out endocrine, neurological, and psychological causes.
Empathetic and structured reassurance, addressing concerns about masculinity, relationships, and long-term health.
Evidence-based management plan, including lifestyle changes, pharmacotherapy, cardiovascular risk assessment, and follow-up.
Patient-centred approach, ensuring clear communication, support, and a stepwise management plan.

PITFALLS

Failing to explore psychosocial factors, focusing only on physical causes of ED.
Overlooking cardiovascular risk, missing an opportunity for prevention.
Inappropriately prescribing testosterone replacement therapy without confirming deficiency.
Not addressing the patient’s concerns about relationships and masculinity, leading to dissatisfaction.
Failure to arrange follow-up, missing the opportunity to assess treatment response and lifestyle changes.

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.
1.5 Provides clear and sensitive explanations of potential diagnoses and management options.

2. Clinical Information Gathering and Interpretation

2.1 Takes a thorough history to identify underlying causes of men’s health issues.
2.2 Identifies red flags for serious underlying conditions.
2.3 Orders and interprets appropriate investigations to confirm diagnosis and assess risk factors.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises clinical features suggestive of common men’s health conditions (e.g., erectile dysfunction, depression, metabolic syndrome).
3.3 Considers and rules out alternative diagnoses.

4. Clinical Management and Therapeutic Reasoning

4.2 Provides appropriate counselling, lifestyle advice, and treatment options.
4.4 Arranges specialist referral if indicated (e.g., urology, endocrinology, psychology).

5. Preventive and Population Health

5.2 Provides education on lifestyle modifications and risk reduction strategies.

6. Professionalism

6.2 Demonstrates sensitivity in discussing personal and potentially stigmatising health concerns.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate screening and follow-up for men’s health issues.

9. Managing Uncertainty

9.1 Addresses patient concerns about long-term health implications and psychological impact.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and initiates management for cardiovascular risk factors and psychological distress.

Competency at Fellowship Level

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