SCA (Simulated Consultation Assessment)

What is SCA

The SCA at a glance:

An assessment of twelve simulated consultations, each lasting twelve minutes
Conducted remotely in a local GP surgery
Sat only during ST3 training year
Delivered across 9 months of the year
The first 9 diets of the SCA will take place on the following dates:
January 2024: 9 January
February 2024: 6 February
March 2024: 5 to 8 March
April 2024: 2 to 5 April
May 2024: 8 to 9 May
June 2024: 4 to 5 June
September 2024: 3 to 4 September
October 2024: 8 to 9 October

The SCA exam fee will be £1,180

Here is a link to a presentation explaining in details about SCA as much is known at this stage.

SCA exam for 2023.pptx

SCA Mock cases for practice

Please use this link to download some mock SCA cases which trainees and trainers can use to practice for SCA

SCA Mock cases

SCA support

We offer comprehensive cosnultation skills training focussed towards SCA exam within the HDR sessions. Please ensure you practice the skills learnt with patients seen in your practice. Also it is recommended to practice simulated consultations in peer groups to fine tune some of the skills for your Exam. If you are looking for courses or further support then please have a look at the link below on what is available for those taking exam first time as well as if you failed your SCA and planning to resit the exam.

SCA support for trainees

Detailed feedback

Case instructions for trainees

Email from district community nurse today:

Dear GP,

I have just seen Mr. McLean, as part of my routine visit to see his wife. He has had diarrhoea for the past few days.

• Afebrile, tongue dry, abdomen soft and non-tender.
• BP 120/70 sitting (BP 110/60 standing), all other findings normal.
• Blood glucose from finger prick was seven.
• Urinalysis normal, with no ketones.

I asked him to give you a call, as he wasn’t his normal happy self.

Thanks,
District Nurse

Name: Steven McLean

Age: 75

Past medical history:

• Type 2 diabetes, diagnosed 10 years ago.
• Essential hypertension, diagnosed 10 years ago.
• On carer’s register (wife has dementia).

Current medication:

• Metformin: 500mg tablets, two tablets every morning and evening.
• Candesartan: 8mg one daily.
• Atorvastatin: 20mg one daily.

Summary of attendance at Practice Diabetic Clinic 3 months ago:

• Doing well with no symptoms.
• Recent diabetic retinal screening was normal.
• Foot check – normal.
• BP 146/82 (stable).
• Routine bloods: electrolytes normal. GFR 55 (CKD3) has been at this for around 2 years. HbA1c 53.  
• Liver function tests normal, cholesterol normal.
• Continue medication. 

Case instructions for the Role Player:

Name: Steven McLean

Gender: Male

Age: 75 years 

Background:

• Any ethnicity
• Ex-taxi driver
• Non-smoker
• Married to Patricia, age 72, with one son living in Nottingham.
• You are a carer for your wife, who has dementia, and the district nurse visits regularly.
• Diagnosed with type 2 diabetes 10 years ago.
• Diabetes reasonably well controlled on metformin twice daily – one morning and one evening.
• You have been prescribed candesartan once daily for the past 10 years – you understand this is to help your kidneys and blood pressure.
• You take a statin tablet in the evening to reduce your cholesterol.
• You normally keep well and attend the Practice Diabetic Clinic annually.
• You were contacted after the last clinic and told your blood tests were stable.

Scenario:

The district nurse visits twice a week to see your wife and she changes her leg ulcer dressings. You told her you weren’t feeling well today and have been having diarrhoea for the past 2 days. She took your blood pressure, checked your blood sugar by pricking your finger, examined your abdomen and checked a urine sample, which she said looked okay on her testing. The nurse asked you to contact the surgery.

Demeanour:

You are matter of fact and not alarmed about your current symptoms, but you do feel a bit weak and flat.

Opening statement:

‘Doctor thank you for the call, the district nurse has just called to redress my wife’s ulcer and she suggested I called a doctor. I have had diarrhoea for the past 2 days and I don’t feel so great. The nurse said she was going to email the surgery to let you know she had seen me’.

Information the patient can give out freely, if asked by trainee:

• The diarrhoea started 48 hrs ago.
• You are quite sure it was due to the meat pie you ate at football.
• Football is the one thing you do for relaxation, as a carer comes to keep an eye on your wife so you can go out.
• You haven’t vomited, which you are relieved about.
• You have stopped eating and drinking to try and stop the diarrhoea, but it doesn’t seem to have helped.

Information to be given if asked:

Current problem:

• Your motions are quite loose and watery.
• You are going every 2-3 hours – normally it’s once a day.
• You have not passed any blood.
• You have not vomited.
• You have mild colicky central abdominal pain before bowel movements, but this is manageable and not there all the time.
• You feel a bit thirsty, and your mouth feels dry, but you haven’t been drinking much since the diarrhea started because you think if you don’t eat or drink much, the diarrhoea will go away quicker.
• You feel weak and wobbly when you get up to go to the toilet. You don’t feel faint just a bit unsteady and sitting down is fine.
• You last passed urine 4-5 hours ago. The urine was dark in colour, but there was no blood or discomfort.
• You have not taken any over-the-counter medicines for this condition.

 Medication:

You have taken your medication as normal.

(You will have freely given out the information you have stopped eating and drinking, the trainee needs to ask if you have stopped your tablets too –you are still taking these as you thought they were important).

      Diabetes care:

• You attended the Practice Diabetic Clinic three months ago, where you saw the nurse. As far as you know everything was fine, although the nurse said she needed to monitor your kidneys, but you didn’t need to worry.
• You test your blood sugar with a BM machine about once a week and it is normally less than 10. The nurse checked it today and she said it was 7.
• You do have a blood pressure machine at home, but it has always been fine, and the nurse checked this today, she said she was going to tell you the results.
• You have not been abroad recently.
• No one else is affected in the household.

Social:

• You live with your wife and are registered as her carer.
• If asked about your wife, say she has dementia, she isn’t too bad, mostly forgetful but she can wander out of the house and then she wouldn’t know how to get back home. You don’t leave her on her own.
• She has been assessed by the Old People’s Mental Health team and you have a number of a nurse to call, if you are worried about her, therefore you feel well supported.
• You do the cooking and cleaning and you have been able to do the cooking for her, but just not eating it yourself.
• You are a non-smoker and don’t drink alcohol.

Concerns:

If asked what you think is going on say, ‘It’s like a holiday tummy, when you eat something which isn’t cooked properly’. You fully expect it’s the pie you ate, you only phoned as the district nurse advised you to.

Answers to possible management scenarios:

If the trainee wants to visit, then say you don’t need this as the district nurse has been in today and already seen you and she will be back in 3 days to bandage your wife’s’ leg ulcers.

If the doctor says they want to examine your abdomen say, ‘The district nurse did this already and she said it felt alright’. If the trainee insists, agree, but ask what they would do if they got the same results as the nurse. You must get the doctor to give you a management plan.

If the doctor picks up that the nurse thought you weren’t your normal self, then say you are fine, it’s just quite tiring having diarrhoea.

The doctor should explain that you more than likely have gastroenteritis/food poisoning and that it should settle.

You have dehydration which is why your blood pressure is dropping and there is a risk of kidney problems if you don’t stop your pills. Don’t be alarmed by any of this but just ask what you can do.

If the doctor wants to do blood tests, ask if they can be done at home. You don’t want to have diarrhoea whilst you are out, as you have to rush to the toilet and you can’t leave your wife unless someone sits with her.

If the doctor asks for a stool sample, say you can’t do this today as you don’t want to leave the house and can’t leave your wife, but you don’t mind doing this in the next few days if things settle down a bit.

If the doctor wants to admit you, then this is currently not an option, and you would rather see how things go at home first as you need to look after your wife.

Agree to increasing fluids, agree to stopping your pills but ask when these should be restarted.

You are happy to monitor your blood pressure on your home machine if this is offered – but ask if you need to send the readings to someone. If this is not mentioned ask if you can take Imodium to stop the diarrhoea– this ideally is not the correct management but agree to whatever the doctor says.

Notes for calibration role player training:

Data gathering and making a diagnosis:

The diagnosis is gastro-enteritis/ food poisoning, complicated by dehydration, with a risk to patient’s kidney function. The trainee needs to be given information that enables them to ascertain this. However, it should not be presented so that no data gathering skills are demonstrated. Discuss and calibrate how this can be achieved.

Management and medical complexity:

The role player is not necessarily worried by his symptoms but needs to be firm that he can’t go to hospital and can’t get to the surgery for blood tests or bring stool samples to the surgery today. This is because he can’t get anyone to sit with his wife. But he will equally appreciate that if he starts to feel more faint, wobbly, or his stomachache worsens, then he will have to review this.

He won’t have any issues with someone coming to take blood tests at his home or doing any home management, i.e., checking his blood pressure /increasing fluids /rehydration solution.

The role player should not bring up his pills but will agree to stop these and if not told needs to ask when these are restarted.

If not mentioned the role player needs to bring up imodium and go along with whatever answer, he receives.

Likewise, he will agree to further tests if symptoms do not settle.

Relating to others:

The role player needs to remain calm, unless the explanation of his diagnoses is done in an alarming way that incites fear. The role player should respond with comments such as ‘that sounds a bit frightening’. If the trainee becomes insistent that he must go to hospital, then the role player can become very resistant that they clearly misunderstand his responsibilities towards his wife.

Notes for calibration for the examiner marking for the passing / failing candidate:

Use the following to discuss pass/ fail boundary and what a clearly passing and clearly failing trainee may look like.

Data gathering and making a diagnosis:

The trainee needs to conduct a sufficient history, to recognise this is food poisoning, rather than anything else, but with a risk of him becoming dehydrated.

The role player will freely give out the information that he has stopped drinking and eating but will need to be asked by the candidate about his tablets.

The information from the district nurse about his dropping blood pressure also needs to be recognised and trainees may also notice his GFR result from the candidate briefing.

Clinical Management and Medical complexity:

The markers need to decide how to mark the management domain if concerns about AKI are not raised specifically, but the patient is still managed as if they might have this.

The role player needs to be advised to increase his fluids, to start eating and to stop his candesartan and metformin.

It needs to be discussed, in the examiner calibration, how the marks are affected if only one tablet is stopped. (The role player will ask when these should be restarted and this needs to be also answered in a safe way).

A sensible follow-up needs to be offered by the trainee for either test / follow up etc.

It needs to be discussed, in marking, if the trainee recommends Imodium.

Relating to others:

The diagnosis needs to be explained to the patient in a way that the patient understands.  This should include the risk to his kidneys but done in a non- frightening way.

The plan needs to be negotiated, taking into account his role as a carer to his wife, and this needs to be recognised and acknowledged.

Marking Schedule Case Name: Stephen McClean     

Station Title: Telephone consultation with a 75-year-old man who the district nurse has recently seen. He has had diarrhoea for the past 2 days.

What the candidate must do to pass the station:

• Identifies the potential risk of acute kidney injury in the patient.
• Negotiates with the patient and offers appropriate advice regarding rehydration.
• Stops metformin and candesartan, temporarily, due to dehydration and hypotension and risk of AKI.
• Acknowledges his role in looking after his wife, which affects his management.

Domain 1 – Data Gathering and making a diagnosis:

Standards –

Systematically gathers and organises relevant and targeted information to address the needs of the patient and their problem(s).

Adopts a structured and informed approach to problem-solving, generating an appropriate differential diagnosis or relying on first principles where the presentation is undifferentiated, uncertain or complex.

• Systematically gathers information, using questions targeted to the patients presenting health problem.
• Makes effective use of existing information received from the district nurse and candidate briefing.
• Uses an understanding of probability based on prevalence, incidence, and natural history to reach a diagnosis of gastroenteritis.
• Revises hypotheses as necessary in the light of additional information i.e., recognises current medication /restricting fluids may be worsening his dehydration/ causing AKI.

Domain 2 – Clinical Management and Medical Complexity: 

Standards –

Demonstrates the ability to formulate flexible personalised care options which include time, and self-management based on shared understanding, autonomy, and continuity.

Demonstrates commitment to providing optimum care in the short and long-term, whilst acknowledging the challenges.

• Thinks flexibly around health problems, generating functional solutions e.g., advice regarding hydration, monitoring blood pressure, need for blood testing.
• Applies sickness day rules in suggesting medication is temporarily stopped.
• Suggests safe and sensible follow up arrangements if the symptoms don’t settle.
• Recognises that patient looks after his wife and advice given (e.g., support/hygiene advice).

Domain 3 – Relating to Others:

Standards –

Demonstrates ethical awareness.

Shows ability to communicate in a person-centred way. 

Demonstrates initiative and flexibility in using various consultation approaches in order to overcome any communication barriers and to reach a shared understanding with the patient.

• Communicates and explains likely diagnoses of gastroenteritis, with risk of dehydration and reduced kidney function
• Elicits social information to place the patient’s problem in context (carer for wife who he can’t leave unattended)
• Works in partnership with the patient, negotiating a mutually acceptable plan which is clear and understandable
• Respects patients’ autonomy in his decision to stay at home
• Checks the patient’s understanding of the consultation including any agreed plans