Consultation Structure for the SCA – Hitting the Marking Domains

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Introduction

The simulated consultation assessment (SCA) is one of the two key exams GP trainees must pass during their GP training programme. The SCA involves completing twelve simulated consultations with simulated patients.

The SCA marking domains (which will apply to every case) are:

• Data gathering and diagnosis
• Clinical management and medical complexity
• Relating to others

The weighting of each domain will vary between cases. For example, some cases may have slightly more marks available for data gathering and diagnosis, while others may have more for clinical management. 

The Clinical Management and Medical Complexity domain will carry slightly more weight overall (as it is linked to more capabilities). Examiners are unaware of case weighting and are not influenced by this. Don’t worry too much about weighting or trying to work out the “most important” domain for each case – if you prepare for all of them and demonstrate each domain within the station, you will do well.

Demonstrating the domains

So, how do you demonstrate that you have hit all of these domains in 12 minutes?

The RCGP website has a lot of helpful information on the capabilities that comprise the three domains. Demonstrating these will show that you are a safe and patient-centred doctor. Reading over this is a good place to start.

The 6-minute split

The Geeky Medics article Tips for the Simulated Consultation Assessment (SCA) has some excellent advice about sitting the SCA, including using your time well. For most cases, a simple 6-minute split will work well.

• 6 minutes to demonstrate data gathering and diagnosis
• 6 minutes to demonstrate clinical management and complexity
• The relating to others domain will be hit throughout both sections

12 minutes might not sound like a lot for a potentially complex case, but the good news is that you don’t have to wait for the patient to walk into the room and take off their coat; you also don’t need to type up the consultation afterwards. So, following the structure will give you plenty of time to get to grips with each case.

Below, the three domains have been broken down into tips and examples based on the capabilities they link to. There shouldn’t be any surprises here! Hopefully, this is all the good GP stuff you will do in your daily consultations.

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The first 6 minutes: Data gathering and diagnosis

Don’t rush your first 6 minutes. Take the time to gather all the relevant information that you need from the patient. Be a detective – think about the information you have been provided, and try and pick up on subtle clues. Consider what questions you can ask to get the richest information from the patient.

To pass in this domain, you should demonstrate that you have:

• Systematically gathered and organised relevant and targeted information to address the needs of the patient and their problem(s)
• Adopted a structured and informed approach to problem-solving, generated an appropriate differential diagnosis or relied on first principles where the presentation is undifferentiated, uncertain, or complex

Data gathering

Make sure you use the data gathering skills you will be developing all the time in your real life consultations. Start with broad open questions. Once you understand the problem in the patient’s own words, bring in your own focused or closed questions to rule things in or out.

This is particularly important for red flags – make sure you ask about red flags in all your consultations. This shows that you are thinking about them.

For example, in a patient with abdominal pain, make sure you are asking about rectal bleeding, change in bowel habit, weight loss and fevers. If in doubt, weight loss and fevers are good things to ask about in many different consultations!

Remember to use the information you have been provided. If you have been given details about a recent consultation – use it! Check with the patient if they still have symptoms, if they recall the previous visit, if it changed anything.

Psychosocial history

Ask about psychosocial information – this is key in the SCA!

If you tend to forget this, you can even scribble “social history!” on your whiteboard or the online notebook to jog your memory whilst talking to the patient.

A great question is “What impact is this having on you?”. Get into the habit of asking this with every patient you see. This offers a natural way to bring up ICE, and patients often reveal information about their work and home situations.

Smoking, alcohol and recreational drug history is a quick thing to ask about and can be very relevant in some cases. Again, try to build a habit of asking about this in your day-to-day consultations.

Making a diagnosis

This is a natural way to move from data gathering to management.

Talk through your diagnosis

Talk through your differential diagnoses with the patient and use evidence from what they have said (or information you have been provided) to rule certain conditions in and out.

Essentially – do your thinking out loud, and share it with the patient!

Using the above format, you also demonstrate that you are aware of the prevalence and incidence of different illnesses and how they tend to progress. For example, you can use phrases such as “it’s possible that it could be X, but in that case I would have expected it to improve by now” or “the timeframe of your symptoms really fits with Y”.

Changing your diagnosis

Don’t be afraid to backtrack or adjust your differential if the patient throws in or out new information! Do not skim over new information because it doesn’t fit neatly into the structure of your consultation.

Don’t be afraid to ask a few more questions to clarify the patient’s situation if you need to. Likewise, if a patient brings up a possible diagnosis too early for your liking (some patients might even open the consultation by saying they are worried about cancer!), then acknowledge it, assure them you will come back to it, but that you need to ask a few more questions first.

Unclear diagnosis

You may see a patient whose presentation is undifferentiated or unclear, and you can’t piece it together easily. Don’t panic! This could well be the point of the station.

Don’t be afraid to tell the patient if you don’t know what is happening, but you can usually make some kind of differential, even if it is very broad. For example, “I’m not quite sure what is causing your symptoms, but there are a few possibilities. It could be an unusual type of infection or maybe a hormone problem. Was there anything else that had crossed your mind?”

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The second 6 minutes: Clinical management and medical complexity

Uh-oh! You are still talking about smoking and alcohol, but you’ve just glanced at the clock, and you have six minutes left. What to do? Essentially – it’s time to move on.

If there is anything extremely important that you haven’t got to yet, then do so (have you asked about red flags? Have you got any psychosocial information from the patient). Discussing the differential diagnosis (see above) is a handy way to move from the patient’s symptoms and experience – to what could be going on – and what exactly are you going to do about it?

To pass in this domain, you should demonstrate that you have:

• Shown the ability to formulate safe and appropriate management options which include effective prioritisation, continuity and time and self-management
• Shown commitment to providing optimum care in the short and long-term, whilst acknowledging the challenges

Clinical management

Wait and see

Don’t be afraid to use a “wait and see” approach where appropriate, just as you would in a GP setting. If you suggest this, checking how the patient feels about this is a good idea.

Lifestyle measures

Encourage patients to take a proactive approach to self-care and lifestyle improvements. This is important in stations which feature an element of health promotion.

For example, “Have you thought about any ways you could make changes to your diet?” or “Can you think of anything that might help you manage that stress?”

Be encouraging and supportive of their suggestions and use them in the management plan.

Using guidelines and prescribing

You can use your local guidelines or national guidelines in the management plan. You can explain this to the patient, which will also help clarify it to the examiner. For example, when choosing an antibiotic or augmenting treatment for hypertension or diabetes. You can also use this for non-pharmaceutical methods, such as offering talking therapies to patients with depression.

If you prescribe medications, make sure you do so safely. Warn the patient about any worrying side effects.

Consider things like sick day rules (for medications such as ACE inhibitors, diuretics and metformin); severe and rare complications (e.g. osteonecrosis of the jaw when prescribing bisphosphonates or Fournier’s gangrene in SGLT2 inhibitors); and the risk of drowsiness for medications such as codeine, where it might be important to advise on driving.

Referrals

If you think the patient needs to be referred to a specialist, do so, but be careful not to waste resources. If a 70-year-old patient presents with postmenopausal bleeding, then it might be sensible to send an urgent 2-week wait referral to gynaecology. But if it’s a 30-year-old patient with an unusual lump down below, it would probably be sensible to examine them in your surgery first.

Follow up

Ensure that you have a safe and clear follow-up plan agreed with the patient.

This is one benefit of the SCA compared to your everyday practice. If you want to review them later in the week or the following day, there will always be an appointment available! This could also be the case for other local services, such as GUM clinic (just don’t be too unrealistic – and as discussed above, don’t misuse the resources just because you can!).

Coordinating with and utilising these other services is a good idea and shows you understand community care.

Other considerations

Make sure your management plan suits the patient. There is no point in offering an urgent face-to-face appointment to a patient at the other end of the country. Equally, if they are not on board with the plan, they will leave dissatisfied and may not engage with it. Use their preferences when agreeing on a plan: “You mentioned you were worried about X… so why don’t we do this?”

Sometimes, you might have to think a bit differently about managing a patient you are seeing virtually. Use your initiative and think about how you can solve the problem together.

Some of the cases in the SCA may involve challenging patients who want you to do things that you uncomfortable with. For example, sign them off sick with no clear reason, or prescribe a medication that isn’t indicated. In these cases, make sure that any decisions are safe and evidence-based (again, much like your current everyday practice), and stick to your guns if necessary!

Medical complexity

You are likely to get some complex patients in the SCA. In your data gathering, try and clarify which issues are new and which are longer standing.

Consider how pre-existing conditions and medications might be impacted by any new treatment you offer. If you get stuck, it’s ok to acknowledge the complexity with the patient and talk things through out loud. For example, “I think we might need to do X… but I’m just concerned about how it might affect your underlying Y condition… can you tell me how that is at the moment?”

As well as multimorbidity, consider the implications of polypharmacy in your management plans. For example, “The antibiotic we usually use for this is taken four times a day, but I’m worried that might be difficult for you to remember, as you are on so many medicines already. What do you think?”

Try to demonstrate prioritisation in your management plan. “We probably will need to do X, but I think it’s really important that we rule Y out first.” This shows that you have a good understanding of risk.

Dealing with uncertainty

Be comfortable sitting with some uncertainty. As discussed in the ‘Diagnosis’ section, you might not always know exactly what is going on, and your management plan may reflect this.

Alongside the patient, make a plan that can help sift through the uncertainty. If they remain anxious despite this, go back and check that you haven’t missed one of their concerns! If you really have no idea what is going on, you are unlikely to go too wrong with a set of blood tests and a face-to-face examination.

Health promotion

Health improvement and promotion are likely to feature in the SCA. If you have gathered the relevant psychosocial and lifestyle information discussed in the previous section, you can easily tie this in.

Good options include:

• Referrals to local exercise programmes
• Pulmonary rehabilitation classes
• Drug and alcohol support services
• Smoking cessation services

If you know any local support groups or services, you can offer to signpost the patient there.

Practicing holistically, promoting health, and safeguarding

As mentioned above, referring to support services can make a real difference to a patient and/or family.

If you start to wonder whether they need social services, OT or physiotherapy, it is probably a good idea. If you offer a social services referral and they firmly decline (unless it’s a safeguarding concern), at least you have shown that you have thought about it.

A safeguarding case may come up. These can be tricky (especially in real life), but the first challenge is recognising the red flag of safeguarding waving in your face. Sharing your concerns with the patient or family member is key – tell them why you need to make the referral and what will happen next.

Be empathetic but clear, and explain that you must share the information. Emphasise that the referral’s role is to ensure that the patient is safe and that any further support can be put in place if needed.

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Relating to others

The good news is that you don’t need to worry about your 6 minutes here. You should be demonstrating these skills throughout the consultation. The tips below give you some ideas about how to hit the domain as you go through.

To pass in this domain, you should demonstrate that you have:

• Demonstrated ethical awareness
• Shown ability to communicate in a person-centred way
• Demonstrated initiative and flexibility in using various consultation approaches in order to overcome any communication barriers and to reach a shared understanding with the patient

Fitness to practice

Treat all your patients kindly and with respect. This may be particularly relevant when your patients are ‘challenging’ – for example, when they don’t want to hear your advice! Or perhaps they may have a crippling drug addiction, which has prevented them from implementing the fantastic-yet-fantastical lifestyle changes suggested in their last consultation.

Ensure you don’t outwardly show frustration and offer everyone the same level of care and support.

Be confident and take ownership of your decisions, even whilst recognising with the patient that you don’t have all the answers. Practice in your everyday clinics – tell the patient that whilst you don’t know exactly what is wrong, together, you can come up with a sensible plan. Patients generally respond well to this, and the SCA is no different.

Maintaining an ethical approach

You will likely encounter various cultural and personal differences in your exam. Don’t be afraid to ask and talk about these – it will likely feed into the “impact” of the current situation. The consultation could even centre around a religious event, such as a patient with diabetes wanting to fast during Ramadan. Act non-judgmentally and respect the autonomy of your patients.

You can still get a lot of marks in this domain, even if you don’t know the exact management of the top of your head.

Ensure that you are acting in the patient’s best interests. This might be particularly important if your consultation is with a fellow professional or family member rather than the patient. Consider the patient’s current and/or previous wishes as much as possible. Consider whether they have formal written documentation, such as an Advance Decision or an Advance Care Plan.

Don’t be afraid to get a second opinion or request a best interests meeting if you need to.

As well as best interests, other medico-legal concepts such as informed consent and mental capacity may well feature in the SCA. Remember, if you are having a third party consultation with a family member or friend, make sure you have consent to discuss with them first!

If there is no clear recorded consent, make it clear that although you can listen to their concerns, you won’t be able to discuss the patient. If there is a clear documented consent, it is good to acknowledge this at the start – this demonstrates that you have thought about it.

Communication and consultation skills

Don’t forget about ICE! If you tend to forget this, it could be another useful thing to scribble on your whiteboard. Establish the patient’s health beliefs, what has caused them to attend today, what worries them, and what they hope to get from the appointment. Then incorporate their concerns and expectations into the management plan.

Because the SCA is a remote exam, you cannot demonstrate your physical listening skills to the same extent (for example, body language mirroring). Make sure your verbal and non-verbal listening skills are up to speed. A good way to do this is to video consultations and watch them back – do you look engaged by what the patient is saying?

You might have a station with a patient with learning difficulties or a poor understanding of health terminology. Practice explaining a few concepts in simple language (for example, what is high blood pressure? How would you explain diabetes?) so you are used to doing so. If in doubt, make it shorter and simpler!

Don’t forget about other useful materials, such as information leaflets or online tools. Just as you would in your normal clinic, you can offer to send these to the patient.

Make it clear that you have made a shared management plan with the patient. Rather than telling them what to do, enquire about what they think. For example, “You told me you were worried about lung cancer, and you used to be a smoker, so what do you think about getting a chest x-ray?” or “I think we have a couple of options here. We could wait a few weeks and see if this improves, or we could try some treatment now. Do you have a preference?”

Demonstrate to the examiners that you are checking the patient’s understanding of the plan. If you try to do this for the first time in the exam, it can feel unnatural and clunky. Practice doing this with your everyday patients until it feels natural. “I’ve given you quite a lot of information today; can I just check you’re happy with everything?” 

Be empathetic and caring. You are talking to actors, but treat them like any other patient. If they tell you about an awful symptom or a recent bereavement, acknowledge how difficult that must be, and use this as a gateway to ask about impact.

Working with colleagues

You will almost certainly end up signposting or referring to different team members inside or outside general practice. Be confident and complimentary when talking about their roles. For example, “There is a fantastic breastfeeding team in this area. They are really experienced helping women with the problem you are describing. Would you like me to send you their details?”.

There might be a case where a patient has had a negative previous experience with a colleague. If they start ranting to you, empathise, but don’t get pulled in! It’s fine to acknowledge they have had a difficult time and apologise for things that haven’t gone well. But make sure you aren’t laying blame at someone’s door. The opposite might also be true – if someone has made a serious error in the past, don’t attempt to make excuses for them!

A conversation with a fellow health professional will likely come up in the SCA as a station. Examples might be a paramedic or a district nurse. These are useful consultations to practice (particularly as they can provide observations and examination findings).

Ask for their opinions and value them. If you disagree with their suggested plan or want to do something different, explain your reasons for this clearly and stay respectful throughout.

Practicing holistically, promoting health, and safeguarding

We have already touched on impact a couple of times. This is just a reminder to ask about it again. As well as the impact on people close to them.

Respecting the patient’s opinions and ideas is important, but it doesn’t mean you have to agree with them. You can gently challenge their beliefs and behaviours. For example, “What do you think it would be like if you weren’t drinking so much?” or “Why do you think we would have prescribed these medications if there is no point to them?”

Above all, take the time to understand what matters to the patient and work with them to enhance their care. Cases where this might be important could be palliative care patients, or those approaching the latter years of their lives with complex co-morbidity.

What is most important for them – and what can you do to prioritise this? This will demonstrate that you have the patient at the heart of your consultation.

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Final tips

If you can use and demonstrate these tips, you will likely do well in the SCA. Even if you have no idea how to manage a case (I had one in my exam where I wasn’t sure if the patient needed to go to hospital as an emergency or could be reassured and stay at home…), then take an excellent history, show off your skills at relating to the patient, share your uncertainty in the differential, and then do something vaguely sensible.

If you are looking for practice SCA cases, the Geeky Medics SCA case bank has over 120 cases written by expert authors and tailored to match the exam format.

Lastly, remember that if one station goes horribly – don’t panic! That examiner will not see the rest of your stations, so you have a fresh slate. Take a deep breath, remember your structure, and move on. Good luck!

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