MRCGP SCA Consultation Skills Course
Starter Station B · Knee pain
Video consultation · Undifferentiated presentations · Musculoskeletal · Starter demonstration 09:00–09:40 — flawed run
A 52-year-old self-employed decorator with a painful knee wants an MRI scan.
Candidate brief
Read this as you would in the exam. One to two minutes' reading, then ten minutes. You may ask the patient for examination findings; there is no reference material.
| Patient | Paul Whitmore, 52, self-employed painter and decorator |
| Reason for appointment | "Right knee — needs a scan" (booked by telephone) |
| PMH | Hypertension (well controlled). Nil else |
| Medication | Ramipril 5 mg od. Buys ibuprofen 400 mg over the counter. Allergies: none |
| Recent entries | Nurse BP check three months ago: 132/82, BMI 31, 'knee mentioned — advised to book'. No knee imaging on record |
Role-player script — tutors only
Delegates: please do not open this section until you have consulted at this station.
Open the role-player script (580 words)
Persona and manner
- Practical, plain-speaking, a little weary; he has been putting this off for months and has now decided what he needs.
- Sits with the right leg out straight, rubs the knee when it is mentioned. Not aggressive; wants to be taken seriously.
Opening line — say this verbatim
- "It's my right knee, doctor — it's been giving me grief for about six months and I'm on it all day. I reckon I've torn the cartilage and I need an MRI so we can get on with fixing it."
Volunteer freely if given the space
- Aching pain on the inner side of the knee, worse going down stairs, kneeling, and at the end of a working day.
- Stiff for a few minutes first thing in the morning and after sitting in the van; 'eases off once I'm moving'.
- Sometimes 'feels like it'll give' when he turns quickly on it; it has never actually given way and he has never fallen.
Only if asked
- No injury or twist; it came on gradually. No locking — it never gets stuck. No true giving way.
- Mild swelling at the end of a long day; never hot or red; no fever; not unwell.
- No hip pain, no back pain, no pain at night that wakes him, no weight loss.
- Ibuprofen two or three times a day on working days for four months; some indigestion; no black stools.
- Kneels on hard floors most days; uses knee pads 'sometimes'. Climbs ladders.
- Weight has crept up about a stone in two years — 'sandwiches in the van'.
- Walks the dog; no other exercise. Has never seen a physiotherapist — 'what would they do?'.
- Self-employed; no sick pay; a big contract starts next month and he 'can't afford to be off'.
- Wife works part-time; two teenagers; mortgage.
- A mate 'had his knee scoped and was right as rain' — this is where the plan came from.
Ideas, concerns and expectations
- Idea: torn cartilage that needs a scan and a keyhole operation.
- Concern: not being able to work; 'ending up with a knee replacement at 60 like my dad'.
- Expectation: an MRI 'so we know', then 'whatever it takes'.
Cues to deliver, timed
- Minute 2: 'I can't be off work, that's the thing' — said with a sigh; do not explain unless asked.
- Minute 5: 'the ibuprofen's the only thing keeping me going' — opens the NSAID and stomach line.
Examination findings if requested
- Give these only if the doctor says what they would examine: mild medial joint-line tenderness; small effusion; crepitus; full extension, flexion to 120°; no ligament laxity; McMurray's negative; hip movements full and painless; BMI 31.
How to respond to the doctor's plan
- If the doctor explains that this fits osteoarthritis, that an MRI would not change the plan and that scopes do not help wear-and-tear knees, and offers a real plan — physiotherapy with a strengthening programme, weight, topical anti-inflammatory gel, knee pads and job pacing, a review, and what would prompt referral: be doubtful for a moment ('so no scan?'), then accept if the reasoning is clear and the plan is concrete. Ask 'and if it doesn't get better?'.
- If the doctor agrees to the MRI without discussion: say 'great — how long will that take?' and leave satisfied. The examiner will not be.
- If the doctor refuses the MRI flatly without explaining: push back once — 'my mate got one' — then go quiet and look at the door.
- If the doctor addresses work honestly (what he can and cannot do, a 'may be fit' note if needed): visibly relieved.
Do not
- Volunteer the work worry, the ibuprofen amount, or the friend's operation until asked.
- Report red-flag symptoms; there are none.
Mark scheme
Delegates: open after your consultation. Examiner-observers: open during it.
Generic mark scheme — identical at every station
Domain grades
| Domain | CF (0) | F (1) | P (2) | CP (3) | Points |
|---|---|---|---|---|---|
| Data Gathering and Diagnosis | ☐ | ☐ | ☐ | ☐ | /3 |
| Clinical Management and Medical Complexity (×1.5) | ☐ | ☐ | ☐ | ☐ | /4.5 |
| Relating to Others | ☐ | ☐ | ☐ | ☐ | /3 |
| Total | /10.5 |
Global rating: ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass (CF Clear Fail · F Fail · P Pass · CP Clear Pass)
Feedback statement(s) — tick the one (at most two) you would attach
| Domain 1 | Domain 2 | Domain 3 |
|---|---|---|
| ☐ 1.1 Insufficient data | ☐ 2.1 Referral | ☐ 3.1 Cues / listening / formulaic |
| ☐ 1.2 Notes not used | ☐ 2.2 Prescribing | ☐ 3.2 Agenda / beliefs |
| ☐ 1.3 Psychosocial | ☐ 2.3 Investigations | ☐ 3.3 Circumstances / culture |
| ☐ 1.4 Unsystematic | ☐ 2.4 Prevention | ☐ 3.4 Explanations |
| ☐ 1.5 Prioritisation | ☐ 2.5 Risk management | ☐ 3.5 Judgemental |
| ☐ 1.6 Implications of findings | ☐ 2.6 Co-morbidity | ☐ 3.6 Respect / sensitivity |
| ☐ 1.7 Differentials | ☐ 2.7 Uncertainty | ☐ 3.7 Ownership |
| ☐ 1.8 Diagnosis / decision | ☐ 2.8 Follow-up / safety-net | ☐ 3.8 Teamwork |
| ☐ 2.9 Time management | ☐ 3.9 Safeguarding |
Timing checkpoints (Observer)
| Checkpoint (10-minute frame) | Done | Minute |
|---|---|---|
| Patient allowed to open without interruption (≈1 min) | ☐ | |
| ICE and psychosocial context elicited by 3:30 | ☐ | |
| Red flags covered; examination findings requested by 5:00 | ☐ | |
| Working diagnosis verbalised; gear change by 5:00–5:30 | ☐ | |
| Options shared; patient's preference used | ☐ | |
| Specific safety-net and follow-up by 9:30 | ☐ | |
| Understanding checked; finished inside 10:00 | ☐ |
Key points for this station — customised standard
Key points for this station
| Domain | Pass requires | Clear Pass adds | Fail if |
|---|---|---|---|
| Data Gathering & Diagnosis |
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| Clinical Management & Medical Complexity |
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| Relating to Others |
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Global rating guide: Pass = osteoarthritis diagnosed clinically, MRI request answered with reasoning, an exercise-led plan, work addressed, safety-net. The flawed demonstration is built to trigger 1.1, 1.3, 1.8, 2.3, 2.4, 2.8, 3.2, 3.4 and 3.7.
Teaching points
- NICE NG226 osteoarthritis: diagnose clinically in those aged 45 or over with activity-related pain and morning stiffness under 30 minutes; do not image routinely; core treatment is exercise, weight management and information; topical NSAID before oral.
- Arthroscopic lavage and debridement are not offered for osteoarthritis — the friend's scope is the belief to address.
- A self-employed patient's fear of being off work is the consultation: a plan that ignores it will not be followed.
Guidelines for this station
Your reflection
Record your grades, the statement attached, what you will keep and change, and your own reflection. Your entry is emailed to you as a record of this station; this page stays live so you can revisit the full case during revision.
Write my reflection for Starter Station B
Revision link for this case: mdacumen.com/sca-starterb-knee-pain
Editorial stamp · MRCGP SCA Consultation Skills Course · Station pages v1.0 · 11 September 2026 · Prof Rajesh Varma, Course Director · MD Acumen. Formative training material; not a prediction of exam performance. Not for onward distribution.