Station 12 · PSA result

Candidates: do not open until you have consulted.

Persona and manner

• Ian Prescott, 55, an airline ground operations manager; organised, brisk, used to managing logistics; you want facts and a timeline and you hide anxiety behind questions about schedules. You are in your car in a car park; occasional airport noise.
• You become quiet when your brother is mentioned.

Opening line (verbatim)

• “Hello — I'm ringing for my PSA result. I only had it because my brother made me. I'm assuming it's fine? I'm flying to Perth for my son's wedding a week on Thursday, so if there's anything, I'd rather know now.”

The story

• “No symptoms at all. I'm fit. I run.”
• “The wedding: my son lives in Australia. Three weeks away. Non-negotiable.”
• If asked about waterworks: “Maybe I get up once at night. That's normal, isn't it?” Stream fine; no blood; no pain; no bone pain; no weight loss.
• If asked about the test: no recent urine infection, no catheter, no cycling before the test, no sex within 48 hours; “the nurse asked”.
• No one has ever examined your prostate. If a rectal examination is proposed by phone: “No thanks, not today.” You will agree to come in for one before or after the flight.
• Your brother Neil: diagnosed at 58, two years ago. “They took the whole thing out. He wears pads. He can't… you know. It's wrecked him.” You have decided you will not have that operation.
• Your father died at 80 of a stroke; no other cancer in the family.
• Married to Julie; two sons. Julie “will want to know everything”. You have not told her the test was done.
• You would rather have any referral after the wedding, “I don't want it hanging over the trip”, but if told that two weeks matters, “then get me in before”.

Ideas, concerns and expectations

• Idea: “Probably nothing. No symptoms.”
• Concern: Ending up like Neil; the trip being cancelled; telling Julie.
• Expectation: A normal result, or a plan that fits around the wedding.

Impact

• Work: you run a team; a day off is a day of explaining.
• Home: Julie does not know the test was done; your sons are grown; the wedding is the family event of the decade.
• Driving and money: no concern.

Red flags

• Present: A PSA above the age-specific referral threshold with a first-degree relative diagnosed under 60; no rectal examination recorded.
• Absent: No lower urinary tract symptoms of note, no haematuria, no bone pain, no weight loss.
• Absent: No recent urine infection, catheter, cycling or ejaculation that would raise the PSA falsely.

Hidden facts and their triggers

• Getting up once at night — released only if asked about waterworks
• Neil's incontinence and the decision never to have that operation — released only if asked why your brother made you test, or what his treatment was like
• That Julie does not know the test was done — released only if asked who knows, or who you would want to tell
• Your preference for the referral after the wedding — released only if the doctor raises timing, or at minute seven
• That you would come in before the flight if told it matters — released only if the doctor explains why two weeks matters

Behaviour

• Minute 1: “I'm assuming it's fine?”
• Minute 3, if asked why your brother made you test: “It's wrecked him.”
• Minute 7: “After the wedding, if possible.”
• If the doctor gives the result clearly with a warning that it is not what you hoped, explains what the number does and does not mean, explains the pathway and that the next step is a scan before any biopsy and long before any operation, takes Neil's story seriously, arranges the examination and the referral now with the travel dates noted so the scan can be fitted before or straight after, involves Julie as you wish, and safety-nets: exhale. “So nobody's cutting anything out next week.” Ask the doctor to “get the ball rolling, and I'll tell Julie tonight.”
• If the doctor says it is a bit high and suggests repeating it in three months: relieved. “Great, after the wedding then.”
• If the doctor says you need an urgent referral with no explanation of the pathway: “Do I need to cancel the flight?” Panic.
• If the doctor gives the result baldly with no warning: go silent for a few seconds, then ask for it again.

Examination findings, if the candidate states what they would examine and why

• None: audio-only telephone consultation. There are no examination findings to give.
• If the candidate proposes a rectal examination: “No thanks, not today.” You will come in for one tomorrow or after the flight; the candidate should say that the referral does not wait for it.

Domain grades — with the key facts that earn a clear pass at this station

Global rating (recorded, not added to the total): ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass

The domain grades (RCGP descriptors): CP clear pass — above the standard of a newly qualified, independent GP · P pass — sufficiently demonstrated at the standard · F fail — insufficiently demonstrated at the standard · CF clear fail — clearly demonstrated below the standard.

The RCGP grades each domain CF, F, P or CP and weights clinical management and medical complexity against the other two domains; the examination's maximum is 126 over twelve cases, which is 10.5 per case. The RCGP does not publish the mark each grade carries. MD Acumen's training sheet uses CF 0 · F 1 · P 2 · CP 3, with clinical management weighted ×1.5 (0 · 1.5 · 3 · 4.5), so that a case is marked out of 10.5 and a twelve-case circuit out of 126. A P in all three domains is 7.0; MD Acumen treats that line as the training standard for a case. The examination's pass mark is set by borderline regression for each diet and is published in the RCGP's diet summary reports; it is not a fixed fraction of 126.

Weighting rationale, in the RCGP's words: “To reflect the capability coverage within the clinical management and medical complexity domain this is weighted in comparison to the other two domains.”

Written to the standard of a newly qualified independent GP; the clear-pass row describes practice above that standard. It is a debriefing aid, not a checklist: the grade is a judgement that the essentials, the italic key facts on the mark sheet, were done well, at the patient's pace and in plain language. MD Acumen training standard; the RCGP does not publish case mark sheets.

Where candidates lose this station

• Saying the result is a bit high and suggesting a repeat in three months, so that “Great, after the wedding then” ends the call (statement C3)
• Hearing “It's wrecked him” and moving on to the referral without exploring what Neil's story means for whether Ian will attend (statement R2)
• Announcing an urgent referral without explaining the pathway, so that he asks whether to cancel the flight and panics (statement R4)

What the examiner is listening for in the last four minutes

By 8:00 the assessment should have been stated: a PSA above the age-specific threshold with a first-degree family history, which meets the urgent referral criteria. The examiner is listening for: the referral made now with the travel dates on it; the examination arranged but not a condition; the pathway in steps (first appointment within two weeks, a scan first, biopsy only if needed, decisions long before any operation, surveillance common); the separation of referral from surgery said aloud; Julie involved on his terms; a safety-net that names retention, bone pain and blood in the urine; the named contact; and his own words on the next step.

The ten statements below are postulated: the feedback an examiner would most likely attach at this station, chosen from the RCGP's standardised list of 26 feedback statements that applies to every SCA case and spans the three marking domains (Data Gathering and Diagnosis; Clinical Management and Medical Complexity; Relating to Others). They are a prediction from the case content, its complexity and the marks that matter, not an examiner's record: any statement on the full list can be attached to any case, and feedback plays no part in the mark. Record the statements that applied in the practice log.

The full list of 26 statements, with the generic meaning of each, is on the exam and the mark scheme.

Points of fact the examiner should have to hand

Each statement is drawn from the named guideline, in its current version, with the date it was checked. The examiner marks against these facts; the candidate is not expected to quote them.

1. Refer men using a suspected-cancer pathway referral for prostate cancer if their prostate feels malignant on digital rectal examination, or if their PSA is above the age-specific threshold: 2.5 at 40 to 49, 3.5 at 50 to 59, 4.5 at 60 to 69, 6.5 at 70 to 79, 5.0 at 80 and over (micrograms per litre); a digital rectal examination is recommended but its absence should not delay referral. NICE — NG12 Suspected cancer: recognition and referral, section 1.6, urological cancers: prostate, 2015, last updated 2025, checked 10 Oct 2026
2. Before a PSA test, exclude and allow for factors that raise the level transiently: an active urinary infection (wait six weeks), ejaculation within 48 hours, vigorous exercise such as cycling within 48 hours, a prostate biopsy within six weeks, and a rectal examination within a week; a raised level in an asymptomatic man above the age threshold is referred, not repeated. GOV.UK (NHS England) — Prostate cancer risk management programme: advising well men about the PSA test, information for GPs, factors affecting the PSA level; action on a raised result, 2016, updated 2022, checked 10 Oct 2026
3. Offer multiparametric MRI as the first-line investigation for people with suspected clinically localised prostate cancer; offer a biopsy only if the MRI Likert score is 3 or more, or if the score is 1 or 2 and the clinical suspicion is high after discussion; many localised cancers are managed by active surveillance. NICE — NG131 Prostate cancer: diagnosis and management, section 1.2, assessment and diagnosis; section 1.3, localised and locally advanced prostate cancer, 2019, last updated December 2021, checked 10 Oct 2026
4. A first-degree relative diagnosed with prostate cancer, particularly under 60, roughly doubles a man's risk; men with a family history are among those for whom the PSA conversation and a lower threshold for investigation are relevant. NICE CKS — Prostate cancer, background information: risk factors, current online version, checked 10 Oct 2026
5. People referred on a suspected-cancer pathway should be seen within two weeks of referral; the faster diagnosis standard aims to tell the person whether they have cancer within 28 days of referral; a referral should carry the information the receiving team needs, including dates the person is unavailable. NHS England — Early diagnosis: the faster diagnosis standard and cancer waiting times, version 12, 2023, checked 10 Oct 2026
6. When breaking significant news by telephone, confirm the person's identity and that they can talk privately, give a warning that the news is not what they hoped, give the information in small amounts, check understanding, and arrange a follow-up contact; written information supports the conversation. GMC — Decision making and consent, paragraphs 10 to 20, sharing information and discussing options, November 2020, checked 10 Oct 2026
7. Lower urinary tract symptoms in men are assessed with a symptom score, a rectal examination, urinalysis and consideration of PSA after counselling; nocturia once a night is within the usual range for a man in his fifties and does not itself indicate disease. NICE — CG97 Lower urinary tract symptoms in men: management, section 1.1, initial assessment, 2010, last updated June 2015, checked 10 Oct 2026
8. Men aged 50 and over who ask about the PSA test may have it after a discussion of its benefits and limitations; the GP does not offer it unprompted to men without symptoms. The test does not diagnose cancer: about three in four men with a raised PSA do not have prostate cancer on biopsy, and about one in seven men with a normal PSA do. A raised result in a man without symptoms is investigated through the urology pathway, not repeated to see whether it settles. GOV.UK (NHS England) — Prostate cancer risk management programme: advising well men about the PSA test, information for GPs, the PSA test: benefits and limitations; what to tell men, 2016, updated 2022, checked 10 Oct 2026
9. For localised prostate cancer the choice of treatment is made with the man after multidisciplinary review: active surveillance is offered as an option for low-risk disease and considered for intermediate-risk disease, with radical prostatectomy and radical radiotherapy the alternatives. Before any radical treatment, men are told about the likely effects on urinary continence, erectile function and bowel function, and are offered the support of a specialist nurse; treatment is decided after diagnosis and staging, not at referral. NICE — NG131 Prostate cancer: diagnosis and management, section 1.3, localised and locally advanced prostate cancer: treatment decisions and adverse effects, 2019, last updated December 2021, checked 10 Oct 2026
10. Consider a PSA test and a digital rectal examination to assess for prostate cancer in a man with any lower urinary tract symptoms (nocturia, frequency, hesitancy, urgency or retention), erectile dysfunction or visible haematuria. The safety-net for a man awaiting urology assessment names the symptoms that change the urgency: inability to pass urine, new bone pain and visible blood in the urine. NICE — NG12 Suspected cancer: recognition and referral, section 1.6, urological cancers: prostate, when to consider a PSA test, 2015, last updated 2025, checked 10 Oct 2026
11. Information about a patient is shared with a spouse or family member only with the patient's consent, express or implied, and the patient decides how much is shared and when; where a patient asks that a result be kept from a relative, that wish is respected and recorded. A patient may ask for a family member to be present at a consultation or to be told the outcome, and the doctor records what has been agreed. GMC — Confidentiality: good practice in handling patient information, disclosures with consent; sharing information with those close to the patient, 2017, checked 10 Oct 2026
12. The Renal and urology Topic Guide expects the GP to counsel men about PSA testing before it is requested, to perform a digital rectal examination and describe prostate size, tenderness and nodules, to apply the suspected-cancer referral criteria and know the pathway that follows, to break significant news safely including by telephone, and to recognise urinary retention, haematuria and bone pain as the symptoms that change the urgency. RCGP — GP curriculum: Renal and urology, Topic Guide: knowledge and skills, Being a GP, 2025 curriculum, checked 10 Oct 2026

Working references for this station

12 statements, 724 words. Every statement is signed by the Course Director before it is published; a station whose facts have changed since signature carries no signature line until it is signed again.

Record your three domain grades, your case total out of 10.5, your global rating, the RCGP feedback statements that applied, and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for SCA-12