Station 19 · A consultation through an interpreter

Candidates: do not open until you have consulted.

Persona and manner

• Rukhsana Begum, 58; quiet and dignified; you understand more English than you speak; you look at the doctor when spoken to directly and answer in Sylheti with a few English words. You defer to your son in front of strangers but you have your own views.
• Imran, 27, her son, interprets; helpful, protective, in a hurry; he summarises, adds his own opinions, and sometimes answers for her. He softens if the doctor includes him without letting him take over.

Opening line (verbatim)

• “Imran: “She's been really tired and she's drinking water all the time, like litres. She's lost weight as well. I told her it's probably her age but she wanted to come. And she wants to know if she can fast — Ramadan's in three weeks.””

The story

• Through Imran, and directly when the doctor speaks slowly: thirsty day and night for three months; up three or four times a night to pass water; tired; her clothes are loose; blurred vision some days.
• If asked directly, in simple English or through the interpreter: she has had thrush twice; she thought it was the heat; a tingling in her feet at night.
• Diet: rice, curry, bread; sweet tea four or five times a day; she cooks for the family.
• Her mother had diabetes and died of a stroke at 70; her brother in Sylhet is on insulin and has lost part of a foot. She is frightened of insulin and of “losing my leg like my brother”.
• If asked about fasting: she has fasted every Ramadan since she was twelve; last year she felt faint twice but did not break the fast; she will not miss it this year unless “the doctor says it is dangerous, and the imam agrees”.
• Imran, if not managed: “She doesn't need to know all that, just tell me what to do.” And: “She won't take tablets, she never does.”
• If asked, she takes the amlodipine most days; Imran sets out the tablets.
• Mood: fine; she worries about her brother; she sleeps badly because of the toilet.

Ideas, concerns and expectations

• Idea: Hers: “It is my age and the hot weather.” Imran's: “It's probably diabetes, everyone in our family has it.”
• Concern: Hers: insulin; losing a leg like her brother; not being able to fast. Imran's: that his mother will not take the tablets and that this will take hours.
• Expectation: Hers: to be told the truth, and whether she can fast. Imran's: a prescription and a quick exit.

Impact

• Home: she cooks for seven; she will not change the family's food.
• Faith: fasting is central; breaking it needs a reason she can give to herself and to the imam.
• Family: Imran manages appointments and medicines; she does not want to be a burden.

Red flags

• Present: An HbA1c of 84 with symptoms (thirst, polyuria, weight loss, blurred vision, thrush, tingling feet), a family history of insulin and amputation, and a month's fast in three weeks.
• Absent: No vomiting, abdominal pain or breathlessness; no ketone symptoms; she is eating and drinking; not acutely unwell.
• Absent: No foot ulcer; no chest pain; no visual loss.

Hidden facts and their triggers

• The thrush and the tingling feet — released only only if asked directly, not through Imran's summary
• Her fear of insulin and of her brother's foot — released only if asked what worries her, directly
• That she felt faint twice last Ramadan — released only if asked how fasting went last year
• That she would break the fast if the doctor explained the danger and the imam agreed — released only if the doctor asks what would make her consider not fasting, or offers to write a letter
• Her own view that she can manage tablets — released only if asked directly whether she will take a tablet, rather than accepting Imran's answer

Behaviour

• Minute 1: Imran speaks for her; she watches the doctor.
• Minute 3, if the doctor addresses her directly and slowly: she answers in English with a few words and smiles; Imran interrupts to correct her.
• Minute 5: Imran: “She doesn't need to know all that, just tell me what to do.”
• If the doctor speaks to her directly, uses the telephone interpreter for the important parts, explains the result and the diagnosis in plain words to her, includes Imran as her son and not as the patient, answers the fear of insulin and the foot honestly, agrees a tablet she will take, deals with the fast with a plan and a letter for the imam if she wishes, arranges the foot and eye checks, and reviews in two weeks: she thanks the doctor in English and says, “I will not fast this year if you write it.” Imran relaxes.
• If the doctor talks only to Imran: she looks at the floor and says nothing.
• If the doctor refuses the interpreter because Imran is here: Imran is pleased; she is not.
• If the doctor forbids fasting without explanation: she says, in English, “I will fast.”

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

• If the candidate explains and asks: blood pressure 150/92; weight 76 kg; capillary glucose 17.2 mmol/L; urine ketones negative; feet: pulses present, reduced sensation to the monofilament at the toes on both sides, no ulcer; fundi not examined today (retinal screening to be arranged).

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

• Conducting the whole consultation with the son, so that the thrush, the feet and her own view of tablets are never heard (statement R3)
• Forbidding the fast without explanation, so that she says “I will fast” and will (statement R4)
• Starting treatment through the son without checking what she has understood or whether she consents (statement R7)

What the examiner is listening for in the last four minutes

By 8:00 the working diagnosis should have been stated to her, through the interpreter, in words she can repeat. The examiner is listening for: metformin started with a titration she will manage and the second agent planned; education in her language, eye screening and foot care arranged; the blood pressure and cholesterol plan; the fast advised against this year with the reasons and the letter offered, and the path to safer fasting later; a safety-net for vomiting, pain or drowsiness; the review with the interpreter; and her own words, not Imran's, on what she will do.

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. Diabetes is diagnosed on an HbA1c of 48 mmol/mol or more; in a person with symptoms a single result is sufficient; an HbA1c of 84 with thirst, polyuria and weight loss is diabetes with significant hyperglycaemia, and ketones are checked where there is weight loss or an acute presentation. NICE — NG28 Type 2 diabetes in adults: management, section 1.1, individualised care; diagnosis (referring to the WHO criteria), 2015, last updated February 2026, checked 10 Oct 2026
2. Offer standard-release metformin as the first-line drug for adults with type 2 diabetes; start at a low dose and increase gradually to minimise gastrointestinal side-effects; if symptomatic hyperglycaemia persists, consider early dual therapy; rescue therapy with insulin or a sulfonylurea is for symptomatic hyperglycaemia where needed. NICE — NG28 Type 2 diabetes in adults: management, section 1.7, drug treatment: first-line and rescue therapy, 2015, last updated February 2026, checked 10 Oct 2026
3. Offer structured education to adults with type 2 diabetes and their family at and around the time of diagnosis, with annual reinforcement; the programme should be accessible to people with language and literacy needs and culturally appropriate. NICE — NG28 Type 2 diabetes in adults: management, section 1.2, patient education, 2015, last updated February 2026, checked 10 Oct 2026
4. People with poorly controlled diabetes (HbA1c above 75 mmol/mol or very high glucose), symptomatic hyperglycaemia, or who are newly diagnosed and not yet stable, are at high risk from fasting and are advised not to fast; those at lower risk who choose to fast need a pre-Ramadan assessment, medication adjustment, glucose monitoring during the fast, and advice on when to break the fast. Diabetes UK and the British Islamic Medical Association — Ramadan and diabetes: guidance for healthcare professionals, risk stratification; pre-Ramadan assessment, 2024, checked 10 Oct 2026
5. Assess the feet of a person with newly diagnosed diabetes and at least annually; loss of protective sensation on monofilament testing places the person at moderate risk and warrants referral to the foot protection service; refer newly diagnosed people for retinal screening. NICE — NG19 Diabetic foot problems: prevention and management, section 1.3, assessing the risk of a diabetic foot problem, 2015, last updated October 2019, checked 10 Oct 2026
6. Make sure arrangements are made to meet patients' language and communication needs; where an interpreter is needed, use a professional interpreter rather than a family member wherever possible, particularly for consent, diagnosis and the discussion of treatment, so that the patient's own views are heard. GMC — Good medical practice, domain 1, working with patients: communication; paragraph on language needs, 2024, checked 10 Oct 2026
7. Consent is valid only when the patient understands the information and makes the decision themselves; where a relative is present, the doctor must satisfy themselves that the patient, not the relative, is consenting; information must be given in a way the patient can understand, with an interpreter where needed. GMC — Decision making and consent, paragraphs 10 to 20, the dialogue; paragraph 25, when the patient needs support to understand, November 2020, checked 10 Oct 2026
8. In adults with type 2 diabetes, aim for a clinic blood pressure below 140/90 mmHg; offer atorvastatin 20 mg for primary prevention where the 10-year cardiovascular risk is 10% or more; both are reviewed at diagnosis. NICE — NG136 Hypertension in adults: diagnosis and management, section 1.4, treatment targets, 2019, last updated February 2026, checked 10 Oct 2026
9. Diabetes is diagnosed on an HbA1c of 6.5% (48 mmol/mol) or more, a fasting plasma glucose of 7.0 mmol/L or more, a two-hour value of 11.1 mmol/L or more on an oral glucose tolerance test, or a random glucose of 11.1 mmol/L or more in a person with classic symptoms of hyperglycaemia. Without unequivocal hyperglycaemia, two abnormal results are needed; with symptoms and a random glucose of 16.4 mmol/L, one is enough. ADA — Standards of Care in Diabetes 2025, section 2: Diagnosis and classification of diabetes, criteria for the diagnosis of diabetes, 2025, checked 10 Oct 2026
10. Agree an individual HbA1c target: 48 mmol/mol for a person managed by lifestyle or a single drug that does not cause hypoglycaemia, 53 mmol/mol on a drug that can, and intensify treatment if the HbA1c rises to 58 mmol/mol or more. Consider an SGLT2 inhibitor alongside metformin where there is heart failure or established cardiovascular disease, or where the ten-year cardiovascular risk is 10% or more. NICE — NG28 Type 2 diabetes in adults: management, section 1.6, HbA1c measurement and targets; section 1.7, drug treatment (2022 update), NG28, 2015, last updated June 2022, checked 10 Oct 2026
11. Standard-release metformin is started at 500 mg once daily with breakfast for at least a week, then 500 mg twice daily with meals for at least a week, then 500 mg three times a day, to a maximum of 2 g a day; a modified-release preparation can be tried if gastrointestinal effects persist. Check renal function before starting and at least annually; reduced vitamin B12 is a recognised effect and is measured if symptoms of deficiency appear. BNF (NICE) — Metformin hydrochloride, indications and dose; monitoring requirements; MHRA advice on vitamin B12 (2022), current online version, checked 10 Oct 2026
12. Give sick-day advice at diagnosis: during an illness with vomiting, diarrhoea or fever, keep drinking fluids, keep taking insulin if prescribed, and temporarily stop metformin and any SGLT2 inhibitor while dehydrated or unable to eat and drink, restarting 24 to 48 hours after eating and drinking normally. Seek urgent help for persistent vomiting, abdominal pain, drowsiness or rapid breathing, which may indicate ketoacidosis. NICE CKS — Diabetes - type 2, management: advice on sick-day rules and when to seek help, current online version, checked 10 Oct 2026
13. Patients who need an interpreter should have access to a professional interpreter, booked for the full consultation, in person or by telephone or video; the need is recorded on the record and the patient's preferred language and any preference about the interpreter's sex are noted. Family members and friends are used only in an emergency or at the patient's explicit request after the risks are explained, and children are not used to interpret. NHS England — Guidance for commissioners: interpreting and translation services in primary care, principles: access, booking, recording the need, use of family and friends, 2018, checked 10 Oct 2026
14. The curriculum expects the GP to diagnose type 2 diabetes from symptoms and results, to explain it in a way the person can understand, to start and titrate treatment and arrange structured education, retinal screening and foot care, to recognise ketosis and the need for insulin, and to plan care around the person's culture and religious practice, including fasting during Ramadan, with an interpreter where needed. RCGP — GP curriculum: Metabolic problems and endocrinology, diabetes: diagnosis, management and culturally appropriate care, Being a GP, 2025 curriculum, checked 10 Oct 2026

Working references for this station

14 statements, 784 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-19