MRCGP SCA Consultation Skills Course
Station 5 · Bowel symptoms
Video consultation · Undifferentiated presentations · Older adults · Circuit 1 · 09:40–11:00 · 13-minute station
A 62-year-old with looser stools, some blood and a stone in weight lost does not want 'the camera' — his father died after one.
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 | Kenneth Doyle, 62, retired bus driver |
| Reason for appointment | "Piles — wants cream" (booked by his wife) |
| PMH | Type 2 diabetes (diet-controlled). Hypertension. Smoker 20/day. Alcohol 30 units/week |
| Medication | Amlodipine 10 mg. Metformin stopped last year (eGFR fine; HbA1c 44). Allergies: none |
| Recent entries | Annual review 4 months ago: weight 92 kg. No FIT test on record. Bowel screening: declined 2024. Father died of bowel cancer at 66 'after an operation' |
Role-player script — tutors only
Delegates: please do not open this section until you have consulted at this station.
Open the role-player script (527 words)
Persona and manner
- Bluff, humorous, minimising; here because his wife made the appointment and is 'in the next room listening'. Deflects with jokes; goes quiet when frightened.
- Uses 'piles' to explain everything.
Opening line — say this verbatim
- "The wife's made me come — it's just my piles playing up, bit of blood now and then, I only need some cream, that's all it is."
Volunteer freely if given the space
- 'Bit of blood' when he wipes, 'on and off for months'; bright red 'mostly'.
- Bowels 'a bit loose', going three or four times a day for 'a couple of months'; 'the diet's changed since I retired'.
- 'Lost a bit of weight — the wife's pleased.'
Only if asked
- Blood: sometimes mixed in with the stool, darker; occasionally mucus. Never had piles diagnosed by a doctor.
- Weight: 92 kg to 85 kg in four months without trying; trousers loose; appetite 'not what it was'.
- Bowels: looser and more frequent for three months; sometimes wakes at night to go; a feeling of not emptying properly.
- Tired; a bit breathless walking the dog uphill, which is new. No abdominal pain; some bloating.
- No vomiting; no indigestion; no difficulty swallowing.
- Father: bowel cancer at 66, 'had the camera, then an operation, then died six months later' — Kenneth believes the operation killed him. He declined the screening kit 'because I knew what they'd want to do'.
- Wife Maureen has cancer of her own — breast, treated last year, 'she's the one who should be here'.
- Smokes 20 a day; drinks four cans most nights.
- Drives a minibus for the church on Sundays.
Ideas, concerns and expectations
- Idea: 'piles'. Underneath — he knows. If asked what he thinks it could be: long pause, then 'same as my dad'.
- Concern: the camera and an operation; leaving Maureen; 'I'd rather not know'.
- Expectation: cream.
Cues to deliver, timed
- Minute 1: jokes — 'she's listening, so I'd better behave'.
- Minute 3: 'my dad had all that' — dismissive wave.
- Minute 6: if a test or referral is raised: 'I'd rather not know, if I'm honest.'
How to respond to the doctor's plan
- If the doctor takes a proper history, recognises red flags (rectal bleeding with change in bowel habit and weight loss at 62), explains that this needs an urgent suspected-cancer referral, offers a FIT test and bloods alongside, addresses his father's story with honesty about how treatment has changed, explores what 'rather not know' means and respects his right to decide while making the consequences clear, involves Maureen if he wishes, and safety-nets: he is silent, then 'you're saying it could be the same as my dad', then 'if I go, will you be the one telling me?'. He agrees to the referral 'for Maureen'.
- If the doctor prescribes cream and offers a FIT 'to be safe' with no explanation: he takes the cream; the examiner will not.
- If the doctor refers without exploring why he declined screening: 'I'm not going' — and he will not.
Examination findings if requested
- Looks thinner than the photograph on record; pale; abdomen soft, no mass; PR examination (arrange, or if described): no external haemorrhoids, no palpable rectal mass, soft brown stool with a streak of dark blood on the glove.
Do not
- Volunteer the weight figures, the night-time stools or the father's story detail unless asked.
- Refuse outright; he can be brought round by honesty.
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 |
|
|
|
| Clinical Management & Medical Complexity |
|
|
|
| Relating to Others |
|
|
|
Global rating guide: Pass = red flags recognised, 2WW referral made and negotiated through his fear, honesty about the father's story, safety-net.
Teaching points
- NICE NG12 (2023 FIT update): FIT for most lower-GI symptoms — but refer on suspected cancer pathway regardless of FIT if there is a rectal mass, an anal mass, or unexplained anal ulceration; and use clinical judgement when symptoms strongly suggest cancer even before FIT returns. Weight loss, change in bowel habit and rectal bleeding in a 62-year-old smoker with a first-degree family history: refer now, send FIT and bloods in parallel.
- A patient's refusal is a belief to explore (3.2), not an end-point; the door to change his mind is his father's story, told accurately.
- The carer role (his wife's cancer) is the psychosocial nuance that unlocks motivation.
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 Station 5
Revision link for this case: mdacumen.com/sca-station5-bowel-symptoms
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.