Station 5 · Bowel symptoms

Candidates: do not open until you have consulted.

Persona and manner

• Kenneth Doyle, 62, a retired bus driver; bluff, humorous, minimising; here because your wife made the appointment and she is “in the next room listening”. You deflect with jokes and go quiet when frightened.
• You use “piles” to explain everything.

Opening line (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.”

The story

• “A bit of blood when I wipe, on and off for months. Bright red, mostly.”
• “My bowels are a bit loose, three or four times a day, for a couple of months. The diet's changed since I retired.”
• “I've lost a bit of weight. The wife's pleased.”
• If asked about the blood: sometimes mixed in with the stool and darker; sometimes slime with it. No doctor has ever told you that you have piles.
• If asked about weight: 92 kg to 85 kg in four months without trying; your trousers are loose; your appetite is “not what it was”.
• If asked about your bowels: looser and more often for three months; sometimes you wake at night to go; a feeling of not emptying properly.
• Tired; a bit breathless walking the dog uphill, which is new. No stomach pain; some bloating. No vomiting; no indigestion; no trouble swallowing.
• You smoke 20 a day and drink four cans most nights. You drive the minibus for the church on Sundays.
• Your father: bowel cancer at 66. “He had the camera, then an operation, then he died six months later.” You believe the operation killed him. You declined the screening kit “because I knew what they'd want to do”.

Ideas, concerns and expectations

• Idea: “Piles.” Underneath, you know. If asked what you think it could be: a long pause, then “Same as my dad.”
• Concern: The camera and an operation; leaving Maureen; “I'd rather not know.”
• Expectation: Cream.

Impact

• Maureen: breast cancer treated last year; “She's the one who should be here.” You drive her to appointments; you do the shopping.
• Church: you drive the minibus on Sundays; it is the thing you still do for other people.
• Money: no concern. Driving: no concern.

Red flags

• Present: Rectal bleeding mixed with the stool, a change in bowel habit for three months, unintended weight loss of 7 kg, nocturnal stools and tenesmus, new exertional breathlessness, a first-degree relative with bowel cancer.
• Absent: No abdominal pain; no vomiting; no difficulty swallowing; no indigestion.
• Absent: No fever; no jaundice; no bone pain.

Hidden facts and their triggers

• The weight figures, 92 to 85 kg in four months — released only if the doctor asks what you weigh now, or reads the weight from the record and asks
• The night-time stools and the feeling of not emptying — released only if asked in detail about the bowels
• The blood mixed in and darker, and the slime — released only if asked what the blood looks like and where it is
• Your father's story in detail and why you declined screening — released only if asked about the family, or why you did not do the kit
• “Same as my dad” — released only if the doctor asks what you think it could be, and waits

Behaviour

• Minute 1: joke — “She's listening, so I'd better behave.”
• Minute 3: “My dad had all that.” A dismissive wave.
• Minute 6, if a test or a referral is raised: “I'd rather not know, if I'm honest.”
• If the doctor takes a proper history, recognises that this needs an urgent suspected-cancer referral, sends the stool test and bloods alongside without waiting for them, tells the truth about how treatment has changed since your father's day, explores what “rather not know” means and respects your right to decide while making the consequences clear, offers to involve Maureen, and safety-nets: silence, then “You're saying it could be the same as my dad,” then “If I go, will you be the one telling me?” You agree to the referral “for Maureen”.
• If the doctor prescribes cream and sends a stool test “to be safe” with no explanation: take the cream and go.
• If the doctor refers without exploring why you declined screening: “I'm not going.” And you will not.
• If the doctor lectures you about screening or smoking: go quiet and look at the door.

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

• Video: you look thinner than the photograph on record if the candidate asks; you can show your tongue and your palms if asked (pale).
• If the candidate states what they would examine in person and why: abdomen soft, no mass; a rectal examination, if arranged and described, finds no external haemorrhoids, no palpable rectal mass, and soft brown stool with a streak of dark blood on the glove. Offer to come in tomorrow; nothing is examined today.

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

• Accepting “piles” because he says it with a smile, and never asking where the blood is or what he weighs (statement D6)
• Sending a FIT instead of the referral, or making the referral without engaging why he declined screening, so that he does not go (statement C1)
• Lecturing about the screening kit so that “I'd rather not know, if I'm honest” is never explored (statement R5)

What the examiner is listening for in the last four minutes

By 8:00 the working diagnosis should have been stated: symptoms that meet the urgent suspected-cancer referral criteria, with piles not the explanation. The examiner is listening for: the referral made today, with FIT and bloods alongside; the pathway explained in steps he can decide at; an honest account of how treatment has changed since his father; a safety-net that names heavier bleeding, vomiting or not opening his bowels, and breathlessness; who will tell him the result; and a check of what he has understood and decided.

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 adults using a suspected-cancer pathway referral for colorectal cancer if they are aged 40 and over with unexplained weight loss and abdominal pain, aged 50 and over with unexplained rectal bleeding, or aged 60 and over with iron-deficiency anaemia or changes in their bowel habit; the FIT update retains referral regardless of FIT where there is a rectal mass, an anal mass or anal ulceration. NICE — NG12 Suspected cancer: recognition and referral, section 1.3, lower gastrointestinal tract cancers, 2015, last updated 2025, checked 10 Oct 2026
2. Quantitative FIT is used in primary care to guide referral for suspected colorectal cancer in adults with symptoms; people with a FIT of 10 micrograms of haemoglobin per gram of faeces or more are referred on the suspected-cancer pathway; referral is not delayed while awaiting the result where the clinical picture strongly suggests cancer, and a negative result does not exclude cancer in a person with persisting symptoms. NICE — DG56 Quantitative faecal immunochemical testing to guide colorectal cancer pathway referral in primary care, section 1, recommendations, August 2023, checked 10 Oct 2026
3. Rectal bleeding that is mixed with the stool, dark, or accompanied by mucus, together with a change in bowel habit, tenesmus or nocturnal defecation, is not explained by haemorrhoids; a rectal examination and a full blood count are part of the assessment of lower gastrointestinal symptoms in primary care. NICE CKS — Gastrointestinal tract (lower) cancers: recognition and referral, assessment, current online version, checked 10 Oct 2026
4. The NHS bowel cancer screening programme in England invites people every two years using a home FIT kit; eligibility has extended to age 50; a person who has declined can request a kit at any time through the screening helpline, and a symptomatic person is investigated through the symptomatic pathway, not screening. GOV.UK (NHS England) — Bowel cancer screening: programme overview, 2025, checked 10 Oct 2026
5. Doctors must work in partnership with patients, share information in a way they can understand, and respect a competent adult's right to decline investigation or treatment after the consequences have been explained; the decision must be the patient's own and must be recorded. GMC — Decision making and consent, paragraphs 1 to 8, the seven principles; paragraphs 16 to 20, the dialogue, November 2020, checked 10 Oct 2026
6. Offer behavioural support and pharmacotherapy to every person who smokes, at every contact, using the opportunity a new diagnosis or investigation provides; the offer is framed around the person's own goals and is repeated without judgement. NICE — NG209 Tobacco: preventing uptake, promoting quitting and treating dependence, section 1.12, stop-smoking interventions, 2021, last updated January 2025, checked 10 Oct 2026
7. The UK Chief Medical Officers' low-risk guideline is not more than 14 units a week spread over three or more days; four cans of 4% lager a night is about 60 units a week, a level at which brief advice and an offer of support are indicated. NICE CKS (citing the UK Chief Medical Officers' 2016 guideline) — Alcohol, problem drinking, background: the low-risk drinking guideline and unit calculation, current online version, checked 10 Oct 2026
8. Under the August 2023 update, offer FIT to adults with an abdominal mass, a change in bowel habit or iron-deficiency anaemia; aged 40 and over with unexplained weight loss and abdominal pain; aged 50 and over with unexplained rectal bleeding, abdominal pain or weight loss; or aged 60 and over with anaemia without iron deficiency. Refer on the suspected-cancer pathway at a FIT of 10 micrograms of haemoglobin per gram of faeces or more, and without a FIT where there is a rectal or anal mass or anal ulceration. NICE — NG12 Suspected cancer: recognition and referral, section 1.3, colorectal cancer: FIT recommendations (August 2023 update), 2015, last updated 2025, checked 10 Oct 2026
9. Haemorrhoids typically cause bright red, painless bleeding on the paper or in the pan, itching, soreness and a lump on straining; the diagnosis is made only after other causes have been excluded by history, abdominal examination, digital rectal examination and, where available, proctoscopy. Blood mixed with the stool, a change in bowel habit, weight loss, anaemia or a family history of bowel cancer are not explained by haemorrhoids. NICE CKS — Haemorrhoids, diagnosis: clinical features and examination; management, current online version, checked 10 Oct 2026
10. Investigation after a suspected-cancer referral is usually by colonoscopy, with CT colonography or flexible sigmoidoscopy where colonoscopy is unsuitable; the person is seen within two weeks of referral and is told at referral that cancer is being investigated, so that the appointment is kept. Primary-care tests are sent alongside the referral, not instead of it: a full blood count and ferritin, urea and electrolytes, liver function tests and a FIT. NICE CKS — Gastrointestinal tract (lower) cancers: recognition and referral, referral: information for the person; investigations in secondary care, current online version, checked 10 Oct 2026
11. Information may be shared with those close to the patient only with the patient's agreement. If a patient does not want a relative told, that is respected, and the doctor neither confirms nor discloses clinical information to a family member without consent; the doctor may still listen to what a relative says. Where the patient wishes, the relative is involved in the consultation and given the same information. GMC — Confidentiality: good practice in handling patient information, sharing information with those close to the patient, 2017 (updated 2018), checked 10 Oct 2026
12. The AUDIT questionnaire scores 0 to 40: 8 to 15 is increasing risk, 16 to 19 higher risk, and 20 or more possible dependence; an AUDIT-C score of 5 or more prompts the full questionnaire. Increasing- and higher-risk drinkers are offered brief structured advice. A person who may be dependent is advised not to stop abruptly because of withdrawal and is referred for specialist assessment, with assisted withdrawal where needed. NICE CKS — Alcohol, problem drinking, assessment: AUDIT and AUDIT-C; management by level of risk, current online version, checked 10 Oct 2026
13. The Gastroenterology Topic Guide expects the GP to recognise the alarm features of lower gastrointestinal symptoms and to use FIT and the suspected-cancer pathway correctly. The Topic Guide 'People with long-term conditions including cancer' expects the GP to support a person's own decision about investigation, to recognise the role of a carer, and to remain the point of continuity through diagnosis and treatment. RCGP — GP curriculum: Gastroenterology, lower gastrointestinal symptoms and suspected cancer; People with long-term conditions including cancer: shared decisions and continuity, Being a GP, 2025 curriculum, checked 10 Oct 2026

Working references for this station

13 statements, 789 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-05