Station 6 · Back pain

Candidates: do not open until you have consulted.

Persona and manner

• Craig Wilkins, 34, a self-employed plasterer; irritable, in pain, short with the doctor; you shift in the chair and cannot get comfortable; impatient with “the usual questions”.
• You are not rude by nature. The irritability is pain and money. You soften if the doctor is straight with you.

Opening line (verbatim)

• “I've done my back again, worse than before — I can barely stand up. I need a sick note for the insurance and something a lot stronger than the stuff from the chemist. I've heard all the back advice before, so we can skip that.”

The story

• “I was lifting a bag of plaster three days ago and I felt it go. It's across the lower back and down both legs to the calves. Worse than the other times.”
• “I can't sleep, I can't sit, and I took the day off yesterday for the first time in ten years.”
• “The insurance policy needs a doctor's note from day one.”
• If asked: the pain goes down both legs this time; the previous episodes were one leg only.
• If asked about the bladder: yesterday afternoon you started dribbling when you pass water and not feeling the flow; this morning you were not sure you had finished; you wet yourself slightly on the way to the car. You are embarrassed and you say at first, “That's just from the painkillers, isn't it?”
• If asked about numbness: “in a strange place”, around your back passage and inner thighs when you sit, “like sitting on a cushion”. You noticed it wiping this morning.
• If asked about bowels: not opened for two days. “That'll be the codeine.”
• If asked about the legs: both feel heavy; you tripped on the step this morning.
• No fever, no weight loss, no night pain before this episode, no history of cancer, no steroids, no injecting drug use.
• Co-codamol 8/500, two tablets four times a day, and ibuprofen 400 mg three times a day, for three days.

Ideas, concerns and expectations

• Idea: “A slipped disc, like last time, but worse.”
• Concern: Money; losing the contract; being fobbed off with paracetamol.
• Expectation: A sick note and “proper painkillers”. You name tramadol, which a mate had.

Impact

• Work: self-employed; a kitchen job that must finish by Friday or you lose the next contract; an income-protection policy with a seven-day deferred period, but “they want a note from day one”.
• Home: your partner works part-time; a baby is due in three months; a mortgage.
• Driving: you drove yourself to the chemist yesterday; you tripped on the step this morning.

Red flags

• Present: Bilateral leg symptoms (previous episodes were one-sided), new urinary symptoms with altered sensation and an episode of incontinence, saddle numbness, constipation for two days, heavy legs and a trip on the step.
• Absent: No fever, no weight loss, no night pain before this episode, no history of cancer, no steroid use, no injecting drug use, no major trauma.

Hidden facts and their triggers

• The bladder symptoms — released only if asked directly about passing water, the flow, or any leaking; you attribute them to the painkillers until the doctor explains why they matter
• The saddle numbness — released only if asked about numbness around the back passage, the inner thighs or when wiping
• That both legs feel heavy and you tripped this morning — released only if asked about weakness or walking
• The baby due in three months and the mortgage — released only if asked about home or money
• That the previous episodes were one leg only — released only if asked how this compares with before

Behaviour

• Minute 1: wince and swear under your breath. “Sorry.”
• Minute 3, if asked about bladder or bowels: “What's that got to do with my back?” Irritated; then answer honestly if the doctor explains why.
• Minute 6, when admission is raised: “I can't go to hospital, I've got a job to finish.”
• If the doctor asks the cauda equina questions clearly, explains why they matter, recognises the emergency and arranges assessment today (an ambulance, or immediate transfer to the emergency department with a call ahead), explains what will happen and why the job must wait, deals with the sick note and the insurance today, and tells you plainly that this is the one back pain that cannot wait: frightened; argue once (“You're joking”), then ask, “What happens if I don't go?” When told honestly, agree. Ask whether your partner should come.
• If the doctor prescribes stronger painkillers and issues a fit note without the red-flag questions: take both and leave.
• If the doctor lectures you about lifting: “I said I've heard it.” Disengage.
• If the doctor threatens rather than explains: “Do what you like.”

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

• Video: if the candidate states what they would examine and why, you can show what you can do. You can stand only with support; you walk with a wide-based gait; you cannot walk on your heels.
• If asked to touch the inner thighs and around the back passage with a tissue: the sensation is reduced on both sides. Your bladder feels full. Do not give a residual volume; reflexes cannot be tested on video. In-person examination will be at the hospital.

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 “That's just from the painkillers, isn't it?” for the bladder symptoms without asking about saddle sensation and the flow (statement D6)
• Recommending hospital without arranging it, or arranging it for tomorrow, so that the emergency becomes a routine (statement C1)
• Lecturing about lifting technique to a man who said he had heard it, so that he disengages before the red-flag questions (statement R1)

What the examiner is listening for in the last four minutes

By 8:00 the working diagnosis should have been stated: suspected cauda equina syndrome, an emergency. The examiner is listening for: the arrangement, made now (an ambulance or the emergency department with a call ahead, the time stated); what will happen there and why the job must wait; no opioid today; the fit note issued today and the insurance addressed honestly; the safety-net for the journey (not to drive himself); who is coming with him; and his own words confirming that he knows what happens in the next hour and why.

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. Red flags for cauda equina syndrome include bilateral sciatica, severe or progressive bilateral neurological deficit of the legs, difficulty initiating micturition or impaired sensation of urinary flow, loss of sensation of rectal fullness, perianal or perineal sensory loss (saddle anaesthesia), and laxity of the anal sphincter; a person with any of these needs emergency assessment. NICE CKS — Back pain, low (without radiculopathy), diagnosis: red flags, including cauda equina syndrome, current online version, checked 10 Oct 2026
2. The national suspected cauda equina syndrome pathway: a person with new bilateral radicular pain, or new bladder, bowel or sexual dysfunction, or new saddle sensory change with back pain, is referred for emergency assessment and MRI the same day; do not wait for retention to become complete or for incontinence to develop. GIRFT (Getting It Right First Time) — National suspected cauda equina syndrome pathway, 2023, checked 10 Oct 2026
3. Do not offer opioids for managing acute low back pain unless an NSAID is contraindicated, not tolerated or ineffective, and do not offer opioids for chronic low back pain; a weak opioid, with or without paracetamol, may be considered only for acute pain in those circumstances. NICE — NG59 Low back pain and sciatica in over 16s: assessment and management, section 1.2, pharmacological interventions, 2016, last updated December 2020, checked 10 Oct 2026
4. Consider alternative diagnoses when examining or reviewing people with low back pain, particularly if new or changed symptoms develop; exclude specific causes such as cancer, infection, trauma or inflammatory disease, and refer according to the suspected cause. NICE — NG59 Low back pain and sciatica in over 16s: assessment and management, section 1.1, assessment, 2016, last updated December 2020, checked 10 Oct 2026
5. A fit note can be issued from the first day of absence and can be backdated; the doctor completes the statement from the assessment they have made, which may be a video or telephone consultation; a fit note may state that the person may be fit for work with adjustments, or is not fit for work. GOV.UK (DWP) — Getting the most out of the fit note: guidance for healthcare professionals, issuing a fit note; backdating, 2022, updated 2024, checked 10 Oct 2026
6. Drivers must not drive if they have a condition that impairs safe control of the vehicle, including sudden weakness, altered sensation or heavy sedation from medication; a person with acute bilateral leg weakness and urinary symptoms should not drive himself to hospital. DVLA — Assessing fitness to drive: a guide for medical professionals, chapter 1, neurological disorders; chapter 8, drugs, 2024 edition, checked 10 Oct 2026
7. At first presentation, use risk stratification (for example the STarT Back tool) to match the intensity of support to the risk of a poor outcome. Do not routinely offer imaging in a non-specialist setting for low back pain with or without sciatica, and explain that an X-ray or scan may not be needed; imaging in a specialist setting is for where the result is likely to change management. NICE — NG59 Low back pain and sciatica in over 16s: assessment and management, section 1.1, assessment: risk stratification and imaging, 2016, last updated December 2020, checked 10 Oct 2026
8. Consider an oral NSAID for low back pain, taking account of gastrointestinal, liver and cardio-renal risk, at the lowest effective dose for the shortest time, with gastroprotection; do not offer paracetamol alone. Do not offer gabapentinoids, other antiepileptics, oral corticosteroids or benzodiazepines for sciatica, and do not offer opioids for chronic sciatica (the December 2020 update); antidepressants are not offered for low back pain. NICE — NG59 Low back pain and sciatica in over 16s: assessment and management, section 1.2, pharmacological interventions, 2016, last updated December 2020, checked 10 Oct 2026
9. The warning signs on the national cauda equina card, each meaning the emergency department at once: numbness or pins and needles between the inner thighs, genitals, back passage or buttocks; altered feeling when using toilet paper; difficulty starting to pass urine, or inability; loss of sensation when passing urine; leaking urine or needing pads; not knowing whether the bladder is full; inability to stop or control a bowel movement; loss of sensation when passing a bowel motion; a change in erection or ejaculation; loss of genital sensation during sex. GIRFT (Getting It Right First Time) — National suspected cauda equina syndrome pathway, patient safety-netting information: the cauda equina warning signs, 2023, checked 10 Oct 2026
10. Since March 2015 it has been an offence in England and Wales to drive with certain drugs above a specified blood limit, including morphine, to which codeine is partly metabolised. There is a statutory medical defence where the medicine was prescribed or bought over the counter and taken as directed, but no defence where driving is impaired: a person who feels drowsy, dizzy or unable to concentrate on co-codamol must not drive. GOV.UK — Drugs and driving: the law, the medical defence; prescription medicines, 2015, current, checked 10 Oct 2026
11. For statutory sick pay an employee self-certifies the first seven days, so the law does not require a fit note for that period, though an insurer may ask for one. Since April 2022 fit notes are issued digitally without a wet signature, and since July 2022 nurses, pharmacists, occupational therapists and physiotherapists may certify them. Hospital doctors issue the fit note for a period in hospital; a self-employed person uses the note for an income-protection claim rather than for statutory sick pay. GOV.UK (DWP) — Getting the most out of the fit note: guidance for healthcare professionals, who can issue a fit note; self-certification; fit notes in hospital, 2022, updated 2024, checked 10 Oct 2026
12. Co-codamol 8/500: one or two tablets every four to six hours, no more than eight tablets in 24 hours, which is the 4 g paracetamol maximum. The side-effects the BNF lists for opioids, including codeine, include constipation, nausea, drowsiness, dizziness and urinary retention; the BNF advises warning patients that drowsiness may affect driving and skilled tasks, and that alcohol increases the effect. BNF (NICE) — Co-codamol, indications and dose; side-effects (opioids); patient and carer advice: driving and skilled tasks, current BNF online, checked 10 Oct 2026
13. The Musculoskeletal health Topic Guide expects the GP to assess back pain with a structured history and examination, to recognise and act on the red flags, including cauda equina syndrome, without delay, to manage analgesia within national guidance and avoid opioid dependence, and to handle fitness for work, fit notes and the person's livelihood as part of the plan rather than as an afterthought. RCGP — GP curriculum: Musculoskeletal health, back pain and red flags; fitness for work, 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-06