MRCGP SCA Consultation Skills Course
Station 6 · Back pain
Video consultation · Urgent and unscheduled care · Undifferentiated presentations · Circuit 1 · 09:40–11:00 · 13-minute station
A 34-year-old plasterer with a bad back wants a sick note and 'proper painkillers'; he has been dribbling urine since yesterday and is annoyed at being asked about it.
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 | Craig Wilkins, 34, self-employed plasterer |
| Reason for appointment | "Back pain — sick note" (booked by patient, same day) |
| PMH | Two previous episodes of low back pain (2022, 2024), settled with physiotherapy. Nil else. Smoker |
| Medication | None. Bought ibuprofen and co-codamol 8/500 over the counter. Allergies: none |
| Recent entries | Physiotherapy discharge 2024: 'mechanical LBP, core programme, advised on lifting'. No fit notes issued previously |
Role-player script — tutors only
Delegates: please do not open this section until you have consulted at this station.
Open the role-player script (652 words)
Persona and manner
- Irritable, in pain, short with the doctor; shifts in his chair, cannot get comfortable; impatient with 'the usual questions'.
- He is not rude by nature; the irritability is pain and money. He softens if the doctor is straight with him.
Opening line — say this 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."
Volunteer freely if given the space
- Lifting a bag of plaster three days ago; 'felt it go'; pain across the lower back going down both legs to the calves, 'worse than the other times'.
- Can't sleep, can't sit, took the day off yesterday for the first time in ten years.
- The insurance policy needs a doctor's note from day one.
Only if asked
- Pain down both legs — the previous episodes were one leg only.
- Yesterday afternoon he started 'dribbling' when he passes urine and 'not feeling the flow'; this morning he was not sure he had finished; he wet himself slightly on the way to the car. He is embarrassed and initially says 'that's just from the painkillers, isn't it?'.
- Numbness 'in a strange place' — around his back passage and inner thighs when he sits; 'like sitting on a cushion'. He noticed it wiping this morning.
- Bowels: not opened for two days — 'that'll be the codeine'.
- Legs: both feel heavy; he tripped on the step this morning.
- No fever, no weight loss, no night pain before this episode, no history of cancer, no steroids, no IV drug use.
- Co-codamol 8/500 two tablets four times a day and ibuprofen 400 mg three times a day for three days.
- Self-employed; a kitchen job that must finish by Friday or he loses the next contract; income protection policy with a seven-day deferred period, but 'they want a note from day one'.
- Partner works part-time; a baby due in three months; mortgage.
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' — he names tramadol, which a mate had.
Cues to deliver, timed
- Minute 1: winces and swears under his breath — 'sorry'.
- Minute 3: if asked about bladder or bowels: 'what's that got to do with my back?' — irritated, then answers honestly if the doctor explains why.
- Minute 6: 'I can't go to hospital, I've got a job to finish' — when admission is raised.
How to respond to the doctor's plan
- If the doctor asks the cauda equina questions clearly, explains why they matter, recognises the red flags (bilateral leg symptoms, saddle numbness, urinary retention/incontinence, constipation), and arranges emergency assessment today (999 or immediate transfer to the emergency department with a phone call ahead), explains what will happen (MRI, possible surgery) and why the job must wait, addresses the sick note (issued today, covering the emergency period) and the insurance, and tells him plainly that this is the one back pain that cannot wait: he is frightened, argues once ('you're joking'), then asks 'what happens if I don't go?' — and when told honestly, agrees. He asks whether his partner should come.
- If the doctor prescribes stronger analgesia and issues a fit note without asking the red-flag questions: he takes both and leaves; the examiner will not.
- If the doctor lectures him about lifting technique: 'I said I've heard it' — and disengages.
Examination findings if requested
- Video: he can stand only with support; walks with a wide-based gait; cannot heel-walk; describes reduced sensation on both inner thighs and around the anus when he touches with a tissue; both ankle reflexes he cannot test — offer that in-person examination will be done at hospital. Bladder: feels full. Do not give a residual volume.
Do not
- Volunteer the bladder or saddle symptoms unless asked directly — he attributes them to the painkillers.
- Refuse admission outright; he can be persuaded by honesty about paralysis and incontinence.
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 |
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| Clinical Management & Medical Complexity |
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| Relating to Others |
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Global rating guide: Pass = cauda equina recognised and acted on today, urgency explained, the sick-note request handled honestly rather than refused. Any Pass without emergency referral is a Clear Fail in Clinical Management.
Teaching points
- NICE CKS / GIRFT cauda equina pathway: bilateral sciatica, new bladder or bowel dysfunction, saddle anaesthesia, sexual dysfunction — emergency referral the same day for MRI; do not wait for retention to be complete.
- The patient's explanation ('it's the codeine') is the trap; the examiner watches whether you ask about saddle sensation and urinary sensation specifically.
- The angry, time-pressed patient tests Relating to Others: statement 3.1 (listening) and 3.4 (explanation adapted) are scored on whether he agrees to go.
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 6
Revision link for this case: mdacumen.com/sca-station6-back-pain
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.