MRCGP SCA Consultation Skills Course
Station 7 · Diabetes
Video consultation · Long-term conditions · Prescribing · Professional (fitness to drive) · Circuit 2 · 11:20–12:45 · 14-minute station
An HGV driver with type 2 diabetes has an HbA1c of 69 and a falling kidney function; the drug that helps his kidneys is not the one he is worried about.
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 | Derek Onwudiwe, 61, HGV driver (Group 2 licence) |
| Reason for appointment | Diabetes review — results (booked by practice after bloods) |
| PMH | Type 2 diabetes (9 years); hypertension; BMI 33; ex-smoker |
| Medication | Metformin 1 g bd; gliclazide 80 mg bd; ramipril 10 mg; atorvastatin 20 mg. Allergies: none |
| Recent entries | HbA1c 69 mmol/mol (was 58 a year ago); eGFR 52 (was 68 two years ago); urine ACR 6.2 mg/mmol; BP 146/88; lipids: non-HDL 3.9. Retinal screening: background changes. Foot check: low risk. No hypoglycaemia recorded. Flu and COVID vaccines: declined last year |
Role-player script — tutors only
Delegates: please do not open this section until you have consulted at this station.
Open the role-player script (568 words)
Persona and manner
- Warm, proud of his job, a little defensive about his health; talks about the road and his grandchildren; not keen on 'more tablets'.
- He has heard from a driver mate that 'the new diabetes tablets' cause 'water infections' and that if he 'goes hypo' he loses his licence.
Opening line — say this verbatim
- "The nurse said my sugar's crept up and my kidneys aren't what they were. I'll be honest, doctor — I'm 61, I've got four years left on the lorries, and I need to keep my licence. What are we looking at?"
Volunteer freely if given the space
- Long shifts, motorway food, 'a coffee and a pastry keeps me going'; eats one big meal at night.
- Has 'never had a hypo'; checks his sugar 'when I remember' — the DVLA meter is in the cab.
- Feels well; a bit more tired; up once or twice at night to pass urine.
Only if asked
- Glucose checks: DVLA requires testing at least twice daily and within two hours before driving; he does 'most days' but not always before every shift; readings 'seven to twelve'. Never below four that he has seen.
- Has had two 'funny turns' — sweaty and shaky mid-afternoon after skipping lunch — settled with a chocolate bar. Did not check glucose. Has not told anyone.
- Takes his tablets 'most of the time'; misses gliclazide when he forgets lunch because 'that's when the shakes come'.
- Weight up half a stone in a year. No chest pain; no breathlessness; no foot problems; vision 'fine with glasses'.
- Declined vaccines because 'I don't like needles and I never get ill'.
- Family: wife works in a school; two grown children; four grandchildren he 'lives for'. Retirement at 65 planned, pension depends on it.
- He will accept a tablet 'if it doesn't get me hypos and doesn't cost me the licence'.
Ideas, concerns and expectations
- Idea: 'I just need to try harder with the diet.'
- Concern: losing the Group 2 licence; the mate's story about 'water infections'; needles (insulin).
- Expectation: to be told what to change and reassured about the licence.
Cues to deliver, timed
- Minute 2: 'I've got four years left on the lorries.'
- Minute 4: 'a couple of funny turns, but that's just missing lunch' — dismissive, only if asked about hypos.
- Minute 7: 'is that the one that gives you water infections?' — if an SGLT2 inhibitor is proposed.
How to respond to the doctor's plan
- If the doctor recognises the two afternoon episodes as probable hypoglycaemia, explains the DVLA Group 2 rules (twice-daily and pre-driving testing; a severe hypo or impaired awareness means notification and licence review; sulphonylureas are permitted only with proper monitoring), proposes an SGLT2 inhibitor for kidney and heart protection with honest advice on genital thrush, hydration and sick-day rules, reduces or stops gliclazide to remove the hypo risk, checks metformin at his eGFR, addresses blood pressure and lipids, offers vaccinations and a diet plan that fits shift work, and books review with bloods in 3 months: relieved — 'so the new one's actually safer for my licence than the old one?' — and agrees.
- If the doctor simply increases gliclazide: 'and the hypos?' — then accepts; the examiner will not.
- If the doctor raises insulin: 'no way, not with the licence' — and disengages unless the doctor explains it is not being proposed.
Examination findings if requested
- BP 148/86; weight 101 kg; feet: pulses present, sensation intact; no oedema; capillary glucose now 9.8.
Do not
- Volunteer the funny turns, the missed pre-driving checks or the pension unless asked.
- Refuse everything; he is persuadable by 'safer for the licence'.
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 = hypoglycaemia recognised, SGLT2 inhibitor started and gliclazide de-escalated, DVLA Group 2 rules accurate, cardiovascular risk addressed, review booked.
Teaching points
- NICE NG28 (2022): offer an SGLT2 inhibitor to people with type 2 diabetes and CKD with ACR >30 mg/mmol; consider if ACR 3–30 — here eGFR 52 with ACR 6.2, plus established cardiovascular risk, supports it. Metformin continues to eGFR 30.
- DVLA Group 2 (bus/lorry) with sulphonylureas or insulin: glucose testing at least twice daily and within two hours before driving, recorded on a memory meter for three months; any severe hypo in the previous 12 months, or impaired awareness, disqualifies. Sulphonylurea hypos are the commonest reason drivers lose Group 2 licences.
- The mate's story (SGLT2 inhibitors and genital infection) is a belief to answer with numbers, not dismiss: about 1 in 10 women and 1 in 30 men; treatable; hydration and hygiene advice.
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 7
Revision link for this case: mdacumen.com/sca-station7-diabetes
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.