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MRCGP SCA course · Station 7
Station 7 · Diabetes
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.
Reviewed and kept current
Video consultation · Long-term condition · Prescribing · Professional conversation · 12-minute case · 3 min reading · Last editorial review: 11 October 2026 · Next scheduled refresh: 11 April 2027 · Clinical content signed by Course Director, 11 October 2026.
Candidate instructions
Read this as you would outside the room
Read the brief as you would in the examination (RCGP: twelve consultations with simulated patients, each lasting twelve minutes, with 3 minutes' reading at the start of each). There is no reference material. Everything below the brief is folded until the consultation is over.
| Information | |
|---|---|
| Frame | You have 3 minutes to read, then 12 minutes. Video consultation. Everything below this brief is folded away until the consultation is over. |
| Your role | GP partner at a semi-rural practice, doing the diabetes results list. |
| Patient | Derek Onwudiwe, 61. |
| Reason for consultation | Diabetes review: results. Booked by the practice after his annual bloods. |
| Format | Video. He is in the cab of his lorry in a depot, parked; you can see his face. You cannot examine him; the practice nurse's recent findings are in the record. |
Information available
The records extract, printed as it appears. Results carry units and reference ranges.
| Problem list | Type 2 diabetes, 9 years. Hypertension. BMI 33. Ex-smoker. HGV driver (Group 2 licence). |
| Medication | Metformin 1 g twice daily. Gliclazide 80 mg twice daily. Ramipril 10 mg daily. Atorvastatin 20 mg daily. Allergies: none recorded. |
| Bloods, 10 days ago | HbA1c 69 mmol/mol (target 53; was 58 a year ago). eGFR 52 mL/min/1.73m² (was 68 two years ago). Urine albumin:creatinine ratio 6.2 mg/mmol (below 3). Non-HDL cholesterol 3.9 mmol/L. Potassium 4.6 mmol/L (3.5–5.3). |
| Nurse, 10 days ago | BP 146/88. Weight 101 kg. Feet: low risk. Retinal screening: background changes. No hypoglycaemia recorded. Flu and COVID vaccines declined last year. |
| Driving | Group 2 licence holder; on a sulfonylurea. DVLA requirements discussed: not recorded. |
Your task
•
Review his results with him.
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Reach a working assessment of each problem and explain it.
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Agree the changes to his treatment, including what they mean for his licence.
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Address his concerns.
Folded away
For the role player and the observer
Open these after the consultation, or during it if you are observing. The role-player script and every marking section are public (D-76): this is practice material, not an examination.
1 · Role-player script — opening line, story, ICE, hidden facts and triggers (examination findings last)
Candidates: do not open until you have consulted.
Persona and manner
- Derek Onwudiwe, 61, an HGV driver; warm, proud of your job, a little defensive about your health; you talk about the road and your grandchildren; not keen on “more tablets”.
- You have heard from a driver mate that the new diabetes tablets cause water infections and that if you “go hypo” you lose your licence.
Opening line (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?”
The story
- “Long shifts, motorway food. A coffee and a pastry keeps me going. I eat one big meal at night.”
- “I've never had a hypo. I check my sugar when I remember. The meter's in the cab.”
- “I feel well. A bit more tired. Up once or twice at night to pass water.”
- If asked about testing: you know the rules say twice a day and within two hours before driving; you do it “most days” but not before every shift; readings seven to twelve; never below four that you have seen.
- If asked properly about hypos or funny turns: two episodes, sweaty and shaky in the middle of the afternoon after skipping lunch, settled with a chocolate bar. You did not check your sugar. You have not told anyone.
- If asked about the tablets: you take them “most of the time”; you miss the gliclazide when you forget 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”.
- You declined the vaccines because you do not like needles and you never get ill.
- Your wife works in a school; two grown children; four grandchildren you “live for”. Retirement at 65; the pension depends on it.
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, which to you means insulin.
- Expectation: To be told what to change and to be reassured about the licence.
Impact
- Work: four years to retirement; the pension depends on keeping the licence; a hypo at the wheel is the thing you will not say aloud.
- Home: the grandchildren at weekends; your wife worries about the food in the cab.
- Money: fine while you are driving; not otherwise.
Red flags
- Present: Two probable hypoglycaemic episodes on a sulfonylurea in a Group 2 driver, unreported and untested; a falling eGFR with a raised albumin:creatinine ratio; blood pressure above target.
- Absent: No severe hypoglycaemia needing another person's help; no loss of awareness of hypoglycaemia that you know of.
- Absent: No chest pain, breathlessness, foot ulcer or visual loss; no symptoms of infection.
Hidden facts and their triggers
- The two funny turns after missing lunch — released only if asked specifically about hypos, shakes or funny turns; a general “any problems?” gets “none”
- That you do not always test before every shift — released only if asked exactly when you test and how often
- Missing the gliclazide when you skip lunch — released only if asked how you take the tablets
- The pension and the four years — released only if asked what the licence means to you
- The needle fear behind the declined vaccines — released only if asked why you declined them
Behaviour
- Minute 2: “I've got four years left on the lorries.”
- Minute 4, only if asked about hypos: “A couple of funny turns, but that's just missing lunch.” Dismissive.
- Minute 7, if a new tablet is proposed: “Is that the one that gives you water infections?”
- If the doctor recognises the afternoon episodes as probable hypos, explains the Group 2 rules accurately, proposes a kidney-protecting tablet with honest advice on thrush, hydration and sick days, reduces or stops the gliclazide to remove the hypo risk, checks the metformin at your kidney function, addresses the blood pressure and cholesterol, offers the vaccines and a diet plan that fits shifts, and books a review with bloods in three months: relieved. “So the new one's actually safer for my licence than the old one?” Agree.
- If the doctor simply increases the gliclazide: “And the hypos?” Then accept.
- If the doctor raises insulin: “No way, not with the licence.” Disengage unless the doctor explains it is not being proposed.
- If the doctor threatens the licence: go quiet; answer in single words.
Examination findings, if the candidate states what they would examine and why
- Video: no examination today. If the candidate states what they would examine and why, give the nurse's findings from the record: BP 146/88; weight 101 kg; feet low risk with pulses present and sensation intact; no ankle swelling.
- If asked to check a capillary glucose on the cab meter now: 9.8 mmol/L.
2 · Examiner mark sheet — generic SCA scheme plus the key facts for this case
Domain grades — with the key facts that earn a clear pass at this station
| Domain (RCGP wording) · key facts for this case | CF (0) | F (1) | P (2) | CP (3) | Score |
|---|---|---|---|---|---|
1 · Data gathering and diagnosis
| ☐ | ☐ | ☐ | ☐ | /3 |
2 · Clinical management and medical complexity (×1.5)
| ☐ (0) | ☐ (1.5) | ☐ (3) | ☐ (4.5) | /4.5 |
3 · Relating to others
| ☐ | ☐ | ☐ | ☐ | /3 |
| Case total | /10.5 |
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.”
3 · Expanded station standard — what earns a clear pass, pass, fail and clear fail here
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.
| Grade | Data gathering and diagnosis | Clinical management and medical complexity | Relating to others |
|---|---|---|---|
| CP | Reads the five results as one picture in the first minute and says so: rising HbA1c, falling kidney function with protein in the urine, blood pressure above target, early eye changes. Asks about hypoglycaemia by name and by description before anything else, because the treatment is the risk to the licence. Establishes exactly when he tests and whether anyone has been told. Reasons aloud that a sulfonylurea plus missed meals equals hypos. | Prioritises safety at the wheel: stops the gliclazide and explains why, starts the SGLT2 inhibitor with counselling in his terms (thrush, drinking water, sick-day rules, what ketoacidosis feels like), continues metformin at this kidney function, steps up the blood pressure treatment and the statin, offers the vaccines with a plan for the needle fear. States the Group 2 testing rules accurately and documents them. Books bloods and review at three months. | Builds the whole plan around “four years left on the lorries” and says so. Answers “Is that the one that gives you water infections?” with the numbers and what to do if it happens. Reframes: the new drug protects the licence by removing the hypos, and the kidney benefit is explained in his words. Uses the grandchildren as his reason without moralising. Negotiates the vaccines rather than instructing. Checks what he will do before his next shift. |
| P | Reviews the results as a set: HbA1c rising, eGFR falling, albumin:creatinine ratio raised, blood pressure above target. Asks specifically about hypoglycaemia and recognises the funny turns. Establishes the licence group, the testing routine and his awareness of the DVLA rules. Asks about adherence, the diet pattern, weight and symptoms, and reviews the vaccines, the retinopathy and the feet. Reaches a working assessment of each problem. | Offers an SGLT2 inhibitor for the kidney disease with counselling on genital infection, dehydration, sick-day rules and the warning signs of ketoacidosis. Reduces or stops the gliclazide to remove the hypoglycaemia risk; continues metformin at an eGFR of 52. States the Group 2 rules accurately (test before driving and every two hours, carry a hypo kit, a severe hypo must be notified) and documents them. Adds a second antihypertensive, offers the vaccines, books review at three months with a safety-net. | Responds to “four years left” with a plan built around the licence. Answers the mate's story factually. Shares the decision on which tablet and is honest about side-effects. Checks his understanding of the testing routine. Does not threaten the licence; does not lecture on diet. |
| F | Treats the HbA1c number alone. Does not ask about hypoglycaemia, or asks “any hypos?” and accepts “no”. Ignores the licence, or asks about it only at the end. Does not link the kidney results to the choice of drug. Does not ask how he actually takes the tablets or when he tests. | Increases the gliclazide. Or proposes insulin without need. Or gives the Group 2 rules incorrectly or not at all. Starts an SGLT2 inhibitor with no counselling on sick days or genital infection. Leaves the blood pressure and the statin untouched. No review date; no safety-net; no documentation of the driving advice. | Threatens the licence (“if you have another one of those I'll have to tell the DVLA”) before explaining the rules. Dismisses the water-infection concern. Lectures on diet. Talks about tablets without asking what the licence means to him, so that the plan is imposed rather than shared. Jargon (SGLT2, ACR, eGFR) unexplained. |
| CF | No enquiry about hypoglycaemia at all in a Group 2 driver on a sulfonylurea; the licence never discussed; the results read as a list of numbers with no meaning given. Or the consultation spent on diet with no assessment of risk at the wheel and no working diagnosis stated. | Unsafe: gliclazide increased in a driver with two unreported hypos; or insulin started; or the DVLA rules stated wrongly so that he drives in breach of them; no plan for the kidney disease; no safety-net. He leaves with a higher hypo risk and a false sense that the licence is secure. | Threatens, lectures or patronises; dismisses the mate's story as nonsense without answering it; talks over his questions; ends without any check that he knows what to do before his next shift. No partnership: the plan is imposed, and he will not follow it. |
Where candidates lose this station
- Asking a single closed question about hypos and accepting the denial, so the two funny turns after missing lunch are never found (statement D1)
- Increasing the gliclazide for the HbA1c in a Group 2 driver, or stating the DVLA testing rules wrongly (statement C2)
- Threatening the licence before explaining the rules, so that he stops telling the truth about the funny turns (statement R5)
What the examiner is listening for in the last four minutes
By 8:00 the working assessment should have been stated: probable sulfonylurea hypos in a Group 2 driver, early kidney disease and a blood pressure above target. The examiner is listening for: the gliclazide stopped or reduced and the SGLT2 inhibitor started with counselling he can repeat (thrush, water, sick days, ketoacidosis); the Group 2 testing rules stated accurately and documented; the blood pressure and statin stepped up; the vaccines offered; the review at three months with bloods; and his own words on what he will do before his next shift.
4 · RCGP feedback statements — where underperformance was identified — with case-specific examples
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.
| RCGP feedback statement (postulated top ten) | Underperformance it signals (generic) | Station-specific example |
|---|---|---|
| D1 · Data gathering was insufficient to enable safe assessment of the condition/situation Data gathering and diagnosis · Data gathering and interpretation | History too thin to decide safely: the presenting problem not characterised, the essential negatives not asked. |
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| D2 · Existing information about the case was insufficiently utilised Data gathering and diagnosis · Data gathering and interpretation; Organisation, management and leadership | The records, results or the referral note not read or not used; questions asked that the notes already answer. |
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| D6 · The implications of relevant findings identified during the data gathering were insufficiently recognised or understood Data gathering and diagnosis · Data gathering and interpretation | A finding or result is elicited but its meaning is not recognised or not followed up. |
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| D7 · Differential diagnoses or hypotheses were inadequately generated or tested Data gathering and diagnosis · Making diagnosis/decisions | One diagnosis assumed; alternatives not generated, or generated but not tested with a question. |
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| C2 · The management plan relating to prescribing of medication was inappropriate or not reflective of current practice Clinical management and medical complexity · Clinical management | A drug started, continued or stopped against current guidance, or without the checks it needs. |
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| C5 · The plan relating to the medical management of risk was inadequate or inappropriate Clinical management and medical complexity · Clinical management; Organisation, management and leadership | Clinical risk left unmanaged: no plan for the thing that could go wrong, or the risk not weighed. |
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| C8 · Inappropriate or inadequate arrangements for follow-up, continuity and/or safety netting Clinical management and medical complexity · Clinical management | No follow-up, continuity or safety-net, or one too vague to act on. |
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| R1 · Communication skills, including the non-verbal, responding to cues and/or active listening were insufficiently demonstrated Relating to others · Communication and consultation skills | Cues missed; the patient interrupted; non-verbal signals ignored; questions read like a form. |
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| R4 · Explanations were inadequately shared or adapted for the person's needs Relating to others · Communication and consultation skills | Explanation in jargon, at the wrong pace, or not adapted to the person's level and concerns. |
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| R5 · A judgemental approach was shown to the person Relating to others · Communication and consultation skills; Maintaining an ethical approach | Disapproval, moralising or blame shown in words or manner. |
|
The full list of 26 statements, with the generic meaning of each, is on the exam and the mark scheme.
5 · Examiner points of fact and guidelines
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.
- For adults with type 2 diabetes and chronic kidney disease who are taking an ACE inhibitor or ARB at the highest tolerated dose, offer an SGLT2 inhibitor if the albumin:creatinine ratio is over 30 mg/mmol and consider one if the ratio is 3 to 30 mg/mmol, provided the eGFR criteria in the marketing authorisation are met; continue metformin down to an eGFR of 30. NICE — NG28 Type 2 diabetes in adults: management, section 1.7, drug treatment; section 1.8, chronic kidney disease, 2015, last updated February 2026, checked 10 Oct 2026
- In adults with type 2 diabetes and chronic kidney disease, offer an SGLT2 inhibitor in addition to an ACE inhibitor or ARB if the albumin:creatinine ratio is 30 mg/mmol or more and the eGFR criteria are met; consider it if the ratio is 3 to 30 mg/mmol. NICE — NG203 Chronic kidney disease: assessment and management, section 1.6, pharmacotherapy, 2021, last updated November 2021, checked 10 Oct 2026
- Group 2 (bus and lorry) drivers treated with a sulfonylurea or insulin must monitor blood glucose at least twice daily and at times relevant to driving, within two hours before the start of the first journey and every two hours while driving, using a meter with a memory; they must have no severe hypoglycaemia in the preceding 12 months and full awareness of hypoglycaemia; a severe hypoglycaemic episode must be reported to the DVLA. DVLA — Assessing fitness to drive: diabetes mellitus, Group 2 entitlement: sulfonylureas and insulin, 2024 edition, checked 10 Oct 2026
- SGLT2 inhibitors: counsel on the risk of diabetic ketoacidosis, including with only moderately raised glucose, and advise to stop the drug and seek urgent help with nausea, vomiting, abdominal pain, rapid breathing or unusual sleepiness; interrupt treatment during acute illness, dehydration or fasting (sick-day rules); genital mycotic infection is common and treatable. MHRA — Drug Safety Update: SGLT2 inhibitors, updated advice on the risk of diabetic ketoacidosis, April 2016, reinforced March 2020, checked 10 Oct 2026
- Sulfonylureas cause hypoglycaemia, particularly with missed meals, irregular meals or excess exercise; in people at risk of hypoglycaemia (such as those who drive for a living) a drug with a low risk of hypoglycaemia is preferred, and the person is advised on recognising and treating hypoglycaemia. BNF (NICE) — Gliclazide, cautions; patient and carer advice (hypoglycaemia; driving), current BNF online, checked 10 Oct 2026
- In adults with type 2 diabetes, aim for a clinic blood pressure below 140/90 mmHg (below 150/90 if aged 80 or over); add a second agent (a calcium-channel blocker or a thiazide-like diuretic) when an ACE inhibitor or ARB at the maximum tolerated dose does not reach the target. NICE — NG136 Hypertension in adults: diagnosis and management, section 1.4, treatment targets and steps, 2019, last updated February 2026, checked 10 Oct 2026
- Offer atorvastatin 20 mg for primary prevention to adults with type 2 diabetes and a 10-year cardiovascular risk of 10% or more; in people with chronic kidney disease offer atorvastatin 20 mg and increase the dose if a reduction of more than 40% in non-HDL cholesterol is not achieved and the eGFR is 30 or more. NICE — NG238 Cardiovascular disease: risk assessment and reduction, including lipid modification, section 1.6, statins for people with type 2 diabetes and with CKD, December 2023, checked 10 Oct 2026
- Seasonal influenza vaccination is offered to all adults with diabetes each autumn; people who decline because of needle fear can be offered a conversation about the fear and the option of the vaccine at a visit they have chosen. UKHSA — Immunisation against infectious disease (the Green Book), chapter 19: influenza, clinical risk groups, 2024 update, checked 10 Oct 2026
- Agree an individual HbA1c target: 48 mmol/mol for an adult managed by lifestyle or by a single drug not associated with hypoglycaemia, and 53 mmol/mol for an adult taking a drug associated with hypoglycaemia such as a sulfonylurea; if the HbA1c rises to 58 mmol/mol or more, reinforce lifestyle advice and intensify treatment. Consider relaxing the target where tight control carries a high risk from hypoglycaemia, which NG28 illustrates with people who drive or operate machinery for work. Measure HbA1c every three to six months until stable, then six-monthly. NICE — NG28 Type 2 diabetes in adults: management, section 1.6, HbA1c measurement and targets, 2015, last updated February 2026, checked 10 Oct 2026
- For an adult with type 2 diabetes and chronic kidney disease with an eGFR of 20 mL/min/1.73 m² or more, the ADA recommends an SGLT2 inhibitor with proven benefit to slow the progression of kidney disease and reduce cardiovascular events, independent of the HbA1c; a GLP-1 receptor agonist with proven benefit is the alternative if an SGLT2 inhibitor is not tolerated. Glucose-lowering agents are chosen to avoid hypoglycaemia in people at risk of it, and sulfonylureas carry a high hypoglycaemia risk. ADA — Standards of Care in Diabetes 2026: Pharmacologic approaches to glycemic treatment, section 9, recommendations for adults with type 2 diabetes and chronic kidney disease; hypoglycaemia risk by drug class, 2026, checked 10 Oct 2026
- The Topic Guide 'Metabolic problems and endocrinology' expects the GP to manage type 2 diabetes to national guidance, choosing glucose-lowering drugs by co-morbidity and kidney function, recognising and preventing hypoglycaemia, and reviewing eyes, feet, kidneys, blood pressure and lipids as one plan; it expects the GP to advise on driving and employment in a long-term condition, to apply the DVLA rules for the licence the person holds, and to record the advice given. RCGP — GP curriculum: Metabolic problems and endocrinology, diabetes: management, complications and hypoglycaemia; driving and employment, Being a GP, 2025 curriculum, checked 10 Oct 2026
Working references for this station
11 statements, 670 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.
This case's topic and its signed Golden Triangle, for review after the station.
Golden Triangle
Type 2 diabetes
Knowledge Green · Evidence Green · Real-world Amber
Not yet at the Equinox · UK (NHS England) · as of 7 October 2026 · How the triangle works
6 · RCGP curriculum tags for this case
| RCGP curriculum (2025) | This case |
|---|---|
| Topic Guide(s) | Metabolic problems and endocrinology · Renal and urology · Continuity and quality of care, safety and prescribing |
| Core capabilities | Data gathering and interpretation · Clinical management · Medical complexity · Communicating and consulting |
| SCA Clinical Experience Group(s) | Long-term condition, including cancer, multi-morbidity, and disability · Prescribing · Professional conversation / Professional dilemma |
| AKT blueprint clinical area | Endocrine and metabolic medicine (broader representation) |
| Case type | long-term condition |
| Modality | video |
7 · My marks and reflection — practice log form
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-07
Revision link for this case: mdacumen.com/sca-station7-diabetes
Independence & scope. Formative training material from MD Acumen Ltd; not a prediction of exam performance. Not affiliated with, endorsed by, or delivered on behalf of the Royal College of General Practitioners; the marking domains and feedback statements are the RCGP's published ones, and every descriptor on this page is an Acumen training tool calibrated to them. Clinical content reflects UK guidance at the date of editorial review — always check the current guideline. All patients are fictional.
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