MRCGP SCA Consultation Skills Course
Station 9 · Atrial fibrillation
Telephone consultation (audio only) · Long-term conditions · Older adults · Prescribing · Circuit 2 · 11:20–12:45 · 14-minute station
A 72-year-old is telephoned about a new irregular pulse on his ECG; the drug that protects his brain is the drug his brother died on.
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 | Raymond Hurst, 72, retired postman. Telephone — practice call-back list: "ECG result — nurse found irregular pulse at BP check" |
| PMH | Hypertension; osteoarthritis knees. Non-smoker. Alcohol 20 units/week |
| Medication | Amlodipine 5 mg; paracetamol prn. Allergies: none |
| Recent entries | Nurse yesterday: pulse 96 irregularly irregular; BP 152/90; ECG: atrial fibrillation, rate 94, no acute changes. Bloods today: FBC, U&E, LFT, TFT normal; HbA1c 41. No falls recorded. Weight 84 kg. Lives with wife |
Role-player script — tutors only
Delegates: please do not open this section until you have consulted at this station.
Open the role-player script (504 words)
Persona and manner
- Steady, courteous, a little deaf ('speak up, doctor'); his wife is beside him and prompts him occasionally. Becomes quiet and firm when warfarin is mentioned.
- He has no symptoms and does not see why a pulse he cannot feel matters.
Opening line — say this verbatim
- "Hello doctor — the nurse said my heart's going irregular and you'd ring about the tracing. I feel perfectly well, I must say. Is it serious?"
Volunteer freely if given the space
- No palpitations, 'maybe a flutter now and then'; no chest pain; no breathlessness beyond 'the knees'; no dizziness; no blackouts.
- Walks the dog twice a day; sleeps well; 'as fit as I've been'.
Only if asked
- Duration: the nurse found it; he thinks he has 'felt a flutter' on and off for a few months.
- No stroke or TIA; no weakness or speech problems. No bleeding history; no peptic ulcer; no falls; drinks four pints on a Friday and a whisky most nights — 'about 20 units, maybe a bit more'.
- Brother Eddie: had 'the same heart thing', went on warfarin, 'bled into his brain and died within a week' — eight years ago, aged 70. Raymond is convinced warfarin 'thins the blood too much'. He will say, firmly: 'I'm not going on that stuff.'
- Kidney function is fine — he knows because the nurse told him.
- He drives; wife does not.
- He would 'take a tablet for the rhythm' if that helps.
- Hearing: better on the phone if the doctor speaks slowly; wife repeats things.
Ideas, concerns and expectations
- Idea: 'a bit of an irregular heartbeat at my age is normal'.
- Concern: warfarin; 'ending up like Eddie'. Underneath: a stroke — his wife's mother had one.
- Expectation: reassurance, maybe 'a rhythm tablet'; nothing 'that thins the blood'.
Cues to deliver, timed
- Minute 1: 'speak up, doctor' — and his wife's voice in the background.
- Minute 4: 'my brother died on warfarin' — flat, when anticoagulation is first raised.
- Minute 8: wife, off-phone: 'ask him about the stroke risk, Ray'.
How to respond to the doctor's plan
- If the doctor explains AF and stroke risk in plain terms with his numbers (CHA2DS2-VASc 3: age, hypertension, male — about a 3–4% yearly stroke risk untreated, reduced by two-thirds with anticoagulation), takes the brother's story seriously and explains how DOACs differ from warfarin (no monitoring, lower intracranial bleeding), addresses bleeding risk honestly (ORBIT/HAS-BLED, alcohol), proposes a DOAC (apixaban or edoxaban) with the dose right for his weight and kidneys, discusses rate control (bisoprolol) only if symptomatic or rate high, arranges echocardiogram and follow-up, addresses BP and alcohol, and explains driving is unaffected: he listens, checks with his wife, and says 'if it's not warfarin… I'll think about it — can you send me something to read?' and agrees to start.
- If the doctor says 'we'll start you on a blood thinner' without exploring the brother: 'No. Absolutely not.' — and will not shift unless the doctor asks why.
- If the doctor accepts his refusal and offers aspirin: he is pleased; the examiner is not.
Do not
- Volunteer the brother's story before anticoagulation is mentioned.
- Agree to warfarin under any circumstances; agree to a DOAC only after the difference is explained.
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 = AF and stroke risk explained, anticoagulation recommended and the brother's story worked through to a DOAC, bleeding risk modified, follow-up. Aspirin is a Clear Fail in Clinical Management.
Teaching points
- NICE NG196: offer anticoagulation if CHA2DS2-VASc ≥2 (consider if 1 in men); DOACs (apixaban, dabigatran, edoxaban, rivaroxaban) first-line; do not withhold solely because of falls risk; do not use aspirin for stroke prevention in AF. Assess bleeding with ORBIT.
- Apixaban 5 mg bd unless two of: age ≥80, weight ≤60 kg, creatinine ≥133 — he meets none.
- A bereavement-based refusal is statement 3.2 territory: ask what happened, then explain what has changed. The telephone makes the brother's story easier to miss.
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 9
Revision link for this case: mdacumen.com/sca-station9-atrial-fibrillation
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.