You are an FY2 in GP
Personal Details:
Name: Mark Roberts
Age: 40
Medical Record:
Past medical history: Generalised tonic-clonic epilepsy, diagnosed 2 years ago. Seizure-free for 2 years on medication.
Regular medication: Levetiracetam
Allergies: None known.
Notes:
Mark is attending for a routine epilepsy follow-up. He has been seizure-free for two years.
He works as a scaffolder.
Task:
Review his epilepsy and address his concerns
Opening Sentence: “Hi, Doctor, I’m here for my epilepsy check-up. Everything’s great, I haven’t had a fit in two years, so I’ve stopped taking the tablets.”
Open History (to give freely): “I just felt I didn’t need them anymore. I’ve been feeling perfectly fine, no side effects or anything. It’s great to be off them.”
Cues to give: “It’s just a hassle taking tablets every day for something that’s not there.”
ICE (Ideas, Concerns, Expectations):
Ideas: “I think I’m cured. Two years without a fit means the epilepsy has gone away, right?”
Concerns: “Why do I need to continue the medication? I feel fine.”
Expectation: “I’m expecting you to agree with me and sign me off.”
How to Act: You are cheerful, confident, and a bit stubborn. You genuinely believe you have made a sensible decision and are resistant to changing your mind.
More History (only if asked): You stopped the tablets abruptly one week ago without consulting anyone. You have not had a seizure since stopping. You need to drive for your job as a scaffolder to get to different sites. You have not informed your employer about your epilepsy.
Social History: You are fit and well. You do not smoke or drink heavily.
Questions to ask:
“But I haven’t had a fit. Why do I have to start the tablets again?”
“What are the chances of me actually having a seizure?”
“If I have to stop driving, I’ll lose my job. What am I supposed to do?”
Opening & Epilepsy Review:
Hi Michael, good to see you. This is your annual review. How have things been with your epilepsy? When was your last seizure? How have you been getting on with the Levetiracetam? Any side effects?
Exploring the job nature: And how are things otherwise? Tell me about your job, what do you do? Do you have to drive? Do you drive your own car only or also as part of your job?
When you were diagnosed with epilepsy, did you inform the DVLA?
Did you mention your epilepsy to your new employer?
ICE (Ideas, Concerns, Expectations):
What was your understanding of the driving rules for people with epilepsy?
I can see that this is difficult to hear. What are your immediate worries about what I’ve just said?
What were you hoping for from today’s appointment?
Open up:
Mark, thanks for coming in and for being so open with me. It’s fantastic that you’ve been seizure-free for two years. That shows the medication has been working perfectly. However, I am very concerned that you have stopped taking it. Epilepsy is a long-term condition, and being seizure-free is because the medication is controlling it, not because the epilepsy has gone away.
Addressing and answering the patient’s ICE:
You’re asking why you need to continue the medication when you feel fine. The medication works by stabilising the electrical activity in your brain to prevent seizures. By stopping it abruptly, you are at a very high risk of having a ‘breakthrough’ seizure. This risk is especially high in the first few weeks after stopping. It would be incredibly dangerous if this happened while you were driving or working at height.
Next Steps:
My strong advice is that you must restart your medication immediately. We can’t ‘un-stop’ it, but by restarting it now, you will reduce your risk. Secondly, and this is a legal requirement, you must stop driving immediately. The DVLA rule is that you must be seizure-free for one year to hold a driving licence. Because you have stopped your medication against medical advice, you are no longer considered to be compliant with treatment, and therefore, you are not legally fit to drive. You must inform the DVLA of your situation.
Supportive measures
I understand this has huge implications for your job. This is the third, and very difficult, point we need to discuss. You must inform your employer about your epilepsy and the fact that you can no longer drive. Your job as a scaffolder is extremely dangerous for someone with a high risk of seizures. You would be a danger to yourself and to others. Your employer has a duty to make reasonable adjustments, perhaps finding you a ground-based role while we get this sorted out.
I know this is a lot to take in and feels like a huge step backwards. It’s not the news you wanted to hear. But my duty is to your safety and the safety of the public. Let’s make a plan. We will restart your medication today. I will give you the contact details for the DVLA. And we can give you a letter for your employer explaining the situation. There are also epilepsy support charities that can provide advice on employment issues.
I can also support you with a fit note until we have a clear plan and give you time to discuss things further with your employers.
If the employer can offer a reasonable adjustment, we can support you to find a different job, or give you a supporting letter so you can claim some benefits.
Addressing ideas, concerns, and expectations: Firmly but empathetically correct his belief that he is cured. Clearly explain the risks of stopping medication.
Prescribing/referral/reassurance: The management is providing clear, non-negotiable advice:
1. Restart medication. 2. Stop driving immediately and inform the DVLA. 3. Inform his employer. This is a safety-critical station.
What is scenario testing? This case tests the candidate’s ability to handle a patient who is unknowingly putting themselves and the public at significant risk. It requires the ability to give firm, direct, and legally correct advice in a way that is empathetic to the patient’s difficult social situation (loss of job/licence). The candidate must prioritise public safety over the patient’s immediate wishes.