You are an FY2 in general practice

Personal Details:

Name: Michael Bevan

Age: 50

Medical Record:

Past medical history: Generalised Anxiety Disorder (GAD).

Regular medication: None currently.

Allergies: None known.

Notes:

Michael is a 50-year-old man attending the ‘well man’ clinic for a check-up. He reports a six-month history of urinary frequency. He is very anxious about prostate cancer, as a friend was recently diagnosed. He is requesting a PSA test.

Task:

1. Take a focused history of his lower urinary tract symptoms (LUTS).

2. Counsel him about the PSA test.

Opening Sentence: “Hi, Doctor. I’m here for a check-up. I’ve been having some bladder issues, and I’m worried it might be my prostate.”

Open History (to give freely): “For the last six months or so, I’ve just been needing to pee all the time during the day. It’s really annoying. Then my friend got diagnosed with prostate cancer, and it’s made me really anxious. I’d like to have the PSA blood test.”

Cues to give: “My friend said it’s a simple blood test that can save your life.”

ICE (Ideas, Concerns, Expectations):

Ideas: “I think I should have the PSA test. It’s a cancer test, and I’m 50 now, so it seems sensible.”

Concerns: “I’m worried I might have cancer like my friend.”

Expectation: “I want you to arrange the PSA test for me today to put my mind at rest.”

How to Act: You are highly anxious and fixated on the idea of having cancer. You see the PSA test as a simple solution.

More History (only if asked): Your only symptom is needing to urinate more frequently during the day. You have no problems with the stream, no dribbling, no getting up at night, no pain, and no blood in the urine. You are otherwise fit and well with no significant past medical history other than anxiety. There is no family history of prostate cancer.

Social History: You work as a project manager. You are married with two children.

Questions to ask:

Why wouldn’t I have the test? I don’t understand the downside.

So you think I shouldn’t have it?

What about my frequent urination? What’s causing that?

History of Urinary Symptoms (IPSS framework):

You’ve mentioned trouble with your waterworks.

Let’s go through that.

How frequently do you have to pee? Do you wake up at night to have a wee?

Do you have to rush to the toilet?

Did you notice that you have to strain to push the urine? Or does the urine stream stop and start when you have a wee?

Red Flag Screening: Have you had any pain when you pass urine? Have you seen any blood in your urine? Have you had any new or severe back pain?

ICE (Ideas, Concerns, Expectations): What were your own thoughts on what might be causing these symptoms?

You mentioned your friend. Is your biggest worry that you might have prostate cancer?

You’ve asked for the PSA test. What are you hoping the test will tell you?

Acknowledge

Thanks for coming in, Michael. It’s completely understandable that you’re worried after your friend’s diagnosis, and it’s sensible to get things checked out. The urinary frequency you’re describing is what we call a lower urinary tract symptom, or LUTS. It’s very common in men as they get older and is most often caused by a simple, non-cancerous enlargement of the prostate gland, which we call BPH. However, before we talk about the cause, I’d like to discuss the PSA test you’ve asked for, as it’s not as straightforward as many people think.

Addressing and answering the patient’s ICE, and explain advantage and limitation of the tests:

You see the PSA test as a simple cancer test that will put your mind at rest. I wish it were that simple. The PSA test is not a perfect test for prostate cancer. While it could be raised in some type of prostate cancer, it can be raised for many reasons that are not cancer, such as infection, inflammation, or the benign enlargement I just mentioned. This is called a ‘false positive’, and it can lead to a lot of anxiety and unnecessary, invasive investigations like a biopsy.

On the other hand, the test can sometimes miss significant cancers – this is a false negative.  

We are still using it, and we do it on a daily basis, but I just wanted to explain that it is not 100% accurate and there are some limitations that come with it.

The decision is entirely yours, and as long as you are happy with what we discussed, I can arrange for you to have the test. I can also give you a leaflet with all this information to read at home.

If you want to have the test, it is important to avoid things that can falsely raise the test, like heavy exercise, cycling, or ejaculation.

Regardless of your decision about the PSA test, I would still like to examine you. This would involve a general check-up and, with your consent, a gentle rectal examination to feel the prostate gland. This can give us useful information.

There are simple lifestyle changes, like reducing caffeine, that might help with the urinary frequency.

Addressing ideas, concerns, and expectations: Directly address his request for the test, but reframe the consultation as a counselling session to make an informed choice, not a simple request to be fulfilled. Correct his view of the PSA test as a perfect cancer screen.

The management is counselling. Provide balanced information on the pros and cons of the PSA test. Offer a patient information leaflet. Offer a digital rectal examination (DRE) as part of the assessment. The goal is shared decision-making.

What is scenario testing? This is a classic counselling and shared decision-making station. It tests the candidate’s ability to communicate complex statistical and clinical concepts (false positives, false negatives, overdiagnosis) in a clear, balanced way to an anxious patient. The aim is not to persuade the patient one way or the other, but to facilitate an informed choice.