You are an FY2 in the emergency department.    

Personal Details:

Name: Mr Jones

Age: 68

Medical Record:

Past medical history: Rectal bleeding for 2 months.

Notes:

A 68-year-old man attended with rectal bleeding. He has been assessed by the consultant this morning and had a sigmoidoscopy for rectal bleeding, which showed a rectal polyp.

The consultant has decided he now needs a full colonoscopy. He hasn’t been informed of the sigmoidoscopy result for the next step. The patient has been waiting in the ER for over 10 hours to be told this and is very angry about the wait and the need for another procedure.

Task:

1. Talk to the patient, acknowledge his concerns

Opening Sentence: “Finally! I’ve been waiting here for over 12 hours. Is anyone going to tell me what’s going on? This is a joke.”

Open History (to give freely): “I had that camera test this morning, and then I was just left here. No one has told me anything. Now you’re telling me I need another one? You’ve got to be kidding me.”

Cues to give: “Why didn’t you just do the full test in the first place? I’m not going through all that preparation and the procedure again. No way.”

ICE (Ideas, Concerns, Expectations):

Ideas: “I think you’ve messed up. You should have done the right test the first time.”

Concerns: “Why didn’t you do a colonoscopy before? I don’t want this procedure again. What did you find?”

Expectation: “I expect an apology for the wait, and I’m not having another test.”

How to Act: You are angry, frustrated, and feeling ignored. You are loud and confrontational.

More History (only if asked): The preparation for the sigmoidoscopy was unpleasant, and you found the procedure uncomfortable. You are not keen to repeat it.

Social History: You are a retired builder.

Questions to ask:

“What’s a polyp? Is it cancer?”

“What’s the difference between the two tests?”

Acknowledge Anger: Start with an immediate and sincere apology for the wait. This is crucial to de-escalate the situation.

Explain the Finding: Clearly explain what a polyp is and its significance (pre-cancerous potential).

Explain the Rationale: Clearly explain the difference between a sigmoidoscopy and a colonoscopy and the clinical reason for needing the second, more complete test.

Acknowledge

Mr Jones, first of all, I want to apologise sincerely for your long wait. You are absolutely right to be angry; a 10-hour wait to get your results is not acceptable, and I am very sorry for that. I can see how frustrated you are, and I will do my best to explain everything clearly now.

Addressing and answering the patient’s ICE:

Let me explain what we found. The camera test you had this morning, the sigmoidoscopy, looked at the lower part of your large bowel. During that test, we found a small growth called a polyp. Now, polyps are not usually cancerous, but they have the potential to turn into cancer over time.

Next Steps:

You are asking, quite rightly, why we didn’t do the full test in the first place. A sigmoidoscopy is often the first test we do for rectal bleeding, as it’s quicker and the preparation is easier. However, the rule is that if we find a polyp in the lower part of the bowel, there is a chance that there could be other polyps higher up. That is why the consultant has now recommended a full colonoscopy, which looks at the entire length of the large bowel. We need to do this to make sure we haven’t missed anything.

I understand completely that you do not want to go through the procedure again. The preparation is unpleasant, and it’s uncomfortable. However, it is really important that we do this. If there are other polyps, we can find them and remove them during the colonoscopy, which can prevent them from ever turning into bowel cancer. Refusing the test could mean we miss something important.

Let’s make a plan. We can book the colonoscopy for you as an outpatient. We will give you much stronger sedation for the procedure to make sure you are as comfortable as possible. I will also speak to the consultant, and we will ensure you get your results in a timely manner after the next procedure. How does that sound?

Addressing ideas, concerns, and expectations: Apologise. Empathise with his frustration. Address his refusal by explaining the clinical risk of not having the colonoscopy (missing other polyps/cancer). Offer solutions to make the next procedure more comfortable (stronger sedation).

The goal is to persuade the patient to consent to the colonoscopy. The management is communicative: de-escalate, explain, negotiate, and reassure.

What is scenario testing? This is a challenging communication station with an angry patient. It tests the candidate’s ability to de-escalate conflict with a sincere apology and empathy. It also tests their ability to explain a medical decision-making process (why a second test is needed) and to negotiate with a reluctant patient to consent to a necessary procedure by addressing their specific concerns (discomfort).