Counselling · Intermediate · Endocrinology

Annual Diabetic Review in a 64-Year-Old Man

Practise this PLAB 2 counselling station on Type 2 Diabetes Mellitus. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery conducting an annual diabetic review for Mr Jay Lam, a 64-year-old man with type 2 diabetes for 12 years. The review requires assessment of glycaemic control, blood pressure, lipid management, screening for microvascular complications (retinopathy, nephropathy, neuropathy), cardiovascular risk assessment, and discussion of lifestyle factors and medication compliance. Please conduct a comprehensive counselling session on his current management.

Background notes: PMH: Type 2 DM, Hypertension, Hypercholesterolaemia, Mild osteoarthritis knees

What this station tests

  • Structured annual review covering all NICE-recommended domains: glycaemic control, BP, lipids, complications screening (eyes, feet, kidneys), cardiovascular risk
  • Framing SGLT2 inhibitor or GLP-1 agonist as cardiovascular and renal protection, not just glucose control
  • Exploring medication reluctance: understanding why he declined escalation and addressing his reasoning
  • Using family history (father's diabetic stroke) as motivation without being manipulative
  • Balancing reassurance (he is managing reasonably well) with optimisation (borderline control with room to improve)

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, establish what patient already knows and understands.
  • 1-3 min — Explain Condition: Explain diagnosis or condition using chunk-and-check technique. Use simple language, avoid jargon.
  • 3-5 min — Management Options: Discuss treatment options. Shared decision-making. Risks, benefits, alternatives.
  • 5-7 min — Address Concerns: Explore and address specific concerns. Check understanding. Discuss lifestyle implications.
  • 7-8 min — Closing: Summarise agreed plan. Safety netting. Arrange follow-up. Written information offer.

Consultation approach

The opening

Annual diabetic review stations test structured chronic disease management: glycaemic control, complications screening, cardiovascular risk, and lifestyle. The candidate must cover all domains without the consultation becoming a tick-box exercise. Mr Lam is 64, type 2 diabetes for 12 years, attending for routine review. He feels well and expects confirmation that everything is fine. Open with: 'Mr Lam, how have things been going with your diabetes since your last review?' Start with his perspective, not your checklist.

Core approach

Glycaemic control: his HbA1c is 52 mmol/mol (6.9%), borderline at target. He is on metformin and amlodipine only. Check adherence, home monitoring frequency, and symptoms of hyper- or hypoglycaemia (none). He declined medication escalation 2 years ago. Explore why: he feels well and does not want more tablets. This is the counselling challenge: optimising management in a patient who is comfortable with the status quo.

Complications screening. Eyes: has he had retinal screening? (Last year, 'fine,' but confirm result). Feet: any numbness, tingling, ulcers? Check sensation and pulses if examining. Kidneys: recent urine ACR and eGFR results. Cardiovascular: BP, lipids, smoking status. His father died of a stroke related to diabetes, which is emotionally relevant and a motivator.

Cardiovascular risk: check BP today (target <130/80 per recent NICE), review statin use (hypercholesterolaemia listed but check if he is actually on a statin). If not, this is a gap. Weight and BMI. Exercise and diet. He has mild osteoarthritis which limits exercise.

ICE: He thinks he is managing well. He is worried long-term about his father's fate. He wants confirmation that his current approach is sufficient.

Closing and safety netting

Summarise the review findings positively but honestly. If his HbA1c is borderline, acknowledge his self-management while discussing whether medication escalation (SGLT2 inhibitor or GLP-1 agonist) could provide additional cardiovascular protection beyond glucose control. Frame this as heart and kidney protection, not just sugar control, given his father's stroke.

Address any screening gaps: confirm retinal screening is booked, arrange foot check if not done, check urine ACR. Lifestyle: specific, achievable goals rather than generic advice. Safety net: hypoglycaemia awareness if adding new medications, sick day rules. Follow-up in 6 to 12 months.

How examiners mark this station

Examiners will assess your ability to explain type 2 diabetes mellitus and its management in a patient-centred way. Domain 2 (Clinical Management) and Domain 3 (Interpersonal Skills) are equally weighted and primary. Expect marks for accurate information delivery, shared decision-making, chunk-and-check technique, and addressing the patient's specific concerns. Domain 1 (Data Gathering) is assessed through how well you establish the patient's baseline understanding and elicit their concerns.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: All review domains covered: HbA1c, BP, lipids, retinal screening, foot check, renal function. Medication review with adherence. Cardiovascular risk assessment. Family history incorporated.

Costs marks: Incomplete review. Missing screening domains. Not checking medication adherence.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Accurate interpretation of HbA1c. Medication escalation discussed with cardiovascular framing. Screening gaps identified and addressed. Target BP and lipid values known. Practical lifestyle advice.

Costs marks: Not recognising borderline control. No medication escalation discussion. Not knowing targets.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Engaging the patient rather than running a checklist. Exploring medication reluctance. Using father's history sensitively. Acknowledging his self-management efforts.

Costs marks: Tick-box approach. Ignoring his medication preferences. Not personalising the review.

Common examiner feedback (and how to fix it)

Did not provide adequate explanation or plan to the patient

Fix: Use chunk-and-check: deliver one concept, check understanding, then move to the next. Offer all relevant treatment options with risks and benefits before helping the patient decide.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: Before and during counselling, explicitly ask what concerns the patient most. Respond to emotional cues with empathic statements before continuing with information.

Common mistakes in this station

  1. Running through a tick-box checklist without engaging the patient. Annual review has many domains, but a robotic approach scores poorly on Domain 3. Prioritise based on what matters most clinically and to the patient.
  2. Accepting 'my eyes were fine' without confirming the actual retinal screening result. Patients conflate optician checks with diabetic retinal screening. Candidates must verify that formal screening was completed.
  3. Not offering cardiovascular-protective medications. SGLT2 inhibitors and GLP-1 agonists have evidence for cardiovascular and renal benefit beyond glucose control. A patient with diabetes and a family history of diabetic stroke should be offered these.

Resitting PLAB 2?

If counselling stations have been a challenge, the most common issue is information overload: delivering too much clinical detail without checking understanding. Practise the chunk-and-check technique until it becomes automatic. Remember that shared decision-making, not lecturing, is what scores highly in Domain 3.

Example opening

Hello, my name is Dr [Name]. I understand you've come in today to discuss [topic]. Before I explain things, could you tell me what you've been told so far, so I know where to start?

Frequently asked questions

What is the best way to structure this type 2 diabetes mellitus counselling consultation?

Annual diabetic review stations test structured chronic disease management: glycaemic control, complications screening, cardiovascular risk, and lifestyle. The candidate must cover all domains without the consultation becoming a tick-box exercise. Mr Lam is 64, type 2 diabetes for 12 years, attending for routine review.

Where are marks won and lost in this type 2 diabetes mellitus station?

Examiners reward: All review domains covered: HbA1c, BP, lipids, retinal screening, foot check, renal function. Medication review with adherence. Cardiovascular risk assessment. Candidates are penalised for: Incomplete review. Missing screening domains. Not checking medication adherence.

Where do candidates most often go wrong in this station?

Running through a tick-box checklist without engaging the patient. Annual review has many domains, but a robotic approach scores poorly on Domain 3. Prioritise based on what matters most clinically and to the patient.

Can I do well in this station without real-world experience of type 2 diabetes mellitus?

Structure beats experience here. Focus on framing SGLT2 inhibitor or GLP-1 agonist as cardiovascular and renal protection, not just glucose control. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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