Counselling · Intermediate · Gastroenterology

Colorectal Polyp Found on Colonoscopy in a 52-Year-Old Man

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

Clinical scenario

You are an FY2 doctor in a GP surgery. Mr Ajay Sinha, a 52-year-old man, has come to see you after undergoing a colonoscopy. A large sessile polyp (28 millimetres) with some irregular features was found in the sigmoid colon. The endoscopist removed it and sent it for histology, which has come back as tubular adenoma with high-grade dysplasia. Please counsel him about the findings, explain cancer risk, and discuss surveillance requirements.

Background notes: PMH: Hypertension, Hypercholesterolaemia, Overweight

What this station tests

  • Translating 'high-grade dysplasia' into patient-understandable language: not cancer, but precancerous cells that were completely removed
  • Explaining the adenoma-carcinoma sequence: polyps develop into cancer over years, screening interrupts this process
  • Correct surveillance interval: 12 months for high-risk adenoma (large, high-grade dysplasia), not 3 years
  • Modifiable risk factor counselling: smoking, diet (red meat, fibre), weight, alcohol as concrete targets
  • Addressing familial risk: awareness of bowel screening importance for his children

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

Explaining polyp histology requires translating 'high-grade dysplasia' into language the patient understands while providing accurate risk information without causing unnecessary alarm. Mr Sinha is 52, attending after NHS bowel screening colonoscopy found and removed a 28mm sessile polyp with high-grade dysplasia. He received a confusing hospital letter. Open with: 'Mr Sinha, I understand you had a colonoscopy recently and you have some questions about the results. Can you tell me what you have been told so far?'

Core approach

Explain the findings step by step. 'A polyp is a small growth on the lining of the bowel. Yours was 28 millimetres, which is considered large, and it was completely removed during the colonoscopy. That is good news.' Then address the histology: 'The pathologist looked at the polyp under a microscope and found it was an adenoma, which is a type of benign growth. However, within it there were cells that were showing early abnormal changes, called high-grade dysplasia. This is not cancer. But it tells us that if the polyp had been left in place for years, it could have eventually developed into cancer. The important thing is that it has been completely removed.'

Explain the adenoma-carcinoma sequence simply: 'Bowel cancer almost always develops from polyps over many years. By finding and removing polyps during screening, we interrupt that process. That is exactly what happened with yours.' This reframes the finding positively.

Address surveillance. Because of the size and high-grade dysplasia, he needs a surveillance colonoscopy in 12 months (not the standard 3 years for lower-risk adenomas). Approximately 40% of people develop new polyps, so ongoing surveillance is essential.

Modifiable risk factors: his smoking (ask), diet (high red meat, low fibre), obesity, and alcohol all increase polyp and cancer risk. Concrete advice: increase fibre, reduce red and processed meat, maintain healthy weight, stop smoking, limit alcohol. His children may benefit from earlier screening if he has high-risk polyps.

Closing and safety netting

Reassure clearly: 'The polyp has been completely removed. You do not have cancer. But because of the type of polyp, we need to keep checking. Your next colonoscopy will be in 12 months.' Address his concern about his children: familial risk depends on the number and type of polyps and his age. Referral to genetics is not usually needed for a single adenoma, but his children should be aware of the importance of bowel screening when they are eligible.

Safety net: 'If you develop any change in your bowel habit, blood in your stool, unexplained weight loss, or new abdominal pain, come in and do not wait for the surveillance colonoscopy.' Follow-up in 12 months for repeat colonoscopy.

How examiners mark this station

Examiners will assess your ability to explain tubular adenoma 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 (Supporting)

Scores well: Establishing what the patient understands from the hospital letter. Checking current symptoms (none, screening finding). Assessing modifiable risk factors (smoking, diet, weight, alcohol). Family history of colorectal disease.

Costs marks: Not checking his understanding of the letter. Not assessing risk factors. Not asking about family history.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Accurate histology explanation. Adenoma-carcinoma sequence described. Correct 12-month surveillance. Modifiable risk factor advice. Familial risk discussed. Safety netting for interval symptoms.

Costs marks: Inaccurate histology explanation. Wrong surveillance interval. No lifestyle advice. No safety netting.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Clear, non-alarming explanation of high-grade dysplasia. Positive framing (polyp completely removed, screening worked). Addressing cancer anxiety. Responding to his concern about his children. Checking understanding.

Costs marks: Using 'precancerous' without context. Being overly reassuring (no follow-up needed). Being alarmist. Not addressing his children's risk concern.

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. Saying 'you had precancerous cells' without adequate context. This phrase terrifies patients. The correct framing is: the polyp showed early abnormal changes that could have developed into cancer over years if left in place, but it has been completely removed.
  2. Not knowing the correct surveillance interval. High-risk adenomas (large, high-grade dysplasia) require colonoscopy at 12 months, not the standard 3-year interval. This is commonly tested.
  3. Not discussing modifiable risk factors. The polyp is removed but the conditions that caused it (diet, lifestyle) persist. Candidates who reassure without lifestyle counselling miss the prevention opportunity.

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 tubular adenoma counselling consultation?

Explaining polyp histology requires translating 'high-grade dysplasia' into language the patient understands while providing accurate risk information without causing unnecessary alarm. Mr Sinha is 52, attending after NHS bowel screening colonoscopy found and removed a 28mm sessile polyp with high-grade dysplasia. He received a confusing hospital letter.

Where are marks won and lost in this tubular adenoma station?

Examiners reward: Establishing what the patient understands from the hospital letter. Checking current symptoms (none, screening finding). Assessing modifiable risk factors (smoking, diet, weight, alcohol). Candidates are penalised for: Not checking his understanding of the letter. Not assessing risk factors. Not asking about family history.

Where do candidates most often go wrong in this station?

Saying 'you had precancerous cells' without adequate context. This phrase terrifies patients. The correct framing is: the polyp showed early abnormal changes that could have developed into cancer over years if left in place, but it has been completely removed.

Can I do well in this station without real-world experience of tubular adenoma?

Structure beats experience here. Focus on explaining the adenoma-carcinoma sequence: polyps develop into cancer over years, screening interrupts this process. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

Related cases