Counselling · Foundation · Gastroenterology

Positive Coeliac Screening Results

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

Clinical scenario

You are an FY2 doctor in a GP surgery. Mrs Kathleen Parsons, a 42-year-old woman, has come to review her recent blood test results. Serology testing for coeliac disease has come back positive (tissue transglutaminase IgA and endomysial antibody). She has not yet had an endoscopy. She is confused about the diagnosis and its implications. Please explain the results, discuss management, and arrange appropriate next steps.

Background notes: PMH: Irritable bowel syndrome, Anaemia - iron deficient, Mild osteoporosis (age 40)

What this station tests

  • Connecting coeliac disease to previously attributed IBS symptoms: reframing her health narrative with the correct diagnosis
  • Explaining that iron-deficiency anaemia and osteoporosis are complications of malabsorption, not separate conditions
  • Practical gluten-free diet counselling: what to avoid, what is safe, cross-contamination management, and school lunch solutions
  • Updated NICE guidance: endoscopy may not be mandatory with strongly positive dual serology, shared decision-making applies
  • Family screening: 10% first-degree relative risk, children should be tested

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

Coeliac disease counselling requires explaining an autoimmune condition, its lifelong dietary treatment, and its connection to symptoms the patient previously attributed to IBS. The candidate must reframe her understanding of her health while providing practical dietary guidance. Mrs Parsons is 42, attending for positive coeliac serology (tTG-IgA and EMA positive). She was previously diagnosed with IBS. Open with: 'Mrs Parsons, your blood test results are back and I want to go through them with you. What have you been told so far?' She received a confusing letter and does not fully understand the diagnosis.

Core approach

Explain coeliac disease clearly. 'Coeliac disease is a condition where your immune system reacts to gluten, a protein found in wheat, barley, and rye. This reaction damages the lining of your small intestine, which is where nutrients are absorbed.' Connect it to her symptoms: 'This explains your diarrhoea, bloating, and tiredness. It also explains the iron-deficiency anaemia and likely contributed to your osteoporosis, because your gut has not been absorbing nutrients properly.' She will realise her IBS diagnosis was wrong. Acknowledge this: 'Many people with coeliac disease are initially diagnosed with IBS because the symptoms overlap.'

Discuss whether endoscopy is needed. Per updated NICE guidance, if both tTG-IgA and EMA are positive, symptoms are present, and complications are evident (iron deficiency, osteoporosis), diagnosis can be made without endoscopy through shared decision-making. Discuss the option with her. She may prefer to avoid endoscopy, or she may want confirmation.

The gluten-free diet is the treatment. This is lifelong. Explain what contains gluten (wheat, barley, rye, and therefore bread, pasta, cereals, biscuits, beer, many sauces and processed foods) and what is naturally gluten-free (rice, potatoes, corn, meat, fish, fruit, vegetables, dairy). She is a school teacher concerned about lunch options. Her mother has coeliac disease, so she has some familiarity. Refer to a dietitian (essential, not optional).

Closing and safety netting

Practical support: Coeliac UK membership (food guides, restaurant cards, product lists), dietitian referral, and prescription of gluten-free staple foods (available on NHS prescription). Explain that symptoms should improve within weeks of starting the diet, and blood markers should normalise within 6 to 12 months. Her anaemia and osteoporosis should improve with nutrient absorption recovery, but she may need iron and calcium/vitamin D supplementation in the meantime.

Family screening: first-degree relatives have approximately 10% risk. Her children (12 and 9) should be tested. Her mother is already diagnosed. Address her concern about family meals: the whole family does not need to eat gluten-free, but cross-contamination must be managed (separate toaster, separate butter, separate chopping board for initial preparation).

Follow-up: repeat tTG-IgA at 6 to 12 months to confirm dietary response. Annual review for associated conditions. Safety net: 'If your symptoms do not improve after 6 to 8 weeks of strict gluten-free diet, come back as we may need to check for other causes.'

How examiners mark this station

Examiners will assess your ability to explain coeliac disease 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: Connecting IBS, anaemia, and osteoporosis to coeliac malabsorption. Checking family history (mother has coeliac). Establishing current symptoms and dietary habits. Assessing children's symptoms for screening.

Costs marks: Not linking existing conditions to coeliac. Not checking family history. Not assessing current diet.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Clear explanation of serology results. Endoscopy discussion with shared decision-making. Gluten-free diet with specific foods named. Dietitian referral. Coeliac UK signposted. Family screening advised. Monitoring plan (tTG at 6-12 months). Supplementation for anaemia and osteoporosis.

Costs marks: No dietitian referral. Vague dietary advice. No family screening. No monitoring plan. Not addressing anaemia and osteoporosis management.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Reframing IBS as coeliac without blame. Addressing practical concerns (school lunches, family meals). Providing hope about symptom improvement. Empowering with resources. Acknowledging the lifestyle adjustment.

Costs marks: Dismissing the dietary challenge. Not addressing family meal concerns. Being overwhelming about restrictions. Not providing practical resources.

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. Not connecting her existing conditions (IBS, anaemia, osteoporosis) to coeliac disease. These are not separate problems: they are consequences of undiagnosed coeliac malabsorption. Candidates who treat the coeliac diagnosis in isolation miss the explanatory power of the diagnosis.
  2. Not referring to a dietitian. The gluten-free diet is a medical treatment, not a lifestyle choice. It requires professional dietary support. Candidates who say 'avoid gluten' without arranging dietitian input provide inadequate management.
  3. Not advising family screening. First-degree relatives have approximately 10% risk. Her children should be tested. Candidates who do not mention this miss a preventive health 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

How should I approach coeliac disease counselling in this PLAB 2 station?

Coeliac disease counselling requires explaining an autoimmune condition, its lifelong dietary treatment, and its connection to symptoms the patient previously attributed to IBS. The candidate must reframe her understanding of her health while providing practical dietary guidance. Mrs Parsons is 42, attending for positive coeliac serology (tTG-IgA and EMA positive).

What are examiners marking in this coeliac disease station?

Marks are won for: Connecting IBS, anaemia, and osteoporosis to coeliac malabsorption. Checking family history (mother has coeliac). Establishing current symptoms and dietary habits. Marks are lost for: Not linking existing conditions to coeliac. Not checking family history. Not assessing current diet.

What is the most common mistake candidates make in this coeliac disease station?

Not connecting her existing conditions (IBS, anaemia, osteoporosis) to coeliac disease. These are not separate problems: they are consequences of undiagnosed coeliac malabsorption. Candidates who treat the coeliac diagnosis in isolation miss the explanatory power of the diagnosis.

How do I prepare for this station if I have not managed coeliac disease in clinical practice?

This station rewards process over personal experience. The skill being assessed: Explaining that iron-deficiency anaemia and osteoporosis are complications of malabsorption, not separate conditions. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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