Counselling · Intermediate · Infectious Diseases

Recurrent Sore Throat - Tonsillectomy Request

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

Clinical scenario

You are an FY2 doctor in a GP surgery. Beatrice, a 34-year-old woman, has come to see you demanding a tonsillectomy referral due to recurrent sore throats. Please take a focused history, counsel her on evidence-based indications for tonsillectomy, discuss benefits and risks, and engage in shared decision-making.

Background notes: PMH: Generally healthy, no chronic conditions

What this station tests

  • SIGN criteria for tonsillectomy: 7 in 1 year, 5/year for 2 years, or 3/year for 3 years with documented episodes
  • Quantifying episode frequency accurately: patient perception often exceeds actual documented frequency
  • Managing expectations when criteria are not met: not dismissing suffering but explaining the evidence base
  • Tonsillectomy risk counselling: post-operative bleeding (3-5%), pain for 7-14 days, does not eliminate all sore throats
  • Peritonsillar abscess safety netting: severe unilateral pain, trismus, drooling

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

A patient demanding a tonsillectomy requires the candidate to assess whether they meet the criteria while managing expectations if they do not. Beatrice is 34, frustrated with recurrent sore throats, convinced tonsillectomy is the answer. Open with: 'Beatrice, I can hear how frustrated you are with these sore throats. Let me understand the pattern so we can work out the best approach.'

Core approach

Quantify the episodes accurately. Beatrice perceives she has 'constant' sore throats, but careful questioning may reveal the actual frequency is lower than she believes. SIGN criteria for tonsillectomy: 7 episodes in 1 year, or 5 per year for 2 years, or 3 per year for 3 years. Each episode must be documented (ideally with positive cultures or clinical findings). Ask: how many episodes in the past year? Were they confirmed by a doctor? Were antibiotics prescribed? Were cultures taken?

She may have had 3 to 4 episodes in the past year with 1 to 2 in previous years, which does not meet the threshold. Her perception of frequency is higher than reality because the episodes are disruptive.

If she does not meet criteria: explain this honestly. 'The guidelines for tonsillectomy referral require a certain number of documented episodes because the surgery has risks, and for people with fewer episodes, the risks may outweigh the benefits.' This is not dismissing her suffering; it is explaining the evidence base.

If she does meet criteria: refer to ENT with documented episode frequency.

Closing and safety netting

If not meeting criteria: offer interim management. Lifestyle advice (adequate sleep, stress management, hand hygiene). Prompt treatment of confirmed bacterial episodes. Ask her to document future episodes (date, symptoms, whether seen by GP) so the pattern can be accurately tracked. Reassure: 'If the frequency increases and meets the threshold, referral is absolutely appropriate.'

If meeting criteria: explain tonsillectomy risks honestly. Post-operative bleeding (3 to 5%), infection, pain for 7 to 14 days, general anaesthetic risks. It does not eliminate sore throats entirely but significantly reduces frequency.

Address her frustration: 'I understand this is not the answer you were hoping for today. I am not dismissing your symptoms. I want to make sure we track the pattern accurately so we can make the right decision.' Safety net for peritonsillar abscess: 'If you develop severe one-sided throat pain, difficulty opening your mouth, or drooling, come in urgently.' Follow-up in 3 to 6 months.

How examiners mark this station

Examiners will assess your ability to explain recurrent tonsillitis 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: Episode frequency quantified accurately. SIGN criteria checked. Documentation status established. Differentials considered (peritonsillar abscess, glandular fever). Impact assessed.

Costs marks: Not quantifying episodes. Not knowing criteria. Accepting patient perception without verification.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: SIGN criteria applied correctly. If met: referral with risks explained. If not met: interim management, symptom diary, follow-up pathway. Peritonsillar abscess safety netting.

Costs marks: Referring without criteria check. Refusing without alternative plan. No safety netting.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Acknowledging frustration. Explaining criteria without being dismissive. Providing a pathway forward (diary, follow-up). Managing expectations honestly.

Costs marks: Being dismissive. Simply agreeing to avoid conflict. Not acknowledging her suffering. Closing the door without a plan.

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. Referring for tonsillectomy without checking criteria. Simply agreeing to the referral because the patient is insistent is not evidence-based. Candidates must quantify episodes and check against SIGN criteria.
  2. Being dismissive of her frustration. She is suffering from recurrent sore throats that affect her work and family. Candidates who say 'you don't meet the criteria, goodbye' lose her trust. Acknowledging her suffering while explaining the threshold is the correct approach.
  3. Not documenting future episodes. If she is close to the threshold, asking her to keep a symptom diary creates a clear pathway to referral if the frequency increases. Candidates who close the door entirely miss this pragmatic approach.

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 recurrent tonsillitis counselling in this PLAB 2 station?

A patient demanding a tonsillectomy requires the candidate to assess whether they meet the criteria while managing expectations if they do not. Beatrice is 34, frustrated with recurrent sore throats, convinced tonsillectomy is the answer.

What are examiners marking in this recurrent tonsillitis station?

Marks are won for: Episode frequency quantified accurately. SIGN criteria checked. Documentation status established. Differentials considered (peritonsillar abscess, glandular fever). Impact assessed. Marks are lost for: Not quantifying episodes. Not knowing criteria. Accepting patient perception without verification.

What is the most common mistake candidates make in this recurrent tonsillitis station?

Referring for tonsillectomy without checking criteria. Simply agreeing to the referral because the patient is insistent is not evidence-based. Candidates must quantify episodes and check against SIGN criteria.

How do I prepare for this station if I have not managed recurrent tonsillitis in clinical practice?

This station rewards process over personal experience. The skill being assessed: Quantifying episode frequency accurately: patient perception often exceeds actual documented frequency. 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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